moluscum contageosum

Molluscum contagiosum is an infection caused by proxy virus.The lesions, known as Mollusca, are small, raised, and usually white, pink, or flesh-colored with a dimple or pit in the center. They often have a pearly appearance. They’re usually smooth and firm. In most people, the lesions range from about the size of a pinhead to as large as a pencil eraser (2 to 5 millimeters in diameter). They may become itchy, sore, red, and/or swollen.

Mollusca may occur anywhere on the body including the face, neck, arms, legs, abdomen, and genital area, alone or in groups. The lesions are rarely found on the palms of the hands or the soles of the feet.

Dermatitis Herpitiforms

Dermatitis herpetiformis (DH) is a rare but persistent immunobullous disease that has been linked to coeliac disease

• DH predominantly affects Caucasians aged 15–40 years, but may occur in those younger or older and in other races.
• There is a 2:1 male-to-female ratio.
• More females under the age of 20 are affected than males.
• There is a genetic predisposition and association with human leukocyte antigens (HLAs) DQ2 and DQ8.
• Some patients have a personal or family history of other autoimmune disorders such as viteligo, type 1 DM, alopasia
• DH and coeliac disease are due to intolerance to the gliadin fraction of gluten found in wheat, rye and barley.
• Gluten triggers production of IgA antibodies and an autoimmune process that targets the skin and gut.
• In coeliac disease, gluten causes intestinal inflammation resulting in diarrhoea, tiredness, weight loss and abdominal discomfort.

What are the clinical features of dermatitis herpetiformis?

• DH has a symmetrical distribution.
• Lesions most commonly appear on scalp, shoulders, buttocks, elbows and knees.
• It is characterised extremely itchy papules and vesicles on normal or reddened skin.
• They often appear in groups or serpiginous clusters.
• Blisters are often eroded and crusted due to immediate scratching.
• DH may also present initially as digital petechiae.
• Flat red patches, thickened plaques and wheals may occur resembling other inflammatory skin conditions such as dermatitis, scabies and papular urticaria. 
• Lesions resolve to leave postinflammatory hypopigmentation and hyperpigmentation.

Lichen planus

Lichen planus is a chronic skin condition. It causes itchy, flat, scaly patches on the wrists, legs, trunk, or genitals. It can also affect the inside of the mouth and vagina. There it resembles a white spider web. It may ulcerate. Rarely, it can also become cancerous. The scalp and fingernails can also be affected. It may become wart-like in thickness. Lichen planus may continue on and off for months or years. Scratching makes this condition worse.
A 53-year-old woman presents with intensely itchy skin lesions and burning in her
mouth, which makes eating difficult. These signs and symptoms have become progressively
evident during the past several weeks. Examination of her skin and oral
cavity reveals violaceous, polygonal papules, mainly on the flexural aspect of the
wrists and ankles and in the lumbar region, as well as erosions associated with a lacelike,

white-line network apparent in the posterior buccal mucosa. How should this manage?
The major burdens of lichen planus are itching and residual hyperpigmentation in the cutaneous form and pain and
difficulties with eating in the oral erosive form.
• With the exception of the cutaneous form, which generally heals within 1 year, lichen planus is a chronic condition.
• Given reports of a significant association between lichen planus and infection with the hepatitis C virus (HCV), HCV
serologic testing should be considered in all affected patients.
• In the case of lesions that persist despite treatment, biopsy specimens should be assessed for early dysplasia or
squamous-cell carcinoma, since these conditions have been reported in association with lichen planus.

Most lichen planus is relatively mild. Affected individuals who do not have symptoms do not need treatment. Ultimately, there is no agreed-upon cure for this condition.

https://www.blogger.com/blogger.g?blogID=6294202302428872992#editor/target=page;pageID=6940748946264721553;onPublishedMenu=pages;onClosedMenu=pages;postNum=3;src=pagenameIf the itch or appearance of the rash are unpleasant, topical corticosteroid creams may be of help. Topical steroid creams that, for example, are unwrapping or taped at bedtime may also be useful when practical. For localized, itchy, thick lesions, injections ofmay be given.may blunt the itch, particularly if it is only moderate. This effect is in part due to the sedative effect of antihistamines.

Scabies

Scabies 
What is scabies?Scabies is a parasitic infestation in which Sarcoptes scabei mites burrow under the skin and cause intense itching.

What are the symptoms of scabies?Aside from intense itching, which usually is worse at night, symptoms may include hive-like bumps on the skin. These lesions tend to first appear between the fingers or on the elbows, wrists, buttocks, or waist. The mites can also burrow under fingernails or around the skin near watchbands or rings. The itching of scabies results primarily from the body's allergic reaction to the mites, their eggs and their waste.

Vigorous scratching can break the skin and allow a secondary bacterial infection to occur. Superficial infections of the skin, known as impetigo, are caused most often by staph (staphylococcal) and occasionally strep (streptococcal) bacteria. These bacterial infections can cause localized inflammation marked by redness, swelling, heat and pain as well as a honey-colored exuded fluid.

Scabies can become a serious problem in those with weakened immune systems, such as people with HIV or cancer. Scabies can also be an issue for those with chronic illnesses or living in institutionalized settings such as hospitals, rehabilitation centers, childcare facilities and nursing homes. If the condition becomes chronic, a more severe and very contagious form of scabies may develop called crusted scabies, which causes a hard, scaly rash that covers large areas of the body and can be difficult to treat.

Prevention: To prevent re-infestation and the spread of mites to other people, use hot, soapy water to wash all clothing, towels and bedding that were used at least two days before treatment. Machine-dry with high heat. Dry-clean items you can't wash at home. Vacuum the whole house carefully and throw away the vacuum cleaner bag to prevent any mites from escaping into the house.

Apply permethrin 5% cream or  benzyle benzoate 25% immulsion . For children less than 2 months use sulfer 5% cream for 2-3 days or crotamitone 10% cream for 3-5 days.For infected scabies use flucloxacilline or erythromycine. 

Consider placing items you can't wash in a sealed plastic bag, and leaving it

Pityriasis rosea

Pityriasis rosea is a viral rash which lasts about 6–12 weeks. It is characterised by a herald patch followed by similar, smaller oval red patches that are located mainly on the chest and back.Pityriasis rosea most often affects teenagers and young adults. However, it can affect males and females of any age.Many people with pityriasis rosea have no other symptoms, but the rash sometimes follows a few days after a upper respiratory viral infection (cough, cold, sore throat or similar).

The herald patch

The herald patch is a single plaque that appears 1–20 days before the generalised rash of pityriasis rosea. It is an oval pink or red plaque 2–5 cm in diameter, with a scale trailing just inside the edge of the lesion like a collaret.

Secondary rash

A few days after the appearance of the herald patch, more scaly patches (flat lesions) or plaques (thickened lesions) appear on the chest and back. A few plaques may also appear on the thighs, upper arms and neck but are uncommon on the face or scalp. These secondary lesions of pityriasis rosea tend to be smaller than the herald patch. They are also oval in shape with a dry surface. Like the herald patch, they may have an inner collaret of scaling. Some plaques may be annular (ring-shaped).

Pityriasis rosea plaques usually follow the relaxed skin tension or cleavage lines (Langers lines) on both sides of the upper trunk. The rash has been described as looking like a fir tree. It does not involve the face, scalp, palms or soles.

Pityriasis rosea may be very itchy, but in most cases it doesn't itch at all.iPtyriasis rosea is associated with reactivation of herpes viruses 6 and 7, which cause the primary rash roseola in infants.Pityriasis rosea clears up in about six to twelve weeks. Pale marks or brown discolouration may persist for a few months in darker skinned people but eventually the skin returns to its normal appearance.Pityriasis rosea during early pregnancy has been reported to cause miscarriage in 8 of 61 women studied. Premature delivery and other perinatal problems also occurred in some women.

General advice

• Bathe or shower with plain water and bath oil, aqueous cream, or other soap substitute.
• Apply moisturizing creams to dry skin.
• Expose skin to sunlight cautiously (without burning).
• acyclovire for some

Pyoderma gangrenosum

Pyoderma gangrenosum is an uncommon, ulcerative cutaneous condition of uncertain etiology. It is associated with systemic diseases in at least 50% of patients who are affected.The diagnosis is made by excluding other causes of similar-appearing cutaneous ulceration, including infection, malignancy, vasculitis, collagen vascular diseases, diabetes, and trauma. 

The prognosis of pyoderma gangrenosum is generally good; however, the disease may recur, and residual scarring is common. Pain is a common complaint of patients and may require narcotics.Other organs systems that may be involved include the heart, the central nervous system, the gastrointestinal (GI) tract, the eyes,^{[4, 5]} the liver, the spleen, the bones, and the lymph nodes.

Most patients with pyoderma gangrenosum improve with initial immunosuppressive therapy and require minimal care afterwards. However, many patients follow a refractory course, and multiple therapies may fail. These patients pose a difficult clinical problem that requires frequent follow-up and long-term care.

Tenia versicolor 

his title designates a superficial fungal infection (tinea) that changes color (versicolor). The causative organism was originally called Malassezia furfur and is now called Pityrosporum orbiculare. TV typically causes numerous patchy scally macules on the upper chest and back,  arms, and neck. Facial involvement may occur as shown. The lesions may behypopigmented  as illustrated here, or brown-orange, depending on th e skib color of the patient and the degree of recent sun exposure. The organism is believed to prevent either the formation of melanin or the transfer of melanosomes into keratinocytes. The formation of azelaic acid is another suggested mechanism for the resultant hypopigmentation. Although tinea versicolor usually makes its appearance after puberty, it can develop in child and is occasionally seen in breast-fed infants. Tinea versicolor is usually asymptomatic  but may itch slightly. The organism cannot be cultured, but diagnosis is aided by the orange or brown glow of lesional skin under a Wood's light and by the “spaghetti and meatballs” appearance of clustered hyphae and spores on KOH.

questioner

Neurology questions – questions only

EMQ

1. Essential tremor

2. Parkinsons disease

3. Parkinsons plus disorder

4. Thyrotoxicosis

5. task specific tremor

6. Tardive dyskinesia

Select the most likely diagnosis for the clinical pictures below, then give 2 management strategies for each

A) a 55 year old female presents with history of unintentional weight loss of around 5kg in the past 2 months. She has been feeling a bit agitated and on further questioning seems to not feel the cold despite everyone else around her at home having to wear multiple layers. On examination she has a rest tremor that is unchanged with movement. Heart rate is 98 beats per minute and she reports intermittent palpitations in the past month.

Dx: 

Management: 

B) A 34 year old female presents with tremor which she has noted in both hands. It seems to be much worse after drinking coffee or if she has to give a presentation at work. She states that her mother had a similar problem but it did not require any specific treatment. She also notes that it seemed to be a little better last Friday night after drinking a glass of wine after work with her friends. Examination showed normal tone, muscle bulk and a resting tremor 4-12 Hz which was unchanged with activity

Dx: 

Mx: 

C) A 36 year old female office clerk who is otherwise fit and well with no past medical history and no current medication use. She has been experiencing worsening tremor that is only present when she has to handwrite in her work.

Dx: 

Mx: 

D) A 66 year old gentleman presents with 2 year history of worsening right arm tremor. He seems to be a little bit more clumsy on this side. On examination, there is rest tremor, and he has lead pipe rigidity on tone examination.

Dx: 

Mx 

E) a 78 year old female presenting to the emergency department and is admitted for acute viral gastroenteritis with a plan for antiemetics and IV rehydration. She has a background history of depression with psychotic features.She becomes aggressive towards staff and other patients. The medications on her chart include metoclopramide and her dose of risperidone was increased for management of aggression. She is observed to have repetitive tongue and lip smacking movements in a somewhat rhythmic pattern.

Dx- 

Mx- 

Which of the following medications should be avoided in patients with parkinson’s disease? (More than 1 may be correct)

A) Metoclopramide

B) Domperidone

C) Haloperidol

D) Prochlorperazine

E) Ondansetron

Outline the management of progressive motor problems with advanced parkinsons disease ( 3 points)

Give 3 examples of non motor manifestations of Parkinsons disease and their management

Which of the following should prompt a review of the diagnosis of idiopathic parkinson’s disease?

A) early dementia 

B) early falls 

C) early severe autonomic dysfunction, other neurological signs such as upper motor neurone signs, abnormal eye movements, or cerebellar signs 

D)dopamine antagonist treatment (eg antipsychotic drugs, metoclopramide) at onset of symptoms 

E)history of repeated strokes with stepwise progression of parkinsonian features 

F) All of the above

EMQ:

1. Sinus pain

2. Dental abscess

3. Trigeminal neuralgia

4. Glossopharyngeal neuralgia

5. HSV stomatitis

6. HZV Facial pain

7. TMJ dysfunction

8. Angina

9. Acute glaucoma

10. Facial migraine

A) a 28 year old female presenting with paroxysms of unilateral facial pain, stabbing in nature. The pains never wake her from sleep. She sometimes notices that the attacks seem to be triggered by touching on the face, or brushing her teeth. 

B) Sudden brief attacks of pain at the back of the throat, base of tongue, beneath the angle of the jaw and the R external auditory meatus in a 38 year old man. 

C) 22 year old female with family history of migraine presents with acute unilateral facial pain, associated nausea and vomiting. She is phonophobic. She has had 3 episodes previously in the last few months which resolved  with rest in a quiet room after a few hours and some over the counter analgesia 

D) Severe unilateral facial pain in a 60 year old male with history of varicella infection aged 5. 2 days later he returns to your practice with a vesicular rash 

E) 32 year old female with history of anxiety presents to your practice with 3 day history of R ear pain. TM appears normal on examination. There have been no recent RTI symptoms. She has had increasing ear pain with chewing. 

F)  Pain in the L eye and forehead in a 58 year old gentleman. He has had some change in his vision in the last few hours. On examination he has a diffusely red L eye with corneal clouding, clear watery discharge and a mid-dilated, fixed pupil 

MCQ:

Which of the following statements is false?

A) There is an increased risk of stroke in patients who suffer migraines with aura approximately 2 times increased risk compared to non migraneurs

B) The overall incidence of stroke attributed to migraine is very low (<5:100000)

C) COCP must be used with extreme caution in patients who have a history of migraine with aura, and ideally should be ceased especially where other risk factors( smoking, poorly controlled hypertension) are present

D) Aspirin and clopidogrel have evidence to support their use in protecting against stroke in migraine

With regards to the treatment of migraine Which is TRUE?: (MORE THAN ONE MAY BE CORRECT)

A) more than 2 attacks in a month should be considered for prophylactic therapy

B) NSAIDS can be continued for management until the 2nd trimester until 32 weeks

C) Dihydroergotamine or triptan therapy may be safe to use throughout the pregnancy

D) Amitryptyline, propanolol, sodium valproate can be used for migraine prophylaxis in mothers who are breastfeeding 

E) Migraine in children can present with acute abdominal pain and vomiting

F) CBT is as effective as drug therapy in preventing migraine

With regards to the risk of stroke, which of the following is true:

A) the absolute risk of stroke in patients with non valvular atrial fibrillation is between 2-18 % per year

B) the relative risk of patients with migraine with aura for CVA is 2

C) the relative risk of patients with known cardiovascular disease,  diabetes or currently smoking is 2

D) the relative risk of hypertension is 4

E) All of the above

True or false?

1. Low dose aspirin is of more benefit in primary prevention for cerebrovascular disease than it is in prevention of acute coronary events. 

2. Routine use of aspirin is recommended for primary prevention of stroke in all patients

3. Suitability of patients for low dose aspirin is based on absolute risk of CV events and stroke, with patients at moderate risk of CV disease (1+ risk factors) suitable for LDA therapy

4. The ABCD2 score is used to predict CVA risk in AF and guide decisions re: anticoagulation

5. In patients with AF who are unable to take warfarin due to bleeding risk, clopidogrel should be used instead of aspirin, even when there is no contraindication to aspirin.

6. In an asymptomatic patient with a stenosis >70 % there is a equivalent or greater risk of acute coronary events than stroke events 

7. Aspirin should be routinely given in acute stroke at a dose of up to 300mg on the first day, after haemorrhage is excluded by CT Brain 

Mcq

Maggie is a 72 year old female admitted to emergency after she woke with with L sided weakness and numbness. Her blood pressure is 201/105. With regards to her management, which is true? (more than one correct)

A) She should be offered thrombolysis after CT scan

B) She should be given aspirin after CT scan

C) She should be given fluids containing glucose as the cause may be a correctable hypoglycaemia and may have reduced oral intake due to weakness with swallow

D) Her blood pressure should be acutely lowered to <140/80.

E) Her BP should be lowered but aiming for a target of 180/95

F) She should be commenced on combination of aspirin+ clopidogrel if she does not tolerate aspirin+dipyridamole(asasantin) for secondary prevention 

Which of the following conditions can mimic acute stroke?

G) Migraine

H) Subdural haematoma

I) Tumour

J) Post ictal paralysis

K) Hypoglycaemia

L) Cerebral abscess

M) All of the above