Cutaneous Manifestations of Systemic Diseases — MCQs
A 70-year-old man comes to the emergency department because of a skin rash and severe itching. He appears ill; there is a generalized skin rash that is scaly, erythematous, and thickened. His palms, soles, and scalp are also involved. Which of the following is the most likely diagnosis?
"Keratotic sandal" is seen in which of the following?
Primary skin lesions are seen in all except:
A male patient with purple striae, thin skin, non-healing wound, and pedunculated abdomen, most probable cause?
Woman of 30-years with Raynaud's phenomenon, polyarthritis, dysphagia of 5-years and mild sclerodactyly, blood showing Anti-centromere antibody positive, the likely cause is
Not a cutaneous manifestation of TB:
Lady presents with joint pain in both knees and low-grade fever, which occurs intermittently. On examination, she has a rash on sun-exposed areas. What is the clinical diagnosis?
Which of the following is not classified as a primary cutaneous disorder?
Identify the skin condition depicted in the image.
Koebner's phenomenon is seen in all of the following except:
Cutaneous Manifestations of Systemic Diseases Indian Medical PG Practice Questions and MCQs
Question 1: A 70-year-old man comes to the emergency department because of a skin rash and severe itching. He appears ill; there is a generalized skin rash that is scaly, erythematous, and thickened. His palms, soles, and scalp are also involved. Which of the following is the most likely diagnosis?
- A. erythroderma (exfoliative dermatitis) (Correct Answer)
- B. pemphigus vulgaris
- C. dermatitis herpetiformis
- D. rosacea
Explanation: ***erythroderma (exfoliative dermatitis)*** - Erythroderma is characterized by a **generalized erythematous (red), scaly, and thickened skin rash** covering more than 90% of the body surface, accompanied by **severe itching**. - This condition is often associated with a **systemic illness**, and the patient's description of "appears ill" further supports this diagnosis. *pemphigus vulgaris* - Pemphigus vulgaris typically presents with **flaccid blisters** and erosions, particularly affecting mucous membranes, which are not described here. - While it can be widespread, the primary lesion is a **blister** rather than diffuse erythema and scaling. *dermatitis herpetiformis* - Dermatitis herpetiformis is characterized by intensely **pruritic (itchy) papules and vesicles** typically found on the extensor surfaces (e.g., elbows, knees, buttocks). - It is strongly associated with **celiac disease** and does not present as a generalized scaly, erythematous thickening. *rosacea* - Rosacea primarily affects the **face**, causing **erythema**, flushing, papules, and pustules, often sparing the palms, soles, and scalp. - It is not characterized by generalized scaling, thickening, or severe itching over the entire body.
Question 2: "Keratotic sandal" is seen in which of the following?
- A. Tinea versicolor
- B. Sezary syndrome
- C. Reiter's disease
- D. Pityriasis rubra pilaris (Correct Answer)
Explanation: ***Pityriasis rubra pilaris*** - "**Keratotic sandals**" refer to the characteristic **palmoplantar keratoderma** seen in pityriasis rubra pilaris, which gives the soles of the feet a thickened, yellowish appearance. - This condition also typically presents with **follicular papules**, **confluent erythematous plaques**, and often spared areas known as "islands of normal skin." *Tinea versicolor* - This is a **superficial fungal infection** characterized by **hypopigmented or hyperpigmented patches** with fine scaling, most commonly on the trunk and upper extremities. - It does not involve significant palmoplantar keratoderma or the formation of "keratotic sandals." *Sezary syndrome* - Sezary syndrome is an aggressive form of **cutaneous T-cell lymphoma** characterized by **erythroderma**, **lymphadenopathy**, and the presence of **Sezary cells** in the blood. - While skin involvement is extensive, the specific presentation of "keratotic sandals" is not a typical feature of Sezary syndrome. *Reiter's disease* - Reiter's disease, now known as **reactive arthritis**, is a seronegative spondyloarthropathy characterized by arthritis, urethritis, and conjunctivitis. - Skin manifestations can include **keratoderma blennorrhagicum**, which are papules and vesicles that become hyperkeratotic plaques, primarily on the palms and soles, but the term "keratotic sandals" is specifically associated with pityriasis rubra pilaris.
Question 3: Primary skin lesions are seen in all except:
- A. Lichen planus
- B. Psoriasis
- C. Bowen's disease (Correct Answer)
- D. Reiter's syndrome
Explanation: ***Bowen's disease*** - Bowen's disease is **squamous cell carcinoma in situ** presenting as erythematous, scaly patches or plaques - While morphologically it presents as patches/plaques (which are primary lesions by definition), it is considered the answer here because: - The lesion represents **neoplastic transformation** rather than a purely inflammatory primary skin change - In some dermatology teaching contexts, neoplastic lesions are distinguished from "true" primary inflammatory dermatoses - This distinction is **conceptual rather than morphological** *Lichen planus* - Presents with **polygonal, flat-topped, violaceous papules and plaques** - classic **primary skin lesions** - These are **inflammatory primary lesions** arising de novo on the skin - Wickham's striae may be visible on the surface *Psoriasis* - Characterized by **well-demarcated erythematous plaques** with silvery scales - definitive **primary skin lesions** - Plaques are the primary morphology, scales are secondary change - Arises from keratinocyte hyperproliferation and inflammatory changes *Reiter's syndrome* - Also known as **reactive arthritis** - Manifests with **circinate balanitis** (erosions with serpiginous borders) and **keratoderma blennorrhagicum** (hyperkeratotic papules/plaques) - These are **primary inflammatory skin lesions** occurring as part of the syndrome
Question 4: A male patient with purple striae, thin skin, non-healing wound, and pedunculated abdomen, most probable cause?
- A. Insulin resistance
- B. Hypercortisolism (Correct Answer)
- C. Hypothyroidism
- D. Genetic connective tissue disorder
Explanation: Hypercortisolism - **Purple striae** are characteristic due to the breakdown of collagen and elastic fibers from excessive **cortisol**. - **Thin skin**, **non-healing wounds**, and a **pedunculated abdomen** (central obesity) are all classic signs of chronic high cortisol levels, as seen in **Cushing's syndrome** [1]. *Insulin resistance* - While insulin resistance can lead to conditions like **acanthosis nigricans** and **obesity**, it typically does not cause purple striae or thin skin directly. - It's often associated with **type 2 diabetes**, polycystic ovary syndrome, but not the specific dermatological features presented. *Hypothyroidism* - Hypothyroidism symptoms include **dry skin**, **coarse hair**, **fatigue**, and **weight gain**, but not typically purple striae or thin skin. - It can cause **non-pitting edema** (myxedema), which is distinct from the described skin changes. *Genetic connective tissue disorder* - Genetic connective tissue disorders like **Ehlers-Danlos syndrome** can cause thin, fragile skin and poor wound healing. - However, they do not typically present with the characteristic **purple striae** or **pedunculated abdomen** that point specifically to hypercortisolism.
Question 5: Woman of 30-years with Raynaud's phenomenon, polyarthritis, dysphagia of 5-years and mild sclerodactyly, blood showing Anti-centromere antibody positive, the likely cause is
- A. Rheumatoid arthritis
- B. CREST (Correct Answer)
- C. Mixed connective tissue disorder
- D. SLE
Explanation: ***CREST*** - The constellation of **Raynaud's phenomenon**, **polyarthritis**, **dysphagia**, and **sclerodactyly** are classic features of CREST syndrome, a limited form of systemic sclerosis [1]. - The presence of **anti-centromere antibodies** is highly specific for CREST syndrome. *Rheumatoid arthritis* - While it causes **polyarthritis**, it typically doesn't present with **Raynaud's phenomenon**, **dysphagia**, or **sclerodactyly**. - **Rheumatoid factor** and **anti-CCP antibodies** are characteristic, not anti-centromere antibodies. *Mixed connective tissue disorder* - Features overlap with systemic lupus erythematosus, systemic sclerosis, and polymyositis, but the presence of **anti-U1-RNP antibodies** is diagnostic. - The specific combination of symptoms and the **anti-centromere antibody** point more strongly to CREST syndrome. *SLE* - Can cause **polyarthritis** and **Raynaud's phenomenon** [2], but **scleroderma-like skin changes** like sclerodactyly are less common. - Diagnostically, **anti-dsDNA** and **anti-Sm antibodies** are more specific for SLE, not anti-centromere antibodies.
Question 6: Not a cutaneous manifestation of TB:
- A. Erythema nodosum
- B. Lupus pernio (Correct Answer)
- C. Scrofuloderma
- D. Lupus vulgaris
Explanation: ***Lupus pernio*** - **Lupus pernio** is characteristic of **sarcoidosis**, not tuberculosis. It typically presents as violaceous, indurated plaques on the face, especially the nose, cheeks, and ears. - Its presence usually indicates chronic and systemic sarcoidosis, differentiating it from tubercular skin manifestations. *Erythema nodosum* - **Erythema nodosum** can be a cutaneous manifestation of tuberculosis, often indicating an underlying immune response to the infection. - It presents as tender, red nodules, typically on the shins, reflecting a delayed hypersensitivity reaction. *Scrofuloderma* - **Scrofuloderma** is a direct cutaneous manifestation of tuberculosis, resulting from the extension of an underlying tuberculous infection (e.g., lymph nodes, bones) to the skin. - It involves painless, purplish nodules or plaques that ulcerate and discharge pus. *Lupus vulgaris* - **Lupus vulgaris** is a chronic and progressive form of cutaneous tuberculosis, characterized by reddish-brown plaques with an "apple-jelly" appearance on diascopy. - This manifestation occurs due to hematogenous or lymphatic spread of **Mycobacterium tuberculosis** to the skin in individuals with moderate immunity.
Question 7: Lady presents with joint pain in both knees and low-grade fever, which occurs intermittently. On examination, she has a rash on sun-exposed areas. What is the clinical diagnosis?
- A. Systemic lupus erythematosus (SLE) (Correct Answer)
- B. Rheumatoid arthritis (RA)
- C. Photodermatitis
- D. Porphyria cutanea tarda
Explanation: ***Systemic lupus erythematosus (SLE)*** - The combination of **polyarthralgia (joint pain)**, **low-grade fever**, and a **photosensitive rash** is highly characteristic of SLE. [1] - SLE is a **multisystem autoimmune disease** that can affect joints, skin, and cause constitutional symptoms like fever. [1] *Rheumatoid arthritis (RA)* - While RA causes **joint pain**, it typically presents with **symmetrical polyarthritis** primarily affecting small joints, and a photosensitive rash is not a common feature. [2] - **Fever** can be present in severe RA, but the triad of symptoms in this case points away from RA as the primary diagnosis. *Photodermatitis* - **Photodermatitis** is a skin inflammation caused by sunlight exposure, resulting in a rash. - This diagnosis does not account for the **joint pain** or **low-grade fever**, which are systemic manifestations. *Porphyria cutanea tarda* - This condition primarily affects the skin, causing **photosensitivity**, blistering lesions, and increased fragility, especially on sun-exposed areas. - It does **not typically present with joint pain or fever**, differentiating it from the presented symptoms.
Question 8: Which of the following is not classified as a primary cutaneous disorder?
- A. Lichen planus
- B. Ichthyosis
- C. Reiter's disease (Correct Answer)
- D. Psoriasis
Explanation: ***Reiter's disease*** - **Reiter's disease**, now known as **Reactive Arthritis**, is characterized by a triad of arthritis, urethritis, and conjunctivitis, often triggered by a preceding infection. - While it can involve mucocutaneous lesions (e.g., **circinate balanitis**, **keratoderma blennorrhagicum**), these are secondary manifestations of a systemic inflammatory process rather than a primary disorder originating in the skin itself. *Lichen planus* - **Lichen planus** is a chronic inflammatory disorder that primarily affects the skin, hair, nails, and mucous membranes. - It presents with characteristic **"6 P's"** (pruritic, purple, polygonal, planar papules and plaques), making it a primary cutaneous condition. *Ichthyosis* - **Ichthyosis** refers to a group of genetic skin disorders characterized by abnormally dry, thickened, and scaly skin due to defects in skin barrier function and keratinization. - These are directly classified as primary disorders of the skin's structure and function. *Psoriasis* - **Psoriasis** is a chronic autoimmune disease that primarily affects the skin, leading to rapid skin cell turnover. - It manifests as well-demarcated, erythematous plaques with silvery scales, making it a classic example of a primary cutaneous disorder.
Question 9: Identify the skin condition depicted in the image.
- A. Ichthyosis (Correct Answer)
- B. Syndromic ichthyosis
- C. Cutaneous sarcoidosis
- D. Leprosy
Explanation: ***Ichthyosis*** - The image clearly displays widespread **dry, scaling, and thickened skin**, consistent with the characteristic presentation of ichthyosis. - This condition is characterized by a defect in **skin barrier function** leading to excessive dryness and accumulation of scales. *Syndromic ichthyosis* - While syndromic ichthyosis also involves skin scaling, it is associated with **additional systemic symptoms** or **organ involvement**, which cannot be determined from this image alone. - The term "ichthyosis" broadly covers this appearance, and without more clinical information, specifying it as syndromic is not the most direct identification. *Leprosy* - Leprosy typically presents with **hypopigmented, anesthetic skin patches** or **nodules**, which are not seen in the image. - The texture and color changes in the image are not characteristic of the primarily neurological and dermatological manifestations of leprosy. *Cutaneous sarcoidosis* - Cutaneous sarcoidosis manifests as **reddish-brown papules, plaques, or nodules**, often on the face, neck, or extremities. - The widespread, fine scaling and dryness seen in the image do not align with the typical granulomatous lesions of sarcoidosis.
Question 10: Koebner's phenomenon is seen in all of the following except:
- A. Darier's disease
- B. Molluscum contagiosum
- C. Scleromyxedema
- D. Erythema multiforme (Correct Answer)
Explanation: ***Erythema multiforme*** - **Erythema multiforme** is an acute hypersensitivity reaction that does **NOT** typically demonstrate the Koebner phenomenon. - Unlike chronic papulosquamous disorders, EM lesions arise from immunologic triggers (infections, drugs) rather than trauma-induced spread. - The characteristic **target lesions** develop in response to antigenic stimuli, not mechanical trauma. *Darier's disease* - **Darier's disease** (keratosis follicularis) is an autosomal dominant disorder that exhibits the Koebner phenomenon. - New keratotic papules develop at sites of trauma, scratching, or friction. - This trauma-induced lesion development is a **key clinical feature** of the disease. *Molluscum contagiosum* - **Molluscum contagiosum** demonstrates the Koebner phenomenon through **autoinoculation**. - Scratching can cause viral spread, resulting in **linear arrangements of lesions** along scratch marks. - This is a classic example of trauma-induced spread in viral skin infections. *Scleromyxedema* - **Scleromyxedema** (generalized lichen myxedematosus) can exhibit the Koebner phenomenon. - New papules may develop at sites of trauma in some cases. - While less commonly emphasized than in psoriasis or lichen planus, Koebnerization has been reported in this condition.
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