photo diagnosis - sta · pdf filenon-obstructive sialectasis. chronic asymptomatic parotid...

Cases this month

The Canadian Journal of Diagnosis / March 2006 49

Illustrated quizzes on problems seen in everyday practice

This 42-year-old male has hadcalluses, for as long as he canremember, on the palms of his handsand the soles of his feet.

Questions1. What is your diagnosis?2. What is the cause?3. What is the treatment?

Answers1. Palmoplantar keratoderma.2. Most cases are either hereditary in

nature or represent spontaneousmutations. This category of skinconditions (i.e., hereditarykeratodermas) consists of manydistinct entities with varyingpresentations.

3. Systemic retinoids may be of valueto some patients.

Provided by Dr. Rob Miller, Halifax, Nova Scotia.

CASE 1 : CALLUSED SOLES

1. Callused Soles2. Inflamed Skin3. Finger Lesion4. Purple Lesions5. A Coin Toss6. Too Much Lip

7. Linear Mystery8. Getting Cheeky9. Pearly-White Papules10. Itchy Rash11. Lumpy Torso12. Troubling Tremors

13. Plaque Attack14. Papules & Pustules15. Red Body Papules16. Wax On/Wax Off

Photo Diagnosis

The Canadian Journal of Diagnosis / March 200650

Photo Diagnosis

This 65-year-old male was treated by his physician formultiple actinic keratoses on his forehead.

Questions1. What is your diagnosis?2. What is the treatment?

Answers1. Inflammatory skin reaction secondary to topical

5-fluorouracil (5FU) therapy for his actinic keratoses.2. This will resolve on its own once 5-FU therapy is

discontinued. However, topical steroids can be used tohelp decrease the inflammatory response.


CASE 2 : INFLAMED SKIN

This 35-year-old female has a lesion, which frequentlybleeds when traumatized, on her finger.

Questions1. What is your diagnosis?2. What is the cause?3. What is the treatment?

Answers1. Pyogenic granuloma.2. Frequently no underlying cause is found to explain

them, although pregnancy or recent trauma can beinciting influences.

3. Curettage and electrodesiccation is usually curative.Rarely do they require surgical excision. Some casesmay respond to intralesional steroids or cryotherapy.


CASE 3 : FINGER LESION

Photo Diagnosis

This 69-year-old male noticedasymptomatic purplish lesions on hisscrotum.

Questions1. What is your diagnosis?2. What is the treatment?

Answers1. Angiokeratomas.2. These are completely benign and

no treatment is necessary. Theyoccur as a result of the normalaging process. They may also beseen on the vulvae.


CASE 4 : PURPLE LESIONS

Cont’d on page 54


Photo Diagnosis

A 10-year-old male presents with anacute onset of dull lower sternal andepigastric pain, waxing and waning inquality. He has no history of cough,shortness of breath or trauma. Anabdominal radiograph is taken.

Questions1. What does the radiograph show?2. What is the treatment?

Answers1. A coin in the esophagus. Features

consistent with a coin in the esopha-gus include localization of the coin inthe midline, below the carina and acircular silhouette in the anterior-posterior (AP) view. Conversely, acoin in the trachea lies sagittally andappears as a vertical line end-on in anAP view. A lateral view should beobtained if there is any question oflocalization.

2. Most coins will pass through thegastrointestinal tract withoutintervention. Glucagon, administeredintramuscularly, can be given ifspontaneous passage fails to occur.Endoscopic removal of the coin isusually not necessary.

Provided by Dr. Cecil McKibbin, Lacombe, Alberta,Mr. Alexander A. Leung Jr., and Dr. Alexander K.C.Leung, Calgary, Alberta.

CASE 5 : A COIN TOSS


Photo Diagnosis

A four-year-old female was noted tohave a cystic lesion in the inneraspect of her lower lip.

Questions1. What is your diagnosis?2. What is the significance?3. What is the treatment?

Answers1. Mucocele.2. A mucocele results from blockage

of a minor salivary duct. It oftenpresents as a painless, translucentor bluish, cystic lesion anywhereon the mucosal surface of the oralcavity. The lower lip is the mostcommon site. Fluctuations in sizeare common.

3. Most mucoceles frequentlyrupture spontaneously. However,recurrence is common. Surgicalremoval of the mucocele and theassociated accessory salivarygland prevents recurrence.

Provided by Dr. Alexander K.C. Leung and Dr. C. Pion Kao, Calgary, Alberta.

CASE 6 : TOO MUCH LIP


Photo Diagnosis

A four-year-old male presents witha linear hyperpigmentation thatextends from the umbilicus to thepubis.

Questions1. What is your diagnosis?2. What is the significance?

Answers1. Linea nigra.2. Linea nigra is a benign

condition that is more commonin dark-skinned individuals. Inchildren, the peak age isbetween 11 and 15 years. Thecondition is more common ingirls. The occurrence of lineanigra is not uncommon duringpregnancy, when it assumes thename linea gravidarum. Lineanigra has to be differentiatedfrom postinflammatoryhyperpigmentation andpigmentary demarcation line(Ito’s line).

Provided by Dr. Alexander K.C. Leung and Dr. C. Pion Kao, Calgary, Alberta.

CASE 7 : LINEAR MYSTERY


Photo Diagnosis

This 56-year-old male presents with apainless swelling, which has beenpresent for the past two days, in the leftparotid gland. He had a similar episodetwice in the past six months. Eachepisode lasted for four to seven days.

Questions1. What are the possibilities?

Answers1. A recurrent asymptomatic parotid

enlargement is most likely due tonon-obstructive sialectasis. Chronicasymptomatic parotid enlargement,especially when bilateral, may be secondary to bulimia nervosa, diabetes mellitus, cirrhosis of theliver, chronic pancratitis, sarcoidosis,and hyperlipoproteinemia. It mayalso be a side-effect of medications(e.g., phenylbutazone).

Provided by Dr. Alexander K.C. Leung and Dr. Benny C.L. Cheung, Calgary, Alberta.

CASE 8 : GETTING CHEEKY

Angiotensin converting enzyme inhibitorProduct monograph available upon request.® Registered trade-mark of Aventis Group. Used under licence byAventis Pharma Inc., Laval, Quebec H7L 4A8.CDN.RAM.05.04.05E

Cont’d on page 60


Photo Diagnosis

A 23-year-old male presents with a few pearly-white,oval, umblicated, asymptomatic papules on his lowerabdomen and in the genital area.

Questions1. What is your diagnosis?2. What is the therapeutic option for this condition?

Answers1. Molluscum contagiosum.2. Cryotherapy, curettage, local cantharidin or tretinoin.

Provided by Dr. Jerzy Pawlak, Winnipeg, Manitoba.

CASE 9 : PEARLY-WHITE PAPULES

A four-year-old male presents with a recurrent and itchyrash over the posterior aspect of his legs, close to thebuttocks and in the knee flexures.

Questions1. What is your diagnosis?2. Where else would you look for similar skin lesions?3. What other medical disorders tend to be associated

more frequently in these patients and their families?

Answers1. Atopic dermatitis.2. Face and neck, elbow, wrist and ankle flexures.3. Asthma, hay fever, migraine, cataracts, susceptibility

to drug reaction and topical viral infections.


CASE 10: ITCHY RASH


Photo Diagnosis

A 62-year-old male presents with along history of soft to firm, deep,non-painful masses on his chest andabdomen. He is otherwise healthyand is not taking any medications.

Questions1. What is your diagnosis?2. Are there any specific concerns?

Answers1. Lipomas (multiple lipomatosis).2. Lipomas are the most common

soft tissue tumours and arebenign. Rarely, they may undergosarcomatous change.

Provided by Dr. Jerzy Pawlak, Winnipeg,Manitoba.

CASE 11: LUMPY TORSO


Photo Diagnosis

A 77-year-old female presents with complaints oftremor, heat intolerance, diarrhea, fatigue and a slightdecrease in her memory. Her medical history isinsignificant. She has a positive family history ofthyroid disease. Her mother had a history of goitre. Onphysical examination she has a fine tremor, smoothskin and slightly brisk reflexes. Her pulse is 76 beatsper minute and regular. Her thyroid gland is quite large.Her neck circumference is 38 cm. There are no eyesigns to suggest hyperthyroidism. Her blood workshows a thyroid-stimulating hormone suppressed at0.0031 mu/L and on elevated free T4 at 27.8 mu/L.

Questions1. What are the symptoms of hyperthyroidism?2. What are the signs of hyperthyroidism?3. What is the most probable diagnosis in this case?4. What are the therapeutic options?

Answers1. Nervousness and/or tremor, weight loss (usually

with increased appetite), palpitations, heat intolerance and excessive perspiration, emotionalliability, muscle weakness and hyperdefecation.

2. Tachycardia or atrial fibrillation, widened pulsepressure with increased systolic and decreaseddiastolic pressure, hyperdynamic precordium andaccentuated first heart sound (S1), warm smoothskin, tremor, proximal muscle weakness, thyroidenlargement or abnormality.

3. Graves’ hyperthyroidism vs. toxic nodule.4. a) Chronic antithyroid drug therapy

b) Surgeryc) Radioiodine therapy


CASE 12: TROUBLING TREMORS

A 74-year-old female presents with a slowlygrowing asymptomatic plaque on her cheek.

Questions1. What is your diagnosis?2. What is the number one etiologic factor

for this lesion?3. What are the treatment options?

Answers1. Bowen disease (squamous cell

carcinoma-in-situ).2. Chronic ultraviolet radiation.3. Topical 5-fluorouracil, imiquimod or

aggressive liquid nitrogen cryotherapy canbe tried, although surgical excision, isconsidered more definitive.

Provided by Dr. Benjamin Barankin, Edmonton, Alberta.

CASE 13: PLAQUE ATTACK

JAACT0509E

Marketed with: Aventis Pharma Inc.,member of the sanofi-aventis Group.

Laval, Quebec H7L 4A8

Manufactured and Distributed by: Procter & Gamble Pharmaceuticals Canada, Inc. Toronto, Ontario M5W 1C5

Product Monograph available on request. ® Actonel is a registered trade-mark of Procter & Gamble Pharmaceuticals, Inc., U.S.A. Used under licence by Aventis Pharma Inc.,Laval, Quebec H7L 4A8.

Focused on fracture

(ACTONEL 5 mg 2.4% vs.placebo 6.4%, p<0.001)1*†

Most common side effects in clinical postmenopausalosteoporosis studies (ACTONEL vs. placebo): abdominalpain (11.8% vs. 9.5%), hypertension (10.6% vs. 9.4%)and joint problems (7.1% vs. 5.5%). The most commonside effects in glucocorticoid osteoporosis studies wereback (17.8% vs. 8.8%) and joint pain (24.7% vs. 14.7%). ACTONEL 5 mg daily is indicated for the treatment andprevention of osteoporosis in postmenopausal women(PMO) and for the treatment and prevention of glucocor-ticoid-induced osteoporosis (GIO) in men and women.ACTONEL 35 mg Once-a-Week is indicated for the treat-ment of osteoporosis in postmenopausal women.ACTONEL is contraindicated in patients with hypocalcemiaor known hypersensitivity to any component of this product. ACTONEL is not recommended for use in patientswith severe renal impairment (creatinine clearance <30 mL/min). Since some bisphosphonates have beenassociated with upper gastrointestinal disorders, patientsshould be directed to pay particular attention to the dosing instructions. Failure to take ACTONEL according to instructions may compromise clinical benefits and mayincrease the risk of adverse events.Please refer to accompanying prescribing information forfull dosing instructions and other important information.

* Randomized, double-blind, placebo-controlled study of 2,458 postmenopausalwomen with at least one vertebral fracture. All patients received 1 g/d calcium and, if baseline levels were low, 500 IU/d vitamin D.

† Relative risk reduction.

(ACTONEL 5 mg 2.4% vs.placebo 6.4%, p<0.001)1*†

Demonstratedup to 65%vertebralfracture riskreduction injust 1 year

Demonstratedup to 65%vertebralfracture riskreduction injust 1 year


Photo Diagnosis

A five-month-old female presents witherythematous papules and pustules, which areunresponsive to Ihle’s paste, in her groin region.

Questions1. What is your diagnosis?2. What is a characteristic finding in this condition?3. How could you treat this condition?

Answers1. Candidal dermatitis. This is usually a clinical

diagnosis, although it can be established by apotassium hydroxide preparation or culture.

2. Satellite lesions/pustules.3. Nystatin cream or ointment, four to six times a

day or with each diaper change.


CASE 14: PAPULES & PUSTULES

A 46-year-old female is curious about these redpapules on her body.

Questions1. What is your diagnosis?2. Where are these lesions most commonly found?3. What is the treatment?

Answers1. Cherry angiomas or Campbell de Morgan spots.2. On the trunk in adults and elderly.3. Electrocautery and laser are both effective. Also,

cryotherapy or shave excision can be tried.


CASE 15: RED BODY PAPULES


Photo Diagnosis

A 31-year-old male presents withsore papules evenly spaced on hischest and back. He reports waxinghis chest for the past two months.

Questions1. What is your diagnosis?2. What are the different causes for

this condition?3. How would you manage this

patient?

Answers1. Folliculitis—mechanical.2. Chemical or physical irritation,

infection (bacterial, pseudomonas,pityrosporum), or idiopathic.

3. Advise the patient to discontinuewaxing. The patient can considerlaser hair removal.

Provided by Dr. Benjamin Barankin, Edmonton,Alberta.

CASE 16: WAX ON/WAX OFF

Dx

photo diagnosis - sta · pdf filenon-obstructive sialectasis. chronic asymptomatic parotid...

Documents