A 74-year-old woman develops tense, itchy blisters on her inner thighs and upper arms. Given the likely diagnosis, what will immunofluorescence of the skin biopsy demonstrate?
Correct Answer E: Bullous pemphigoid is an autoimmune condition causing sub-epidermal blistering of the skin. This is secondary to the development of antibodies against hemi-esmosomal proteins BP180 and BP230.
Bullous pemphigoid is more common in elderly patients.
Bullous pemphigoid Features include:
Skin biopsy:
*in reality around 10-50% of patients have a degree of mucosal involvement. It would however be unusual for an exam question to mention mucosal involvement as it is seen as a classic differentiating feature between pemphigoid and pemphigus.
Direct immunofluorescence microscopy of bullous pemphigoid. In a perilesional biopsy, linear binding of IgG at the dermal–epidermal junction is seen. At higher magnification and in thin sections (4 μm), IgG deposition is no longer linear but appears curved with arches closed at the top referred to as ‘n-serrated’ pattern.
A patient who is suspected of having dermatitis herpetiformis undergoes a skin biopsy.
Which one of the following antibodies is most likely to be found in the dermis?
Correct Answer B: Dermatitis herpetiformis - caused by IgA deposition in the dermis.
Dermatitis herpetiformis is an autoimmune blistering skin disorder associated with coeliac disease. It is caused by deposition of IgA in the dermis.
Features: Itchy, vesicular skin lesions on the extensor surfaces (e.g. elbows, knees buttocks)
Diagnosis:
Management:
Dermatitis herpetiformis: direct immunofluorescence. Note granular IgA deposition in the dermal papillae.
A 31-year-old female with polycystic ovarian syndrome consults you as she is troubled with excessive facial hair. Switching her combined oral contraceptive pill to co-cyprindiol has had no effect. On examination she has hirsutism affecting her moustache, beard, and temple areas.
What is the most appropriate treatment?
Correct Answer D: Polycystic ovarian syndrome (PCOS) is a complex condition of ovarian dysfunction thought to affect between 5- 20% of women of reproductive age. Management is complicated and problem based partly because the aetiology of PCOS is not fully understood. Both hyperinsulinaemia and high levels of luteinizing hormone are seen in PCOS and there appears to be some overlap with the metabolic syndrome.
General:
Hirsutism and acne:
Infertility:
*work by occupying hypothalamic oestrogen receptors without activating them. This interferes with the binding of oestradiol and thus prevents negative feedback inhibition of FSH secretion.
A 69-year-old woman with a history of learning difficulties is reviewed in clinic. She is known to have erythema abigne on her legs but according to her carer still spends long hours in front of her electric fire.
Which one of the following skin lesions is she at risk of developing?
Correct Answer A: Erythema ab igne is a skin disorder caused by over exposure to infrared radiation. Characteristic features include reticulated, erythematous patches with hyperpigmentation and telangiectasia. A typical history would be an elderly women who always sits next to an open fire.
If the cause is not treated then patients may go on to develop squamous cell skin cancer.
erythema ab igne from resting against a radiator.
A 43-year-old woman who is a recent immigrant from Mozambique is referred to the dermatology outpatient clinic. She has developed a number of hypopigmented, oval shaped lesions on her body which are associated with reduced sensation. These are mainly located on the extensor surfaces of her limbs. She has no past medical history of note other than suffering from malaria as a child.
What is the most likely diagnosis?
Correct Answer E: Leprosy is a granulomatous disease primarily affecting the peripheral nerves and skin. It is caused by Mycobacterium leprae.
Features:
The degree of cell mediated immunity determines the type of leprosy a patient will develop.
Low degree of cell mediated immunity --> lepromatous epilepsy ('multibacillary'):
High degree of cell mediated immunity --> tuberculoid leprosy ('paucibacillary'):
Indeterminate leprosy. The face of a Nepali child showing vague hypopigmented patch with some central healing. Note the mark of a recent slit-skin smear.
Tuberculoid leprosy. The face of a Pakistani woman showing a reddish plaque with a well-defined active edge, and a small satellite lesion. On the face, such lesions may not be anaesthetic.
Tuberculoid or borderline tuberculoid leprosy. The upper arm of an Indian man, showing a typical dry, hairless, hypopigmented plaque with a scaly, red edge. Such lesions are usually anaesthetic.
Lepromatous leprosy. The forearm of an English man showing red macules and infiltration, which characterize a relapse of dapsone-resistant lepromatous leprosy.
Lepromatous leprosy. The face of a man showing diffuse infiltration of the skin and appearance of nodules on the nose and lip.
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