CME examination Identification No. 880-109

See "Instructions for Category I CME Credit" on page 23Aof the front advertising section.

Questions 1-30, Muhlbauer JE: J AM ACAD DERMATOL3:217-230, 1980.

Directions for questions 1-21: Give single bestresponse.

I. Granuloma annulare was first described bya. Anne Jean Louis Brocq (1856-1928)b. Thomas Colcott Fox (1848-1916)c. Jean Darier (1856-1938)d. Jonathan Hutchinson (1828-1913)e. Moritz Kaposi (1837-1902)

2. The percentage of new patients who come to der­matologists with granuloma annulare is approxi­matelya. 0.02%b. 0.07%c.0.2%d.0.7%e. 1.0%

3. The incidence of localized granuloma annul are inmales, compared with that in females, is approxi­matelya. 2.5: Ib. 1.5: Ic. I: Id. I: 1.5e. 1:2.5

4. The incidence of generalized granuloma annularein males, compared with that in females, is approx­imatelya. 4.0: 1b. 2.5: Ic. I: Id. 1:2.5e. 1:4.0

5. The proportion of patients with localized granu­loma annulare who have only a single lesion IS

approximatelya. 10%b.25%c.40%d.50%e. 65%

6. The most common site of occurrence of localizedgranuloma annulare is thea. trunkb. hands and arms

232

c. legs and feetd. legs and armse. face

7. The proportion of cases of localized granulomaannulare in which recurrent eruptions occur is ap­proximatelya. 5%b. 10%c.20%d.30%e.40%

8. The proportion of cases of granuloma annularewith generalized cutaneous lesions is approxi­matelya. 5%b. 10%c. 15%d.20%e. 25%

9. A histologic finding that is common in all forms ofgranuloma annulare, but is variable to absent inother palisading granulomas, isa. deposition of mucinb. necrobiosis of collagenc. extracellular deposition of fatd. loss of elastotic tissuee. vascular thickening

10. Histologic features which help to differentiatebetween necrobiosis lipoidica diabeticorum andgranuloma annulare include all of the following,excepta. epidermal atrophy in necrobiosis lipoidica dia­

beticorumb. the focal nature of necrobiosis, with interposi­

tion of areas of normal collagen, in granulomaannulare

c. eosinophils in the dermis in necrobiosis li­poidica diabeticorum

d. mucin deposition in granuloma annularee. obliterative vascular changes in the deep der­

mis in necrobiosis lipoidica diabeticorum

II. Subcutaneous granuloma annularea. most commonly occurs in adult Caucasian

women

Volume 3Number 3September, 1980

b. is often present on the chestc. is a benign condition with IgM rheumatoid fac­

tor not present in the serumd. does not occur in conjunction with papular

granuloma annularee. is probably the same disease as benign rheuma­

toid nodule and pseudorheumatoid nodule ofchildhood

12. Perforating granuloma annularea. is not a real entityb. shows isomorphismc. is associated with antithyroid antibodiesd. rarely, if ever, occurs in a generalized forme. may show collagen perforating through the

epidermis on serial histopathologic sections

13. Generalized granuloma annulare has been linked inone report with which of the following histocom­patibility loci?a. iILA B8b. HLA B27c. HLA Bw3d. HLA Bw35e. None of the above

14. The pathogenesis of granuloma annulare isa. believed to involve vasculitis since fibrinoid

necrosis of vessels and deposition of immuno­globulin around vessels are consistent findings

b. proved to be a delayed hypersensitivity reactionbecause of the identical pattern of fibrin de­position in contact dermatitis and in granulomaannulare

c. believed to be related to visible lightd. reported to be due to a defect in monocyte

chemotaxise. not well understood at this time

15. The activity of serum angiotensin converting en­zyme has been reported to be increased ina. granuloma annulareb. sarcoidosisc. necrobiosis lipoidica diabeticorumd. granuloma multiformee. annular elastolytic giant cell granuloma

16. The proportion of patients with localized granu­loma annulare who clear spontaneously within 2years is approximatelya. 20%b.40%c. 50%d.65%e. 80%

CME examination 233

17. The proportion of patients with relapsing granu­loma annulare who clear spontaneously within 2years is approximately

a.20%b.40%c.50%d.65%e.80%

18. The average case of generalized granuloma annu­lare persists fora. I to 2 yearsb. 2 to 3 yearsc. 3 to 4 yearsd. 4 to 5 yearse. more than 5 years

19. A 5-year-old boy is referred for evaluation of asubcutaneous nodule of the eyebrow area. Exci­sional biopsy of the lesion reveals a subcutaneousnecrobiotic change with palisading of mononu­clear cells. The best advice to the parents wouldbe (to)a. reexcision with wide margins because of the

possibility of evolution into a sarcomab. reassurance that the disorder is benign and that

later development of arthritis is unlikelyc. warn them about a high likelihood of juvenile

rheumatoid arthritis in the futured. treatment with penicillin on a monthly basis for

prophylaxis of rheumatic fevere. treatment for tuberculosis

20. A 45-year-old woman with hundreds of erythe­matous reticulate and circinate dermal papules isseen in the clinic. The clinical diagnosis is general­ized granuloma annulare. Your workup should in­clude all of the following, excepta. a complete blood count in preparation for

first-line therapy with chlorambucilb. a skin biopsy to confirm the diagnosisc. a family history for diabetes mellitusd. a fasting blood glucosee. a chest x-ray to explore the possibility of sar­

coidosis

21. Intralesional steroid therapy of granuloma annularewould be expected toa. increase the clearance rateb. be useful only in concentrations greater than 20

mg/dlc. decrease the clearance rated. cause the disease to generalizee. reduce the recurrence rate

234 CME examination

Directions for questions 22-26: Select the aile let ­tered item that is most closely related to eachnumbered item.

a. Annular elastolytic giant ceIl granulomab. Granuloma multiformec. Necrobiosis lipoidica diabeticorumd. Localized granuloma annularee. Generalized granuloma annulare

22. Mkar disease23. Asteroid bodies24. Tends to occur in Eastern Nigerian women25. Necrobiosis of collagen is absent26. Miescher's granuloma

Directions for questions 27-30: Indicate correcta~lSIl'ers . All. some, or none ofthe choices may betrue.

27. Localized granuloma annulare may present witha. target lesionsb. erythematous patchesc. erythematous patches that evolve into papular

lesionsd. superficial papulese. subcutaneous papules

Journal of theAmerican Academy of

Dermatology

28. The superficial and middle dermis, but not thedeep dermis or the subcutis, are characteristicallyinvolved ina. granuloma annulareb. necrobiosis lipoidica diabeticorumc. rheumatic fever noduled. granuloma multiformee. annular elastolytic giant cell granuloma

29. Mucinous material separating collagen fibers ingranuloma annulare stains with which of the fol­lowing?a. Colloidal iron stainb. Alcian blue stain, pH 0.4c. Alcian blue stain, pH 3.0d. Toluidine blue stain , pH 2.0e . Toluidine blue stain, pH 3.0

30. Multinucleated giant cells that engulf elastin arecharacteristically found ina. granuloma annul areb. subcutaneous granuloma annularec. rheumatoid noduled. granuloma multiformee. annular elastolytic giant cell granuloma