Cutaneous Manifestations of Systemic Disease — MCQs

10 questions

A female patient of 26 years, presents with oral ulcers, photosensitivity and skin malar rash in face sparing the nasolabial folds of both side.

Which skin manifestation is characteristically seen in dermatomyositis?

A patient presents with hypotension, hyponatremia, and blackening of the palmar creases. Which of the following conditions is most likely associated with these symptoms?

Which of the following conditions is associated with acanthosis nigricans?

Which type of blood vessel is most commonly affected in hypersensitivity vasculitis?

All of the following are paraneoplastic syndromes for renal cell carcinoma except which of the following?

In a child having diarrhoea with perianal moist crust, which condition is most likely diagnosed?

A farmer complains of a skin rash that worsens with sun exposure and redness of the tongue. Maize is the staple in his diet. Which vitamin deficiency is likely responsible for these symptoms?

Which of the following is not classified as a primary cutaneous disorder?

Q10

Primary skin lesions are seen in all except:

Cutaneous Manifestations of Systemic Disease Indian Medical PG Practice Questions and MCQs

Question 1: A female patient of 26 years, presents with oral ulcers, photosensitivity and skin malar rash in face sparing the nasolabial folds of both side.

A. Sturge weber syndrome
B. Dermatitis
C. Psoriasis
D. SLE (Correct Answer)

Explanation: ***SLE*** - The combination of **oral ulcers**, **photosensitivity**, and a **malar rash** that spares the nasolabial folds is highly characteristic of **Systemic Lupus Erythematosus (SLE)** [1]. - SLE is an autoimmune disease with diverse clinical manifestations involving multiple organ systems. *Sturge weber syndrome* - This is a neurocutaneous disorder characterized by a **port-wine stain** (nevus flammeus) typically on the face, neurological abnormalities like seizures, and ocular involvement. - It does not present with oral ulcers or photosensitivity as primary features. *Dermatitis* - **Dermatitis** is a general term for skin inflammation, often presenting with redness, itching, and sometimes blisters. - It does not typically involve the specific constellation of oral ulcers, photosensitivity, and a malar rash that spares nasolabial folds. *Psoriasis* - **Psoriasis** is a chronic autoimmune disease primarily affecting the skin, characterized by red, scaly patches (plaques) [2]. - While it can cause nail changes and sometimes joint pain, it does not present with photosensitivity, oral ulcers, or the characteristic malar rash described.

Question 2: Which skin manifestation is characteristically seen in dermatomyositis?

A. Butterfly rash
B. Shawl sign
C. Heliotrope rash
D. Gottron papules (Correct Answer)

Explanation: ***Gottron papules*** - **Gottron papules** are raised, erythematous, or violaceous plaques over the **extensor surfaces of the metacarpophalangeal (MCP)** and **interphalangeal (IP)** joints. - They are considered **pathognomonic** (diagnostic) for dermatomyositis and are the most universally accepted characteristic cutaneous marker of the condition. *Heliotrope rash* - The **heliotrope rash** is a characteristic violaceous (purple-red) discoloration on the upper eyelids, often associated with **periorbital edema**. - While highly characteristic of **dermatomyositis**, Gottron papules are more universally accepted as the most pathognomonic feature. *Butterfly rash* - The **butterfly rash** (malar rash) is a classic manifestation of **systemic lupus erythematosus (SLE)**, characterized by redness over the cheeks and nasal bridge, sparing the nasolabial folds. - It is not typically seen in dermatomyositis and suggests a different underlying autoimmune condition. *Shawl sign* - The **shawl sign** refers to a diffuse, flat, erythematous rash over the **shoulders, upper back, and posterior neck**, often exacerbated by sun exposure. - Although seen in dermatomyositis, it is less specific than Gottron papules, which are directly diagnostic of the condition.

Question 3: A patient presents with hypotension, hyponatremia, and blackening of the palmar creases. Which of the following conditions is most likely associated with these symptoms?

A. Conn syndrome
B. Cushing's syndrome
C. Primary ACTH deficiency
D. Addison disease (Correct Answer)
E. Sheehan syndrome

Explanation: ***Addison disease*** - **Hypotension**, **hyponatremia**, and **hyperpigmentation** (blackening of palmar creases) are classic symptoms of **primary adrenal insufficiency** or Addison disease, due to deficient cortisol and aldosterone. - The lack of **cortisol** leads to hypotension and fatigue, while the absence of **aldosterone** causes hyponatremia and hyperkalemia. *Conn syndrome* - This condition involves **primary hyperaldosteronism**, typically leading to **hypertension** and **hypokalemia**, which contradicts the patient's symptoms of hypotension and hyponatremia. - Pigmentation changes are not a feature of Conn syndrome. *Cushing's syndrome* - Characterized by **excess cortisol**, leading to symptoms like **hypertension**, **hyperglycemia**, and central obesity, not hypotension or hyperpigmentation. - **Hyponatremia** is also not typical in Cushing's syndrome. *Primary ACTH deficiency* - Also known as **secondary adrenal insufficiency**, this condition results in low cortisol but typically spares aldosterone production, meaning **hyponatremia** and **hyperkalemia** are less common. - **Hyperpigmentation** does not occur in primary ACTH deficiency because ACTH levels are low. *Sheehan syndrome* - This is **postpartum pituitary necrosis** causing panhypopituitarism, which can lead to secondary adrenal insufficiency with hypotension and hyponatremia. - However, **hyperpigmentation does not occur** in Sheehan syndrome because ACTH levels are low (secondary insufficiency), not elevated as in Addison disease. - The clinical context would typically include a history of postpartum hemorrhage and failure to lactate.

Question 4: Which of the following conditions is associated with acanthosis nigricans?

A. Obesity
B. Gastric adenocarcinoma
C. Type 2 Diabetes Mellitus (Correct Answer)
D. All of the options

Explanation: Acanthosis nigricans is characterized by velvety, hyperpigmented skin lesions, often in intertriginous areas, and is a common cutaneous marker for insulin resistance, which is central to Type 2 Diabetes Mellitus [1]. The elevated insulin levels stimulate epidermal keratinocytes and dermal fibroblast proliferation, leading to the characteristic skin changes. While malignant acanthosis nigricans is associated with internal malignancies, particularly adenocarcinomas of the gastrointestinal tract (like gastric), it is a less common cause than insulin resistance. This form is usually more extensive and rapidly progressing than the benign variant. Obesity is strongly associated with insulin resistance, making it an indirect cause of acanthosis nigricans. However, acanthosis nigricans is a direct indicator of insulin resistance, which can occur with or without significant obesity. While all listed conditions can be associated with acanthosis nigricans, Type 2 Diabetes Mellitus is the most direct and common condition explicitly linked to the underlying pathophysiology of insulin resistance [1]. Gastric adenocarcinoma causes a malignant form, and obesity is a risk factor for insulin resistance, but T2DM directly reflects the metabolic state responsible for the skin changes.

Question 5: Which type of blood vessel is most commonly affected in hypersensitivity vasculitis?

A. Postcapillary venules (Correct Answer)
B. Arterioles
C. Veins
D. Capillaries

Explanation: ***Postcapillary venules*** - Hypersensitivity vasculitis primarily affects **postcapillary venules**, leading to immune complex deposition and subsequent inflammation [1]. - This type of vasculitis results in **nonspecific inflammation**, commonly seen in conditions like **drug reactions** and **infections**. - The immune complex vasculitis typically involves **small vessels such as the vascular plexus of the skin**, which features neutrophilic infiltration [2]. *Veins* - While veins can be involved in various vascular diseases, they are not specifically characteristic of **hypersensitivity vasculitis**. - This type of vasculitis is more centered around **smaller vessels**, particularly venules, rather than the larger venous systems. *Capillaries* - Capillaries are involved in many vascular conditions, but hypersensitivity vasculitis particularly correlates with **venular structures**. - The immune response seen in hypersensitivity vasculitis is more pronounced in **postcapillary venules**, leading to specific symptoms. *Aerioles* - "Aerioles" may refer to arterioles, which are primarily associated with **hypertensive and ischemic events** rather than vasculitis. - Hypersensitivity vasculitis is primarily due to **post-capillary venule** inflammation rather than changes in arterioles. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 514-515. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Cardiovascular Disease, pp. 278-279.

Question 6: All of the following are paraneoplastic syndromes for renal cell carcinoma except which of the following?

A. Fever
B. Amyloidosis
C. Anaemia
D. Acanthosis Nigricans (Correct Answer)

Explanation: Acanthosis Nigricans - Acanthosis nigricans is primarily associated with **insulin resistance** and is not a known paraneoplastic syndrome related to renal cell carcinoma. - Paraneoplastic syndromes typically involve **systemic effects** of tumors rather than dermatological manifestations like acanthosis nigricans. *Fever* - Fever can occur as a result of the body's response to tumors, including renal cell carcinoma, and is classified as a **paraneoplastic syndrome**. - It reflects the **systemic inflammatory response** often seen with malignancies. *Anaemia* - Anaemia is a common paraneoplastic syndrome associated with renal cell carcinoma due to the production of **erythropoietin** or as a result of **chronic disease** [1]. - It can lead to **fatigue** and pallor in affected individuals, making it relevant to renal cancers [1]. *Amyloidosis* - Amyloidosis can occur as a paraneoplastic syndrome in various malignancies, including renal cell carcinoma, due to **protein misfolding** states. - It can lead to complications affecting **kidney function** and other organs, aligning it with renal cell carcinoma, though kidney tumors also frequently present with hypercalcemia [1].

Question 7: In a child having diarrhoea with perianal moist crust, which condition is most likely diagnosed?

A. Acrodermatitis enteropathica (Correct Answer)
B. Pellagra
C. Riboflavin deficiency
D. Kwashiorkor

Explanation: ***Acrodermatitis enteropathica*** - This condition is a **zinc deficiency** syndrome, which can be either inherited or acquired. - It presents with a classic triad of **diarrhoea**, **dermatitis** (often periorificial and acral with moist, crusted lesions), and **alopecia**. - The **perianal moist crust** is a characteristic finding of the periorificial dermatitis seen in this condition. *Pellagra* - Pellagra is caused by **niacin (Vitamin B3) deficiency** and is characterized by the "4 D's": **dermatitis** (often sun-exposed areas), **diarrhoea**, **dementia**, and eventually death. - The dermatitis of pellagra is typically **symmetrical, hyperpigmented, and photosensitive**, not moist perianal crusts, differentiating it from the presented case. *Riboflavin deficiency* - **Riboflavin deficiency** typically manifests as **cheilosis**, angular stomatitis, glossitis, and seborrheic dermatitis, but not specifically perianal moist crusts with diarrhoea. - While it can affect mucous membranes, the specific perianal presentation with diarrhoea points away from this diagnosis. *Kwashiorkor* - **Kwashiorkor** is a form of protein-energy malnutrition that can present with **diarrhoea** and skin changes (flaky paint dermatosis, hypopigmentation). - However, the skin changes are typically **desquamating** and affect dependent areas, not the characteristic **moist, crusted periorificial lesions** seen in zinc deficiency. - Kwashiorkor also typically presents with **edema**, which is not mentioned in this case.

Question 8: A farmer complains of a skin rash that worsens with sun exposure and redness of the tongue. Maize is the staple in his diet. Which vitamin deficiency is likely responsible for these symptoms?

A. Vitamin C deficiency
B. Vitamin K deficiency
C. Niacin deficiency (Correct Answer)
D. Folic acid deficiency
E. Riboflavin deficiency

Explanation: ***Niacin deficiency*** - The symptoms described (dermatitis that worsens with sun exposure, glossitis, and a diet high in maize) are characteristic of **pellagra**, which is caused by a **niacin (Vitamin B3) deficiency**. - **Maize** is a poor source of niacin, and the niacin it contains is largely bound and unavailable, leading to higher rates of deficiency in populations relying on it as a staple. - The classic **3 D's of pellagra** are: **Dermatitis** (photosensitive), **Diarrhea**, and **Dementia**. *Riboflavin deficiency* - **Riboflavin (Vitamin B2) deficiency** causes **angular stomatitis**, **cheilosis**, and **glossitis**, but the dermatitis is typically **seborrheic** (not photosensitive). - The **photosensitive** nature of the rash in this case is the key differentiating feature pointing to niacin deficiency. *Vitamin C deficiency* - **Vitamin C deficiency** leads to **scurvy**, characterized by **gingival bleeding**, **poor wound healing**, and **petechiae**, none of which are mentioned here. - While it can manifest with fatigue, it does not typically cause a photosensitive rash or glossitis as described. *Vitamin K deficiency* - **Vitamin K deficiency** primarily affects **blood clotting**, leading to **bleeding disorders** and **easy bruising**. - It is not associated with skin rashes or glossitis. *Folic acid deficiency* - **Folic acid deficiency** causes **macrocytic anemia**, fatigue, and potentially **glossitis**, but it does not cause a photosensitive rash. - The distinctive combination of photosensitive dermatitis and glossitis points away from folic acid deficiency.

Question 9: 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 10: 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

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