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Cool Cases Quiz


Dr. Matthew Zirwas shared some of his interesting cases with the audience at the SDPA Fall 2014 Conference in San Diego.


Dr. Matthew Zirwas shared some of his interesting cases with the audience at the SDPA Fall 2014 Conference in San Diego.  Read the case descriptions he has provided and see if you can correctly answer the questions. 


Case 1

34 y/o male on chemo for relapsed AML following a bone marrow transplant is transported to your office. 

He has dark spots on neck, cheek, clavicle.  You suspect zoster, but on reviewing the chart see that he has been being treated with IV acyclovir for the last 5 days, before the rash started.


Where do you need to look next? 

His mouth.  His mouth shows mucormycosis fungus growing in his sinus cavity.


What do you need to do next?

  • Start IV solumedrol
  • Start IV Vanco and Zosyn
  • Get an ENT Consult
  • Intubate
  • Hold the Chemotherapy

Answer: Get an ENT Consult

In this case, the mucormycosis fungus had moved through the sinus cavity and into the brain. 


Case 2

36 y/o female is referred from her rheumatologist for therapy resistant lupus.  She has been on hydroxychloroquine and proprotection for 8 months with no improvement.  There is a bump on her shin that is as hard as a rock.  Face is covered in lesions.  She says she has trouble swallowing food.


Which anti-body is likely to be positive?

  • Anti-ssDNA
  • Anti-SCL70
  • Anti-Mi
  • Anti-topoisomerase
  • Anti-centromere

Answer: Anti-centromere

The patient has CREST syndrome.  The bump is calcinosis.  She has Raynaud’s, and trouble swallowing is coming from the esophageal dysmotility.  The face lesions are telangiectasias.


Case 3

22 year old male presents for evaluation and treatment of acne.  On examining the chest and back, you note a brown macule on his chest/shoulder that he states has been present since birth.  His shoulders were a-symmetical.


What activity is most likely to be problematic?

  • Lawn mowing
  • Push ups
  • Picking up girls at the beach
  • Brushing teeth
  • Rising from a chair

Answer: Push ups

Patient has Beckers nevus syndrome.  Remember that this is associated with hypoplasia of the chest with muscular and skeletal defects.  When he did push ups, his shoulder would pop out as iit was underdeveloped muscularly.


Case 4

You see a 51 year old woman who presents with red, edematous plaques on her extensor knees.  They have been coming and going for months.  She often has joint pain associated with them.


What surgery did she most likely have?

  • Bilateral arthroscopic knee surgery
  • Bilateral total knee replacement
  • Roux en Y gastric bypass
  • Gastric banding
  • Bilateral hammer toe repair

Answer: Roux en Y gastric bypass

Bowel associated dermatitis arthritis syndrome.  It can be associated with any gastric surgery.  The leaking of bacterial antigens gives you lesions.  Know that this disease responds to antibiotics.


Case 5

51 year old male is referred to you for patch testing for a moderately pruritic, scattered eruption.  The two worst areas are the left thigh and left forehead.  He has no eyebrow hairs near the forehead eruption.


What relevant positives are likely on patching?

  • None
  • p-phenylenediamine
  • cocamidopropyl betaine
  • formaldehyde releasers
  • fragrance

Answer: None

He has follicular mucinosis.  There is a benign form seen in kids.  Lymphocytes in the hair follicle and it destroys the hair follicle.  You see it as alopecia mucinosa. 

In an adult, it’s likely to be follicular cutaneous T-cell lymphoma. The patches were biopsied and showed Monoclonal B lymphocyte populations.  PUVA was used as treatment along with oral bexarotene.

Image: ed_needs_a_bicycle

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