Blistering Diseases Practice Questions

Q: A patient presents with painful blisters along the chest wall. All of the following tests are useful for diagnosis except:

LDH levels. ***LDH levels*** - **Lactate dehydrogenase (LDH)** is a non-specific enzyme elevated in various conditions causing tissue damage or cellular turnover, but it is not a primary diagnostic tool for herpes zoster. - While systemic inflammation from a severe case of shingles might indirectly affect LDH, it is not used to confirm the diagnosis of this viral infection. *Direct fluorescent antibody* - **Direct fluorescent antibody (DFA)** testing from a blister scraping can rapidly detect varicella-zoster virus (VZV) antigens in cells. - This is a highly sensitive and specific method for confirming VZV infection, differentiating it from other blistering conditions. *Polymerase chain reaction* - **Polymerase chain reaction (PCR)** is a highly sensitive and specific method for detecting VZV DNA from vesicle fluid or crusts. - PCR can rapidly confirm the diagnosis of herpes zoster, especially in atypical presentations or immunocompromised patients. *Tzanck smear* - A **Tzanck smear** involves scraping the base of a blister and examining the cells microscopically for multinucleated giant cells and acantholytic cells. - While not specific for VZV (also seen in HSV infections), it indicates a herpes group viral infection and can be a rapid bedside diagnostic aid.

Q: An elderly patient presents with itchy tense blisters on normal looking skin as well as on urticarial plaques as shown below. The most probable diagnosis is: (AIIMS Nov 2015)

Bullous pemphigoid. ***Bullous pemphigoid*** - This condition typically presents in **elderly patients** with **itchy, tense blisters** on either normal or erythematous/urticarial skin, which aligns with the clinical description and image. - The blisters in bullous pemphigoid are characterized by **subepidermal blistering**, meaning the epidermis separates from the dermis, resulting in tense, fluid-filled lesions. *Pemphigus vulgaris* - Characterized by **flaccid blisters** that rupture easily, leading to erosions, unlike the tense blisters seen in the image. - Pemphigus vulgaris frequently involves **mucous membranes** and is caused by autoantibodies against desmoglein 1 and 3, leading to intraepidermal blistering (acantholysis). *Linear IgA disease* - This autoimmune blistering condition typically presents with **annular or rosette-shaped lesions** with small peripheral blisters, often referred to as a "string of pearls" appearance, which is not evident in the image. - On **direct immunofluorescence**, it shows a linear deposition of IgA at the dermoepidermal junction. *Dermatitis herpetiformis* - Often presents with **intensely pruritic papules and vesicles** typically found on extensor surfaces (elbows, knees, buttocks), and the lesions are often excoriated due to scratching. - Strongly associated with **celiac disease** and characterized by granular IgA deposits in the dermal papillae on direct immunofluorescence, distinguishing it from the tense blisters seen.

Q: The given picture depicts:

Tinea imbricata. ***Tinea imbricata*** - The image shows a distinctive pattern of **concentric, lamellar scales**, often described as "tiles" or "fish scales," which is a hallmark of **tinea imbricata**. - This presentation is caused by specific fungal species, primarily *Trichophyton concentricum*, and is common in certain tropical and subtropical regions. *Toxic epidermal necrolysis* - This condition is characterized by **widespread epidermal detachment** resembling severe burns, leading to large areas of denuded skin and mucosal involvement. - It does not typically present with the **concentric scaly pattern** seen in the image. *Atopic dermatitis* - Characterized by **eczematous lesions**, typically itchy, dry, inflamed skin, often with lichenification in chronic cases. - The appearance is distinct from the **patterned scaling** observed in the image, instead showing erythema, papules, vesicles, and crusting. *Psoriasis* - Psoriasis typically presents as **well-demarcated erythematous plaques** covered with **silvery scales**, often found on extensor surfaces like elbows and knees. - While it involves scaling, it does not exhibit the specific **concentric, imbricated (overlapping) scale pattern** characteristic of the image.

Q: The image shows presence of:

Muehrcke's nails. ***Muehrcke's nails*** - The image clearly displays characteristic **paired white lines** (leukonychia) separated by normal-appearing nail areas, which are hallmarks of Muehrcke's nails. - These lines are caused by **edema in the nail bed** rather than an abnormality of the nail plate itself, and they do not move with nail growth. *Lindsay nails* - Also known as **"half-and-half" nails**, Lindsay nails feature the **proximal half of the nail plate appearing white** and the **distal half appearing red or pink**, typically associated with chronic kidney disease. - This pattern of discoloration is distinct from the multiple transverse white bands seen in Muehrcke's nails. *Koilonychia* - Koilonychia, or **spoon nails**, describes nails that are **thinned and concave with raised edges**, resembling a spoon. - This condition is often associated with **iron deficiency anemia**, and the appearance in the image does not show this characteristic "spooning." *Beau's lines* - Beau's lines are **transverse depressions or grooves** across the nail plate that occur due to a temporary interruption of nail growth. - They are typically seen as a single, deep furrow that grows out with the nail, unlike the multiple, non-palpable white bands of Muehrcke's nails.

Q: All are true about the lesions shown except:

Potent topical steroids resolve most cases. ***Potent topical steroids resolve most cases*** - This statement is **false** and is the correct answer to this "EXCEPT" question. - Dyshidrotic eczema (pompholyx) is a **chronic, relapsing condition** that often requires long-term management. - While potent topical steroids are the **mainstay of initial treatment**, they typically provide symptomatic control rather than permanent resolution. - **Recurrences are common**, and many patients require ongoing maintenance therapy or additional treatments such as systemic steroids, immunosuppressants, or phototherapy for severe or refractory cases. *Itchy lesions on palms* - Dyshidrotic eczema is characterized by **intensely pruritic vesicles** that typically appear on the **palms, soles, and lateral aspects of the fingers**. - The image clearly shows vesicular lesions on the palms, consistent with this classic presentation. *Associated with atopic diathesis* - There is a **strong association** between dyshidrotic eczema and **atopic conditions** (atopic dermatitis, allergic rhinitis, asthma). - Approximately **50% of patients** with pompholyx have a personal or family history of atopy. - This atopic association is an important epidemiological feature of the condition. *Painful deep seated vesicles* - The vesicles in dyshidrotic eczema are characteristically **deep-seated** (often described as resembling "tapioca pudding"), especially in the early stages. - They can be both **intensely itchy and painful**, particularly when they are tense and before rupture. - The image demonstrates these characteristic deep vesicular lesions.

Q: A patient presents with the skin lesions shown in the image. While evaluating for possible blistering disorders, all of the following conditions could present with similar morphology EXCEPT:

Bullous pemphigoid. ***Bullous pemphigoid*** - Presents with **tense bullae** on an erythematous base, typically in elderly patients, unlike the **umbilicated papules** seen in this image. - Involves **subepidermal blistering** with **linear IgG deposition** at the basement membrane zone, not the viral inclusions of Molluscum contagiosum. *Pemphigus vegetans* - A rare variant of pemphigus vulgaris characterized by **vegetating plaques and pustules** in intertriginous areas, not discrete umbilicated lesions. - Shows **intraepidermal acantholysis** with **suprabasal clefting**, histologically distinct from the viral cytopathic changes in Molluscum contagiosum. *Pemphigus vulgaris* - Presents with **flaccid bullae** and painful **mucosal erosions** due to **autoantibodies against desmoglein 1 and 3**. - The **Nikolsky sign** is positive, and lesions are erosive rather than the solid, pearl-like papules characteristic of Molluscum contagiosum. *Pemphigus erythematosus* - Features **erythematous, scaly, crusted lesions** primarily on the **face and upper trunk** with a butterfly distribution. - Combines features of **lupus erythematosus** and pemphigus foliaceus, showing superficial blistering unlike the viral papules in this case.

Q: All are true about the lesion shown in the image except:

Henderson-Patterson bodies are intranuclear bodies. ***Henderson-Patterson bodies are intranuclear bodies*** - **Henderson-Patterson bodies** are characteristic **eosinophilic viral inclusion bodies** found in cells infected with **molluscum contagiosum virus**. - These inclusion bodies are typically found within the **cytoplasm** (intracytoplasmic), not the nucleus. *Giant extensive lesions in HIV positive patients* - Patients with **compromised immune systems**, such as those who are **HIV positive**, can develop unusually large and extensive lesions. - This is due to their inability to mount an effective immune response against the **molluscum contagiosum virus**. *Auto-innoculated lesions* - **Molluscum contagiosum** lesions can spread to other areas of the body through **self-scratching** or contact. - This process, known as **auto-inoculation**, leads to new lesions appearing where the virus made contact with previously unaffected skin. *Needle extirpation followed by trichloro-acetic acid application* - **Needle extirpation** (pricking the central core of the lesion) followed by the application of **trichloroacetic acid (TCA)** is a common treatment method for molluscum contagiosum. - This approach aims to destroy the infected cells and prevent further viral spread.

Q: The following image shows a flaccid bulla. This finding is characteristically seen in:

Pemphigus vulgaris. ***Pemphigus vulgaris*** - The image shows a **flaccid bulla** with purulent fluid, characteristic of **pemphigus vulgaris**. This condition is marked by autoantibodies against desmogleins 1 and 3, which are crucial for keratinocyte adhesion, leading to **intraepidermal blistering** and the **Nikolsky sign**. - The flaccid nature of the bulla, often leading to easy rupture and erosions, is a hallmark of superficial blistering in pemphigus vulgaris, caused by the **loss of cell-to-cell adhesion** within the epidermis. *Pemphigus vegetans* - This is a rare variant of pemphigus vulgaris characterized by **vegetating plaques** and **hyperkeratotic lesions**, particularly in intertriginous areas. - While it starts with bullae, the predominant feature is the development of fungating, vegetative lesions rather than the flaccid bulla seen here. *Pemphigus erythematosus* - Pemphigus erythematosus, also known as Senear-Usher syndrome, is considered a localized form of pemphigus foliaceus with features of **lupus erythematosus**. - It presents with **scaling, crusting, and erythematous lesions** resembling lupus, along with superficial bullae, typically on the face and scalp. *Bullous pemphigoid* - Bullous pemphigoid typically presents with **tense bullae** that are less prone to rupture, unlike the flaccid bulla shown in the image. - It is caused by autoantibodies against hemidesmosomal proteins (BP180 and BP230), resulting in **subepidermal blistering**, meaning the blister forms below the epidermis and is therefore more resilient.

Q: Pseudo Nikolsky sign is seen in all except:

Erythema Multiforme. ***Erythema Multiforme*** - Erythema multiforme is an acute, self-limiting inflammatory dermatosis, and it typically does not present with a **Pseudo Nikolsky sign** as its lesions are usually fixed or have minimal epidermal involvement. - The disease is characterized by target lesions, often in response to infections (e.g., herpes simplex virus) or drugs, with **subepidermal blistering** in some cases but usually without extensive epidermal detachment. *Toxic epidermal Necrolysis* - **Toxic epidermal Necrolysis (TEN)** is a severe mucocutaneous reaction characterized by widespread **epidermal detachment**, making the Nikolsky sign and Pseudo Nikolsky sign positive due to extensive skin fragility and epidermal loss. - This condition involves full-thickness epidermal necrosis, leading to blistering and sloughing of skin that resembles a **severe burn**. *Stevens Johnson Syndrome* - **Stevens-Johnson Syndrome (SJS)** is a less severe form of TEN, but it also features **epidermal detachment** and usually has a positive Nikolsky sign, and therefore also a Pseudo Nikolsky sign. - It involves smaller body surface area detachment compared to TEN but still demonstrates significant epidermal damage and skin fragility. *Staphylococcal scalded skin syndrome* - In **Staphylococcal scalded skin syndrome (SSSS)**, toxins produced by *Staphylococcus aureus* specifically target **desmoglein-1**, causing superficial epidermal splitting and a prominent positive Nikolsky sign (and Pseudo Nikolsky sign). - This condition results in widespread **flaccid blisters** and exfoliation, particularly in children, without full-thickness epidermal necrosis.

Q: All are true about the lesion shown in a patient with stunting, osmotic diarrhea and anemia except:

Mucosa is not involved. ***Mucosa is not involved*** - This statement is **FALSE** and is the correct answer to this EXCEPT question. - The clinical presentation with **stunting, osmotic diarrhea, and anemia** clearly indicates **significant intestinal mucosal involvement** and malabsorption. - **Dermatitis herpetiformis** is the cutaneous manifestation of **celiac disease**, which by definition involves an immune-mediated injury to the **small intestinal mucosa** triggered by gluten ingestion. - The gastrointestinal symptoms described are direct evidence of mucosal damage, making this statement incorrect. *IgA antibody against epidermal transglutaminase* - This is TRUE. **Dermatitis herpetiformis** involves **IgA antibodies against epidermal transglutaminase (eTG)**, which deposit in the dermal papillae. - Patients also have IgA antibodies against tissue transglutaminase (tTG) due to the underlying celiac disease. - These antibodies are key diagnostic markers for both conditions. *Intense pruritic lesions* - This is TRUE. **Dermatitis herpetiformis** is classically characterized by **severely pruritic vesicular lesions** with a burning or stinging sensation. - The intense itching often leads to excoriations from scratching before vesicles are even visible. - Lesions typically occur on extensor surfaces (elbows, knees, buttocks, scalp). *Genes encoding DR2 present in all patients* - This statement is also FALSE, but less obviously so. **HLA-DQ2** (90-95%) and **HLA-DQ8** (5-10%) are the primary genetic associations with celiac disease and dermatitis herpetiformis. - If "DR2" refers to HLA-DR2, this is incorrect - DR2 is associated with other autoimmune conditions like multiple sclerosis, not celiac disease. - Even if this were meant to say DQ2, it would still be false as not 100% of patients carry these genes.

Question 1

A patient presents with painful blisters along the chest wall. All of the following tests are useful for diagnosis except:

Accepted Answer

LDH levels

Answer

Direct fluorescent antibody

Answer

Polymerase chain reaction

Answer

Tzanck smear

Question 2

An elderly patient presents with itchy tense blisters on normal looking skin as well as on urticarial plaques as shown below. The most probable diagnosis is: (AIIMS Nov 2015)

Accepted Answer

Bullous pemphigoid

Answer

Pemphigus vulgaris

Answer

Linear IgA disease

Answer

Dermatitis herpetiformis

Question 3

The given picture depicts:

Accepted Answer

Tinea imbricata

Answer

Toxic epidermal necrolysis

Answer

Atopic dermatitis

Answer

Psoriasis

Question 4

The image shows presence of:

Accepted Answer

Muehrcke's nails

Answer

Lindsay nails

Answer

Koilonychia

Answer

Beau's lines

Question 5

All are true about the lesions shown except:

Accepted Answer

Potent topical steroids resolve most cases

Answer

Itchy lesions on palms

Answer

Associated with atopic diathesis

Answer

Painful deep seated vesicles

Question 6

A patient presents with the skin lesions shown in the image. While evaluating for possible blistering disorders, all of the following conditions could present with similar morphology EXCEPT:

Accepted Answer

Bullous pemphigoid

Answer

Pemphigus vulgaris

Answer

Pemphigus erythematosus

Answer

Pemphigus vegetans

Question 7

All are true about the lesion shown in the image except:

Accepted Answer

Henderson-Patterson bodies are intranuclear bodies

Answer

Giant extensive lesions in HIV positive patients

Answer

Auto-inoculated lesions

Answer

Needle extirpation followed by trichloro-acetic acid application

Question 8

The following image shows a flaccid bulla. This finding is characteristically seen in:

Accepted Answer

Pemphigus vulgaris

Answer

Pemphigus vegetans

Answer

Pemphigus erythematosus

Answer

Bullous pemphigoid

Question 9

Pseudo Nikolsky sign is seen in all except:

Accepted Answer

Erythema Multiforme

Answer

Toxic epidermal Necrolysis

Answer

Stevens Johnson Syndrome

Answer

Staphylococcal scalded skin syndrome

Question 10

All are true about the lesion shown in a patient with stunting, osmotic diarrhea and anemia except:

Accepted Answer

Mucosa is not involved

Answer

IgA antibody against epidermal transglutaminase

Answer

Intense pruritic lesions

Answer

Genes encoding DR2 present in all patients

Blistering Diseases — MCQs

Blistering Diseases — MCQs

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