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  #1  
Old 12-04-2011
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Skin Started as a sunburn and now more lesions

A 39-year-old woman comes to your office complaining of a skin rash that appeared while she was on vacation in the Caribbean. It started as a bad sunburn, but new lesions are now forming on her scalp, as well as her face, even though she has not been in the sun since her vacation. She has no other complaints. Her past medical history is unremarkable. The family history is significant for heart disease in her father and rheumatoid arthritis in her sister. She has two healthy children of school age. Review of systems is negative for respiratory, gastrointestinal, genitourinary, and musculoskeletal complaints. On physical examination, the patient is in no acute distress. Her vital signs are within normal limits. Inspection of the skin reveals five discrete lesions located on the scalp, lateral cheeks, and arms (shown in photograph). The oral and conjunctival mucosae are unremarkable.

Started as a sunburn and now more lesions-skin-picture.png
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Which of the following is most likely to be associated with this patient’s skin lesions?

A. IgG antibodies to desmoglein 3
B. Guaiac-positive stool
C. Positive rheumatoid factor
D. Positive Schirmer test
E. Scarring alopecia
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  #2  
Old 12-04-2011
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discoid lupus???????
E. Scarring alopecia

GOOD QUESTION!!!!
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Old 12-04-2011
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scarring alopecia...just ruling out others.
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Old 12-04-2011
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IgG antibodies to desmoglein 3
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Old 12-04-2011
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no idea, guessing E. Scarring alopecia
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Old 12-05-2011
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tough one...i will go with A or E
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Old 12-05-2011
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Its discoid lupus erythematosus
Risk factors include
1. female
2. sun exposure
3. involvement of face and scalp

One of the complications is hair loss leading to scarring aloepecia.

Cant be desmoglein as that is seen in pemphigus vulgaris.
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Old 12-05-2011
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The correct answer is E. This patient has discoid lupus erythematosus and she is most likely to develop scarring alopecia as a consequence of discrete lesions located in the scalp. Discoid lupus erythematous is a chronic, scarring, photosensitive autoimmune connective tissue disease. In approximately 5% of these patients, over time, symptoms and signs of systemic lupus erythematosus will develop. Therefore, the typical skin lesions may be seen in the context of systemic disease, as well. The male-to-female ratio is 1:2 and it most often develops in the third or fourth decade (mean age of onset: 38 years). Discoid lupus erythematosus is slightly more common in African American patients than in Caucasians or Asians. Typical skin lesions of discoid lupus erythematosus are well-demarcated, erythematous plaques that develop adherent scale and central atrophy. As the lesions age, patulous follicular openings with hyperkeratotic plugs are seen. Resolution of an active lesion results in atrophy and scar formation. Discoid lupus erythematosus most commonly affects sun-exposed areas. The scalp, face, concha of the ear, and arms are frequently affected. Oral mucosa may also be involved. Approximately 20% will have antinuclear antibodies, and 1 to 3% may have anti-Ro antibodies. Clinical diagnosis is confirmed with histopathologic and immunopathologic evaluation of lesional skin. Standard treatment involves topical or intralesional corticosteroids and systemic antimalarials.
IgG antibodies to desmoglein 3 (choice A) are present in pemphigus vulgaris, a blistering autoimmune skin disease often seen in middle-aged patients of Mediterranean descent.
Guaiac-positive stool (choice B) is not associated with discoid or systemic lupus erythematosus. The gastrointestinal system is usually not involved in the context of this disorder.
Positive rheumatoid factor (choice C) is infrequently detected in patients with discoid lupus erythematosus and should prompt a workup for rheumatoid disease.
In a Schirmer test (choice D), a bent piece of Whatman No. 41 filter paper is placed in the lower conjunctivae, and the amount of tearing on the filter paper is recorded. Normal wetting is greater than 15 mm after 5 minutes, whereas a definitive positive result is less than 5 mm after 5 minutes. This test can be useful to help exclude or confirm significant dryness of the eyes and is often helpful in the diagnosis of xerophthalmia associated with sicca syndrome (part of Sjögren syndrome). It is also positive in up to one-third of elderly patients and is not disease-specific. Discoid lupus erythematosus is not associated with xerophthalmia.
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  #9  
Old 12-05-2011
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Algorithm for Management
Started as a sunburn and now more lesions-01-dec.-05.png
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