image challenge on various common or interesting topics

3. Welcome All

4. IMAGE
QUIZE
Dr M Nurul Huq. BMC. Bangladesh

5. 3y M has HGF x2d,
difficult swallowing,
dribbling, irritability with
this sign. What is the
most probable Dx?
1. Strep throat
2. Diphtheria
3. ITP
4. Herpangina
5. Herpetic stomatitis

6. 4. Herpangina
• It is typically c/by Coxsackie A
• Contagious
• F subsides with appearance of ulcers (2-4mm)
• Normally clears up within 7d
• Supportive Rx

7. Inf. with which organisms is the most likely cause?
1. Coxsackie A16 2. Echovirus 16 3. G AS
4. HSV type 1 5. Norwalk virus

8. 1. Coxsackie virus type A16
The rash represents the characteristic palmar lesions
of uncomplicated hand, foot, and mouth disease due
to coxsackie A16 and enterovirus 71

9. 4y M with HGF x2d, sore mouth, poor app., irritability,
inability to chew, and drooling had this gum. Next day he had
these ulcers. What is most probable Dx?
1. ANUG
2. Herpangina
3. Scurvy
4. Herpes stomatitis
5. Canker sores (aphthae)

10. 4. Herpetic stomatitis
Herpetic stomatitis is c/by HSV T1or oral herpes. Young
children commonly are affected. It can easily be spread
from one child to another. Recovery completely within 10d
without medical Rx. Aciclovir may speed up your child's
recovery

11. 13y F has halitosis, gum pain, bleed, mild F. What is the most
probable Dx?
1. ANUG
2. Herpes stomatitis
3. Scurvy
4. Ariboflavinosis
5. ITP

12. Acute necrotizing ulcerative gingivitis
(ANUG):
aka Vincent's angina. Many other names
Certain germs (including fusiform bacteria and spirochetes)
have been implicated, but the full story is still not clear
Metronidazole is DoC

13. What is the Dx?

14. Aphthous stomatitis (aka recurrent aphthous stomatitis,
recurring oral aphthae or recurrent aphthous ulceration or aphthae)
is common (20%)
• Repeated benign and non-contagious mouth ulcers in otherwise
healthy people. Called canker sores in N America
• Cause is not known: T cell-mediated immune response triggered by
many factors. Different people have different factors: nutritional
deficiency, trauma, stress, hormonal factors, allergy, genetic, etc.
• Periodical. Heal completely. For majority, it lasts 7–10d, attacks 3–6/y.
Most appear on the non-keratinizing epith. surfaces (anywhere
except the attached gum, the hard palate and the dorsum of tongue).
SS: a minor nuisance with eating and drinking. The severe forms may
be debilitating, even causing wt loss
• Childhood or adolescence. Usually for several years before
disappearing. No cure. Rx: manage pain, reduce healing time and
reduce the frequency of episodes of ulceration

15. What is the Dx?

16. Geographic tongue is irregular changing patches like
map on the tongue
• Cause unknown; may be a lack of vit B or irritation from
hot or spicy foods, or alcohol. Less common in smokers
• Change in pattern is due to loss of papillae: flat. Change
can occur v quickly. The flat areas may stay for >1mo
• Soreness and burning pain (in some cases)
• No test. No Rx. Antihistamine gel or steroid mouth rinses
may help ease discomfort. It is harmless. It may be
uncomfortable and last for a long time

17. 14mo M, immunized, had HGF ~104o x4d , a GTC fit for ~4min
and gen. MPR next day on fall of F. What is the most likely
Dx?
1. Roseola infantum
2. Measles 3. Rubella 4. Scarlet fever 5. Infectious mononucleosis

18. 1. Roseola infantum
Roseola (aka 6th d, exanthem subitum, roseola infantum)
commonly affects 6mo-2y children
C/ by HHV 6-7
Usually several days of HGF, f/by a distinctive MPR just
as the F breaks. Febrile seizure in 10-15%

19. 5y boy had F103oF, sore throat, rash on 2nd dy. Tongue is raw
bald by 4d. What is the most probable DX?
1. Scarlet fever
2. Measles
3. Rubella
4. Mucocutaneous LN syn
5. Glandular fever

20. 1.Scarlet fever
Features: Sore throat, HGF, generalized erythema, Pastia’s
sign, circumoral pallor, peeling off of skin later on

21. 5y M with F x5d, pink eyes, rash, unilateral neck swelling,
sore lips, swollen hands. What is the most probable Dx?
1. Kawasaki disease
2. Scarlet F
3. Measles
4. Septicemia
5. Viral hemorrhagic fever

23. 1. Kawasaki disease
FEBRILE is used to remember
the criteria
• Fever
• Enanthem
• Bulbar conjunctivitis (nonpurulent)
• Rash (polymorphic)
• Internal organ involvement (not part of the criteria)
• LAP
• Extremity changes

24. Q
:
What is the diagnosis?
1. Erythema chronicum migrans
2. Granuloma annulare
3. Pityriasis rosea. 4. Sarcoidosis. 5. Tinea circinata

25. 5. Tinea circinata
Skin-scraping with KOH of the violaceous plaque consisting of
4 concentric rings with intervening areas of normal skin and
numerous yellow-white pustules showed multiple hyphae. Dx
of tinea circinata, an uncommon morphologic variant of t.
corporis that is c/by the dermatophyte Trichophyton
tonsurans, was made

26. What is the most likely Dx in a
woman who presents with F,
cough, rhinorrhea, and this
finding?

27. Measles
Serologic testing revealed elevated antirubeola IgM

29. What is the most likely
Dx?
1. Periorbital cellulitis
2. Lyme disease
3. Dermatomyositis
4. Periocular atopic
dermatitis
5. Polymorphous light
eruption

30. Lyme disease
Erythema migrans is a common feature of early,
disseminated LD. The classic rash may be varied in its
presentation, as seen here

31. • 8y M: 10d periorbital rash, preceding knee p, F, HA
• 3w ago, he was bitten by 2 ticks
• He has erythema migrans periorbitally, front of R knee, R
axilla, buttocks
• B burgdorferi IgG 0.58 (<0.20), B. burgdorferi sensu lato
IgG anti-VlsE 75.5 kU/L (<16.0), B. burgdorferi IgM 5.85
(<0.20). Immunoblot testing for B. garinii IgG and IgM
antibodies was positive
• EM is common in early, disseminated LD. However, it may
be varied in its presentation, as seen here
• He got amoxicillin 3w with full recovery

32. Disseminated Lyme Disease

33. What is the most probable
Dx?

34. Cong. Duodenal Obstruction (Double-Bubble
Sign)
• A girl 1080g born at 29w did not tolerate NGT feeding 8h
after birth. Her condition deteriorated, with nonbilious V and a
lack of stools since birth. She had mild upper abdo. Distention
• AXR: double-bubble sign, a distended stomach (arrow) and
D1 (arrowhead) a pathognomonic of cong. DO
• There was no air distally. Laparoscopy: duodenal atresia ,
which was repaired. Oral feedings were initiated successfully
on 7POD. Recovery was uneventful

35. What is the Dx:
1. Spina ventosa
2. Sarcoidosis
3. SCD
4. Osteomyelitis
5. Enchondroma

36. Spina ventosa. 17y M: 2-mo pain and swelling on
dorsal L hand. No F. Visited Pakistan 6mo ago; no trauma
• PE: a hard and suppurative nodule was noted on L 3rd
metacarpal. No systemic symptoms, no LAP
• Lab.: HIV -ve. XR: a slightly thinned cortex with lytic core
with trabecular pieces (arrow); no periosteal reaction. CXR:
normal
ZN staining: AFB (M tb. in CS and a pan-sensitive isolate)
• Rx: ATT 6mo
• TB dactylitis (spina ventosa) is more common in children

37. D 1 D 3 3 mo
What is the Dx?

38. Infective endocarditis
• 34y M with dim vision in the RE. Exertional dyspnea 4 mo;
started 1w after a dental Rx.
• Previous extensive inv. are inconclusive
• He was afebrile, had a pansystolic m and a solitary splinter
hge on R thumb
• Echo.. : m-s MR, with thickening and vegetations
• x4 blood CS: S viridans. IV AB. SS improved, and VA ok 8mo
later. His R fundus is shown, at admn (A), 3d later (B), and
3mo later (C). White-centered hge (Roth spots) is Dx of IE
• A comparison of A and B (3d apart) shows how quickly such
spots can change. Monitoring his MR is ongoing

40. Linear IgA Dermatosis (LAD)
is an autoimmune D in which there is a linear deposition of
IgA at the BM. It affects both children and adults. It may be
drug-related. In non-drug-related category the cause is
unknown. May occur following typhoid, brucella, TB,
varicella, HZ, gynaecological inf, URTI. In children, it has
been known historically as chr. bullous dermatosis
• LAD is characterized by the linear deposition of IgA at BM
zone (BMZ). One function of the BMZ is to maintain the
contiguity of the dermal-epidermal junction; antibody
deposition causes complement fixation and neutrophil
chemotaxis (rapid migration of neutrophils to sites of
inflammation), eventually resulting in blister formation

41. • Antibody deposition leads to complement activation and
neutrophil chemotaxis, which eventuates in loss of
adhesion at the dermal-epidermal junction and in blister
formation. At the molecular level, a variety of antigens have
been identified, some of which are also seen in patients
with bullous pemphigoid. LAD may thus be an umbrella
term for a wide range of conditions, each involving a
different antigen; however, further research is needed. [1]
The immune pathology appears to be identical in adults
and children.
• Epidemiology[1]
• This is a rare condition.The incidence in adults in southern
England has been estimated to be 1 case in 250,000
population per year. There are no figures for the incidence

42. This pt would be predicted to have a
higher risk for which one?
1. Cirrhosis
2. Coronary artery disease
3. Gout
4. Hemorrhagic stroke
5. Hypothyroidism
Q
:

43. 2. Coronary artery disease
A diagonal crease in the earlobe that runs backward from the
tragus at a 450 across the lobule to the rear edge of auricle
may be a predictor of CAD
It is thought to indicate premature aging and loss of dermal
and vascular elastic fibers, has limited sensitivity, and appears
to most useful in persons <60y

44. What is the probable Dx?

45. Cutaneous Leishmaniasis
82y M: swollen L ear, difficulty hearing
• Topical glucocorticoids x4mo: no response
• PE: ear enlarged, indurated, red, no LAP. No visceromegaly
• Biopsy: chr. inflam. infiltration in dermis, confluent epithelioid
granulomas, lymphocytic background. Abundant amastigotes
in dermal macrophages (B)
• L infantum in culture and PCR
• Rx with amphotericin B, with complete resolution after 2mo (C)
and recovery of hearing loss

46. What is the most likely Dx
in a FT neonate with
electrolyte imbalance and
this exam finding?
1. CAH
2. Hypospadias with
cryptorchidism
3. Preterm ovarian
hyperstimulation syn
4. Turner
5. Mixed gonadal
dysgenesis

47. Cong. adrenal hyperplasia
Evaluation of this neonate with ambiguous genitalia revealed
bilateral adrenal hypertrophy, a markedly raised 17-OH
progesterone, 46 XX. Salt-losing CAH due to 21-hydroxylase
deficiency

49. • A FT infant with ambiguous genitalia (A); no FH; noted to
have HR 179, no hypotension
• Lab.: K 7.4mmol/L, Na 125mmol/L, 17-OH progesterone
196μg/L ( 0.5-2.4μg/L), testosterone >15ng/ml (0.1-
0.8ng/ml)
• USG: bilat. adrenal hypertrophy, no visible testes. 46 XX
• Salt-losing CAH (21-OHase deficiency)
• Hypertrophy of clitoris and l. majora and presence of a
urogenital sinus, may resemble hypospadias with
cryptorchidism in males
• Rx of dyselectrolytemias, glucocorticoid, mineralocorticoid.
At 2 y, she underwent surgical reconstruction

50. A 3mo F with swelling of ext. genitalia; born at 27w, stayed
75d in NICU; well at discharge. Her clitoris and vulva were
swollen (A); otherwise ok. What is the most probable Dx?
1. CAH
2. Preterm Ovarian Hyperstimulation
3. Testicular feminizing syn
4. Hermaphroditism
5. Bilat. Inguinal hernia

51. • Lab: raised S. estradiol 310pmol/L (20-40); FSH 17.2 mIU/
ml (0.5-2.4); LH 4.7mIU/ml (.01-.21)
• USG: 2 cysts on the R ovary

52. 2. Preterm Ovarian Hyperstimulation
• Prematurity, vulvar swelling, elevated estradiol and
FSHs, ovarian cysts
• Self-limiting and resolves spontaneously
• Serial FSH and estradiol levels were done during FU
4w after, the estradiol peaked at 700 pmol/L and then
declined, with both normalized. 6w later, swelling had
reduced (B), complete resolution by 14w (C)
Repeat US: ovarian cysts had disappeared. At 12mo: ok

53. What is the most likely
c/of this in a man from
Mexico; biopsy showing
gram-negative bacilli?
1. K rhinoscleromatis
2. M leprae
3. Acinetobacter
baumannii
4. T pallidum
5. M tuberculosis

54. Klebsiella rhinoscleromatis
Rhinoscleroma is a chr. bacterial inf. typically c/by G-ve K.
rhinoscleromatis. Responds to tetracycline/ciprofloxacin.

55. What is the Dx in this
asymptomatic M from N
Africa?
1. Cutaneous leishmaniasis
2. Myiasis
3. Paronychia
4. Syphilis
5. YawsQ
:

57. 1. Cutaneous leishmaniasis
The verrucous lesion at the base of the thumb does
not have the appearance of chr. paronychia; a skin
smear revealed amastigote forms of the leishmania
parasite

58. What is the Dx?

59. • 18y M has a 3-mo coughing, hemoptysis, wt loss, F; a small
swelling on ant. chest 1w
• CT: a collar-button abs (sc abs. connected to a deeper abs.
by a passage): an abs. in a LN in L mediastinum (A, red
arrow) connected to sc abs (A, blue arrow); an extensive
parenchymal abnormality in the LUL. A sputum: AFB, and a
CS: pansusceptible M tb. HIV negative. He received 8 w
standard ATD, but the infx. progressed, with increased
swelling, erythema, and fluctuation (B and C). The abs was
drained. Drug Rx of a tb. abs is seldom sufficient, an open
drainage/excision is often needed. He has been without
s/of relapse since surgery but required cosmetic surgery
TB Abscess

61. Sialolith

62. What is the most likely Dx in this 65y F
with a 7d sore throat and dysphagia?
1. Epiglottitis
2. Foreign body aspiration
3. Peritonsillar abscess
4. Retropharyngeal abscess
5. Thyroid nodule

63. 1. Epiglottitis
The lateral soft-tissue XR: the “thumb sign” that
indicates a swollen inflamed epiglottis
Dx was confirmed on subsequent imaging and
laryngoscopy
She recovered with dexa- and ceftriaxone

64. Epiglottitis
She had muffled voice, hemodynamically stable PaO2 98% in
ambient air
• PE: mild tenderness and swelling in the anterior neck, no
CxLAP or drooling. Lateral soft-tissue radiography of the
neck showed the “thumb sign” (Panel A, arrow): epiglottis
• CT: substantial swelling and edema of the epiglottis (Panel
B, arrow), the base of the tongue, and the lingual tonsil
• Indirect laryngoscopy: red inflamed epiglottis and the base
of the tongue, with clinically significant hypertrophy of the
lingual tonsil and phlegm in the throat
• Ceftriaxone and dexamethasone were initiated
• She was monitored closely 48h. Blood cultures negative
• SS improved, and within 3d, she was able to consume an

66. What is the most likely Dx?
1. Candidiasis
2. Geographic tongue
3. H zoster
4. Lichen planus
5. Pemphigus

67. 3. Herpes zoster
Vesicles along V3 trigeminal dermatome, including the
L tongue and mandible, are most consistent with h
zoster
He got 2w oral valacyclovir

68. What is the most likely
c/of this long-standing
skin finding?
1. Acromegaly
2. McCune-Albright syn
3. Neurofibromatosis
4. Shingles
5. Speckled lentiginous
naevi

69. 3. Neurofibromatosis
Biopsy was consistent with a neurofibroma
Dx of segmental neurofibromatosis, a variant of NF
characterized by neurofibromas or café au lait
macules (or both) that are confined to 1 segment. No
specific Rx

70. What is most probable Dx in
this shepherd?
1. H. whitlow
2. Anthrax
3. MRSA
4. Contagious ecthyma
5. Impetigo

71. • 34y M farmer: a painful pustular rash on hands (A B);
worsening over 18d. He manages livestock. It began a few
days after a sheep bit his L hand while being bolus-fed. He
is expert in sheep care and says multiple sheep had “sore
mouth.” He did not wear gloves
• PE: otherwise ok
• Swabs PCR: confirmed contagious ecthyma c/by orf virus.
This is typically self-limiting
• Rx: wound care and ABT for ?bacterial superinf: recovered
fully/3w. He was advised to use gloves when he handles
animals or contaminated equipment

72. Ecthyma
a skin inf. similar to impetigo; often called deep impetigo
Causes: most often c/by Strep. Sometimes, Staph
• may start in injured skin (scratch or insect bite). Often
develops on legs
Symptoms: Main is a small blister with a red border that may
be filled with pus similar to impetigo, but much deeper
• After the blister goes away, a crusty ulcer appears
Exams and Tests: diagnosed simply by inspection. Rarely the
fluid is sent for exam, or a biopsy is needed
Rx: usually ABT oral or topical. Serious inf: IV antibiotics
• Placing a warm, wet cloth over the area can help remove
ulcer crusts. Your doctor may recommend antiseptic soap

73. “Sore Mouth” (contagious ecthyma, orf)
• aka “scabby mouth,” or CE is a viral inf. c/by a the poxvirus
primarily of sheep and goats
• common throughout the world
Sore mouth in goat kid.

74. What is the Dx?
1. Ac lymphangitis
2. Cellulitis
3. Deep VT
4. Myositis
5. Superficial
thrombophlebitis
Q
:

75. 1. Acute lymphangitis
The erythematous and irregular linear streak extending from
the hand to the axilla is most consistent with ac.
Lymphangitis
CS: S pyogenes; he recovered with IV penicillin G

76. • 23y M: rapidly progressive L arm pain and erythema
• He had felt well until the previous night, when his L 3rd
finger was injured during a lacrosse game. Overnight, the
finger became increasingly painful, with erythema
spreading to wrist. Temp: 36.7°C, HR 64/min, BP
139/85mmHg
• PE: a small blister or abscess on 3rd L finger with local heat,
tenderness, erythema, linear streaking to the elbow. Within
hours, the streaking progressed to the axilla
• Swab was cultured. He quickly underwent incision and
drainage of the lesion, and empirical cefazolin and
vancomycin. CS: S pyogenes, and AB changed to IV
penicillin G; discharged with oral penicillin V

77. What is the Dx in this
case with AP?
1. GI stromal tumor
2. Obstipation
3. Pancreatic phlegmon
4. Subphrenic abscess
5. Trichobezoar

78. 5. Trichobezoar
The heterogeneous, meshlike mass extending from the
stomach into the duodenum is most consistent with a bezoar.
The patient, who had trichotillomania, recovered after
laparotomy and removal of the bezoar

79. What is the most likely Dx in
this pt. from Mauritania whose
foot had developed these over
several years?
1. Actinomycetoma
2. Kaposi’s sarcoma
3. Leishmaniasis
4. Malignant melanoma
5. Yaws

80. 1. Actinomycetoma
Mycetoma, commonly aka Madura foot, is a chr., localized,
slowly progressive, granulomatous infx. of deep dermis and
s.c. tissue c/either by fungi (eumycetoma or implantation
mycosis) or by aerobic actinomycetes (actinomycetoma)
Actinobacteria was confirmed on punch biopsy
He responded to amikacin and cotrimoxazole

81. A 64-year-old man from Mauritania was referred for evaluation of a multinodular tumor of
the left foot. Foot lesions had been present for 38 years, starting on the left heel and
gradually spreading to involve the whole foot and ankle, with walking impairment. At the
time that the patient was first seen, he was in a wheelchair. The patient sought medical
care because of fatigue related to anemia of chronic disease (hemoglobin level, 9 g per
deciliter). He did not report problems with his foot, being accustomed to this condition.
Examination revealed soft-tissue swelling; multiple painless, sometimes ulcerated,
weeping tumefactions; and ipsilateral popliteal and inguinal lymphadenopathy (Panel A
and Panel B show the dorsal and plantar surfaces of the foot). Magnetic resonance
imaging revealed osteomyelitis of the tarsal bones. The suspected diagnosis was a
mycetoma, although Kaposi's sarcoma and epithelioma cuniculatum (verrucous

82. What is the most likely Dx with eosinophilia and a diffuse erythematous
rash while on hydroxychloroquine for Sjogren?
1. Bullous impetigo 2. Exanthematous pustulosis
3. Exfoliative dermatitis 4. Stevens-Johnson syn
5. Sweet’s syn

83. 2. Exanthematous pustulosis
Yellow hyperplastic papules on the tongue of a
hydroxychloroquine-treated pt. with a diffuse erythematous
rash is most consistent with hydroxychloroquine-induced ac.
generalized exanthematous pustulosis. The lesions resolved
following withdrawal and Rx with prednisolone

84. 2y M: 1y refractory
eczema and a 4w Cx LAP
Growth <5th centile,
bilateral proptosis,
serous discharge from
ears, and extensive rash
on scalp, chest, upper
back, palpable defects
in the skull. No HSM or
diabetes insipidus

85. Langerhans'-Cell Histiocytosis

86. Lab.: anemia of chr d., (Hb 6.6g/dl), normal TLC, platelet, LFT
• Skeletal survey: multiple lytic lesions in skull
• LN biopsy: consistent with Langerhans'-cell histiocytosis
• He was Rx with prednisone, vinblastine, mercaptopurine
and had a complete recovery
• At 24mo FU: well
• It is a rare histiocytic d, mostly in toddlers
Suspect it in a young child with refractory eczema and chr ear
discharge

87. What is the Dx in this pt with axillary LAP?
1. Bacterial felon
2. Erysipelas
3. Herpetic whitlow
4. Paronychia
5. Scabies

88. 3. Herpetic whitlow
Direct fluorescence antibody testing of vesicular fluid
confirmed HSV type 2
The pt responded to Rx with oral acyclovir