From Head to Toe: An Image-based Quiz

April 7, 2017
Jonathan A. Schneider, DO
Jonathan A. Schneider, DO

We give you 6 cases with a photo, presenting details, and a differential. Now, what's your Dx?

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Presentation/History

A young mother brings in her 3- and 5-year-old daughters for upper respiratory symptoms but your attention is drawn immediately to her face. 

 -- At first it appears she has a “ruddy” complexion but on closer inspection, you see papular lesions that are flesh-colored with an erythematous, almost vascular base, like telangiectasia.

 -- Lesions are primarily in the nasolabial folds, on the cheeks, and on the chin.

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Physical examination

Both girls do have signs of mild URI.

 -- Further examination reveals the sisters also have somewhat oval, “ash-leaf” shaped depigmented macules on her left lower leg

 -- On additional questioning the mother says both daughters have a seizure disorder. 

 -- An interesting constellation: Acne-like lesions in the mother; hypopigmented lesions on both of the daughters; strong family history of seizures.

Differential diagnosis

A. Neurofibromatosis

B. Incontinentia pigmenti

C. Maternal lupus erythematosus, and congenital lupus

D. Tuberous sclerosis

E. Miller-Dieker syndrome

Your Dx?
ANSWER ON NEXT PAGE>>
Answer: D. Tuberous sclerosis




CASE #2

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Presentation/History

An 11-year-old female presents with complaint of acne that has appeared “out of nowhere.” She had a "clear complexion" until about 3-4 weeks ago.

 -- She is Tanner stage 1 for breast development and has not begun menarche.

 -- Past medical history is noncontributory.

 -- She reports no dietary issues and, by history, does not eat much in the way of fried foods, candy, sodas, chips, etc. She does use skin and hair products and admits that she recently tried a new name brand hair product.

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Physical examination

Noted are non-inflammatory closed comedones about her nasolabial folds and around the eyes; these are papular lesions with no central pumctum; similar lesions are noted aroudn the mouth.

Differential diagnosis

A. Molluscum contagiosum

B. Gram negative acne

C. Staphylococcal infection

D. Insect bites

E. Pomade acne

F. Acne vulgaris

Your Dx?
ANSWER ON NEXT PAGE>>
Answer: E. Pomade acne




CASE #3

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Presentation/History 

A 7-year-old boy had been perfectly well until 4 days before these pictures were taken; his mother brought him to the pediatric clinic concerned about what appeared to be widespread bruising.

 -- No bruising in the past; no nosebleeds; balance of medical history and review of systems is entirely non-contributory.

Physical examination

 -- Afebrile, vital signs within normal limits

 -- Very active, well nourished, well developed

 -- No hepatosplenomegaly

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Physical examination, cont'd

Discolored linear and whorled hyperpigmentation is seen without petechiae or purpura

 -- Rather than bruising, it appears something was smeared on the child's skin

 -- Close inspection of the markings reveal what appears to be a small hand print

Differential diagnosis

A. A drug reaction

B. A Yet-to-be-determined hematologic disorder

C. Phytophotodermatits

Your Dx?
ANSWER ON NEXT PAGE>>
Answer: C. Phytophotodermatitis (in response to playing with mashed limes in the backyard, exposed to sunlight)




CASE #4

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Presentation/History

A 16-year-old male comes to the clinic for a pre-participation sports physical examination. He has no significant past medical history.

Physical examination

When he lifts his shirt to allow auscultation of the chest, the physician notes a variety of moles distributed across the teen’s chest and trunk.

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Physical examination, cont'd

The papular lesions are asymmetric with indistinct borders and variegated color; many are >6 mm in diameter.

Differential diagnosis

A. Squamous cell carcinoma 

B. Clark’s nevi

C. B-K mole syndrome

D. Dysplastic nevi (new nomenclature applies)

E. Photosensitivity

F. Nothing to worry about

Your Dx?
ANSWER ON NEXT PAGE>>
Answer: D. Dysplastic nevi (aka, Clark’s nevi, B-K mole syndrome)




CASE #5

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Presentation/History

A 3-year-old boy is seen for an asymptomatic rash of 7 days duration.

 -- He has had a low grade fever and complained of a sore throat for ~10 - 14 days.

 -- No known infectious exposures.

 -- His past medical history is non-contributory.

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Physical examination

Symmetric flesh-colored flat-topped papules without excoriation are see on face, buttocks, limbs.

 -- Cervical lymph nodes are moderately enlarged and tender; spleen tip is palpable.

 -- CBC shows lymphocytosis with 35% atypical lymphocytes; rapid strep test is “negative.”

Differential diagnosis

A. Erythema multiforme

B. Lichenoid reaction to medications

C. Non-specific viral exanthema

D. Papular acrodermatitis (Gianotti-Crosti syndrome) associated with infectious mononucleosis

E. Rocky Mountain Spotted fever

Your Dx?
ANSWER ON NEXT PAGE>>
Answer: D. Papular acrodermatitis (Gianotti-Crosti Syndrome) associated with infectious mononucleosis




CASE #6

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Presentation/History

A 17-year-old girl complains of “holes” on the soles of her feet that she says she has noticed over the past 4-6 months; initially there was minimal odor but the odor has become foul.

Physical examination

Pitting of the weight bearing surfaces on both plantar surfaces.

 -- There is no callous formation of the involved areas; there is no bruising, no petecchiae.

 -- The plantar surfaces exhibit moistness and significant malodor.

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Differential diagnosis

A. Basal cell nevus syndrome

B. Circumscribed acral hypokeratosis

C. Focal acral hyperkeratosis

D. Keratolysis exfoliativa

E. Tinea pedis

F. Pitted keratolysis

G. Plantar warts

Your Dx?

 

ANSWER AND LINKS TO ALL CASES ON NEXT PAGE>>
Answer: F. Pitted keratolysis


 

Case #1. Tuberous sclerosis
Case #2. Pomade acne
Case #3. Phytophotodermatitis
Case #4. Dysplastic nevi (dysplastic nevus syndrome)
Case #5. Papular acrodermatitis (Gianotti-Crosti Syndrome) associated with infectious mononucleosis
Case #6. Pitted keratolysis