Еще одна пилюлька Hескучина

[yananshs]

An 18-year-old woman comes to the clinic because of a 4-month history of a "red rash" on her elbows, knees, and around her "belly button." She noticed the lesions during the winter, but was not particularly concerned because they were covered up by pants and long sleeves. Now it is summer and she is too embarrassed to wear shorts or a bathing suit. She has no significant past medical history, is up-to-date on her immunizations, and has not traveled recently. She takes no medications and has no known allergies. She tries to avoid all sun exposure because she tends to "burn, not tan." Physical examination shows erythematous plaques on her elbows, knees, and umbilicus. There is a silvery scale covering the majority of each lesion that bleed when you scrape it. The remainder of the examination is unremarkable. The most appropriate next step is to
A. advise her to avoid sun exposure, especially direct sunlight on the lesions
B. biopsy each lesion and send for histologic evaluation
C. inject each lesion with a medium-potency corticosteroid
D. prescribe a medium-potency corticosteroid ointment and topical calcipotriene
E. refer her to a dermatologist

[vosk]

E. refer her to a dermatologist

[yananshs]

Sorry. Wrong.

[exomen]

Похоже на псориаз

There is a silvery scale covering the majority of each lesion that bleed when you scrape it.

- тогда ответ D

to avoid sun exposure

- солнце бы ей помогло синтезировать вит D
Евгений

[Alexey D]

Yes, it's psoriasis. I choose C. Probably it will work faster and there'll be no need in wearing patches over the lesions.

[papadoctor]

Продолжу свой impressive loosing streak! Все-таки сказывается, что работаю выше талии. Да, очень похоже на псориаз, только я ставлю D. Ни разу не читал про уколы в каждую бляшку и фототерапия до сих пор применяется!

[Кондратьев Олег]

Не сочтите за труд разъяснить. Отчего бы дерматологу не полечить псориаз.

[yananshs]

The correct answer is D. This patient most likely has psoriasis, which is a relatively common skin condition that affects approximately 2% of the population. Psoriasis is characterized by erythematous, thickened plaques with a silvery scale. Scraping of the scale may lead to pinpoint bleeding, often called the Auspitz sign. The diagnosis is usually made by physical examination. The treatment for localized lesions typically begins with a topical corticosteroid and topical calcipotriene (a vitamin D analog that enhances normal keratinization and inhibits epidermal cell proliferation). A topical corticosteroid can also be used with a coal tar product, which possibly suppresses epidermal DNA synthesis, as a first-line therapy. These can be tapered if the lesions subside. If this in ineffective, corticosteroid and anthralin or tazarotene therapy combined with ultraviolet phototherapy should be considered. If this is still ineffective, the patient should be sent to a dermatologist.

It is inappropriate to advise her to avoid sun exposure, especially direct sunlight on the lesions (choice A) because sunlight is thought to be helpful in treating psoriasis. She should be encouraged to obtain natural sunlight exposure for a few minutes a day. But she needs to be advised that unaffected areas should be covered with a sunscreen.

While psoriasis can be diagnosed by a biopsy, it is inappropriate to biopsy each lesion and send for histologic evaluation (choice B). The diagnosis can usually be made based on clinical presentation, especially when the lesions are classic, as they are in this case.

It is inappropriate to inject each lesion with a medium-potency corticosteroid (choice C) at this time. This is usually reserved for psoriasis that is not controlled by topical therapy.

It is not necessary to refer her to a dermatologist (choice E) at this time. Any physician should be able to recognize and treat localized psoriasis. If the treatments are not effective in controlling her disease, you should refer her to a dermatologist.

[yananshs]

A 44-year-old Asian man comes to the office for a health maintenance examination. He does not take any medications routinely and has no diagnosed medical problems. He does not smoke or drink alcohol on regular basis. On several occasions, he has tried diet and exercise to shed some weight without success. He is an obese male with hyperhidrosis. There is hyperpigmentation with a velvety appearance on the nape and bilateral axillae. He has similar lesions in the groin area. Oral mucosa and palmoplantar surfaces are unremarkable. The abnormal laboratory test result that is most likely correlated with these findings is an elevated
A. chorionic embryo antigen
B. hemoglobin A1C
C. testosterone
D. total cholesterol
E. triglyceride

[Anna_Shvedova]

Как-то все привлекательно. Я всегда считала, что acantosis nigricans - маркер выраженной инсулинорезистентности, а там и холестерин с триглицеридами, и до СД недалеко, а у женщин и тестостерон повышенный..

Выбираю В, потому как ближе он сердцу эндокринолога.

[Alexey D]

B, чтобы исключить диабет.

[Light]

Да, acanthosis nigricans типа В вполне соответствует описанию пациента. Инсулинорезистентность с приступами гипогликемии, обусловленной инсулиноподобным действием аутоантител к рецептору инсулина.
Можно ожидать повышения гликированного гемоглобина, триглицеридов, холестерина.
Я бы, пожалуй, выбрала ответ Е:
при инсулинорезистентности избыток инсулина вызывает в печени липогенез и образование ЛПОНП, что приводит к гипертриглицеридемии.

[exomen]

definitely B

[Rodionov]

Мне казалось, что гликозилированный гемоглобин - критерий компенсации уже установленного диабета, а не способ его первичной диагностики. Я бы думал в направлении липидного обмена и соглашусь с Ольгой Юрьевной.

[Light]

Хочу добавить, что у нас спрашивают, отклонение какого лабораторного показателя в данном случае наиболее вероятно. Что касается гликозилированного гемоглобина, то он, как справедливо заметил Антон Владимирович, повышается при уже имеющемся нескомпенсированном сахарном диабете, а в клинической задаче приведен пример пациента с инсулинорезистентностью и гипогликемиями: в данном случае гликогемоглобин вполне ещё может быть нормальным. Равно как общий холестерин.
Для инсулинорезистентности более характерна дислипидемия IIВ, т.е. гипертриглицеридемия.