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CME examination for volume 29
JOURNAL of the
AI11eRlCaN Acaoemy OF
DerMaTOLOGY In the June and December issues each year, CME questions based on articles in the preceding volume of the JOURNAL appear. Two hours of Category I CME credit can be earned by reading the text material, reporting the answerson the perforated answer sheet, and following instructions for Category I CME credit.-Editor
CME examination for volume 29* Identification No. 894-306
Instructionsfor CategoryI CME credit and answers to this examination appear in the front advertisingsection.See last page of Contents for page number.
Directions for questions 1-33: Give single best response. 1. Prolidase deficiency is characterized by all of the following except a. skin ulcers b. eczematous eruptions c. mental retardation d. x-linked inheritance, with clinical disease only in male patients e. susceptibility to infections 2. Which of the following therapies has not been reported to be effective in the treatment of solar urticaria?
a. Hj-antagonists b. Antimalarials c. Light hardening d. Melatonin e. PUVA 3. Features that suggest a role for neuropeptides in the pathophysiology of psoriasis include all of the following except a. pruritus b. symmetry c. exacerbation by topical capsaicin d. exacerbation by stress e. remission after surgical denervation 4. The most diagnostic feature of paraneoplastic pemphigus is a. autoantibodies that bind to a subset of epidermal proteins denoted desmoplakin I (250 kd) and II (210 kd) b. the classic appearance of a bullous eruption only in patients with malignancy who are undergoing radiotherapy *Includes entire volume with the exception of CME article.
c. the absence of oral involvement in otherwise typical clinical appearance of pemphigus d. a bullous eruption localized to the site of an underlying abdominal malignancy e. the rapid response of clinical lesions to dapsone therapy 5. Which of the following skin lesions has been described in association with histiocytosis X (Langerhans cell histiocytosis)? a. Bronze pigmentation b. Purpura c. Lipid infiltration of the eyelids d. Granuloma annulate-like plaques e. All of the above 6. Chronic bullous disease of childhood can be distinguished from bullous pemphigoid in children by a. a subepidermal bulla detected by routine histologic examination b. deposition of predominantly IgA in a linear pattern c. deposition of predominantly IgG in a granular pattern d. a characteristic annular pattern of blisters, which has not been described in bullous pemphigoid e. good response to dapsone therapy 7. Which of the following statements regarding {3-carotene is correct? a. It is an essential precursor to vitamin D. b. The U.S. Department of Agriculture and the National Cancer Institute recommend a diet including 5 to 6 mg/day. c. It does not inhibit chemically induced or UV light-induced skin cancers in mice. d. It cannot function as a free radical scavenger. e. It cannot function as an antioxidant.
8. Which of the following organisms can cause tinea capitis in an adult?
a. Microsporum audouini b. Trichophyton mentagrophytes c. Epidermophyton fioccosum d. Trichophyton tonsurans e. Pityrosporum orbiculare 9. Acquired ichthyosis may be a sign of a. internal malignancy
Continued on page 28A 26A
June 1994
Journal of the American Academy of Dermatology June 1994
28A CME examination for volume 29 b. HN-1 infection c. concomitant HIV-1 and HTLV-II infection more frequently than HIV-1 infection alone d. leprosy e. all of the above 1O. Each of the following foods has a high nickel content
except a. shellfish b. chocolate milk c. spinach d. raspberries e. alcoholic beverages 11. HIV-1 infection predisposes patients to a. aggressive B-celllymphoma with extranodal presentation b. indolent Hodgkin's disease c. cutaneous T-cell lymphoma d. undifferentiated lymphomas with a benign course e. no increase in the incidence of lymphoma 12. Which of the following organisms causes erythema
infectiosum? a. Coxsackievirus b. Cytomegalovirus c. Human paravirus Bl9 d. Epstein-Barr virus e. Human herpesvirus type 6 13. When compared with acquired ichthyosis seen in most other patients, acquired ichthyosis in patients with AIDS is a. the same clinically b. more likely associated with pterygium formation c. associated with scales that are larger, more rhomboidal, more coarse, and more generalized in distribution, almost resembling lamellar ichthyosis d. more likely associated with Mees' lines e. less likely associated with pterygium formation 14. Each of the following statements regarding delusions of parasitosis is true except a. the typical patient is a middle-aged or elderly woman who appears frustrated or exhausted. b. evaluation of an affected patient requires a search for a true infestation or organic cause. c. the "matchbox sign" is pathognomonic for the disease. d. an appropriate laboratory evaluation or the affected patient should include skin scrapings, skin biopsies for histologic examination and direct immunofluorescence, chest x-ray, and electrocardiography e. the therapeutic drug of choice is pimozide. 15. Which of the following may be associated with balanitis xerotica obliterans? a. Bulla formation
b. c. d. e.
Urethral meatal stenosis Squamous cell carcinoma Stricture of the foreskin All of the above
16. Diseases that have been reported to occur in association with lymphomatoid papulosis include each of the following except a. Hodgkin's disease b. cutaneous T-cell lymphoma c. follicular small-cleaved lymphoma d. notalgia paresthetica e. diffuse large-cell lymphoma 17. Clonal rearrangements ofimmunoglobulins or T-cell receptor genes may be found in a. pseudolymphoma b. angiolymphoid hyperplasia with eosinophilia c. cutaneous lymphoma, localized to the skin d. cutaneous lymphoma, with systemic disease e. all of the above 18. Each of the following statements regarding atypical mole syndrome CAMS) or dysplastic nevus syndrome is true except a. the AMS phenotype is characterized by many nevi, clinically atypical nevi, and nevi in unusual sites. b. the AMS phenotype is a potent risk factor for melanoma. c. melanoma patients with AMS phenotype are likely to be at increased risk of additional primary tumors. d. the presence of the AMS phenotype in a patient with melanoma merits screening for the first-degree relatives, even in the absence of a family history of melanoma. e. data suggest that only a small percentage of patients with melanoma have the AMS phenotype. 19. Proximal white subungual onychomycosis is an unusual pattern of superficial infection. Its presence suggests a. insufficient treatment b. clinical relapse of previously treated onychomycosis c. underlying HIV infection d. dermatophytosis because it is the most common pattern e. candidal infection 20. Ecthyma gangrenosum is a cutaneous sign of a. hypersensitivity to aspartame b. fiberglas dermatitis c. Osler-Weber-Rendu syndrome d. frostbite e. Pseudomonas septicemia
Continued on page 31A
Journal of the American Academyof Dermatology Volume 30, Number 6
21. Organic illnesses associated with delusional parasitosis include a. cocaine abuse b. dementia c. systemic corticosteroid use d . diabetes mellitus e. all of the above 22. Each of the following statements characterizes lichenoid drug eruptions (LDEs) except a . LDEs wax and wane despite continuation of the offending drug. b. follicular involvement may result in severe alopecia. c. oral mucosal lesions occur more frequentl y in LDEs than in idiopathic lichen planus. d. skin lesions commonly show a pattern of photodistribution. e. common inducers of LDEs include penicillamine, antimalarials, a nd ,B-adrenergic blocking agents. 23. Possible causes for oral ulcerations in HIV infected patients include a. herpes simplex b. eosinophilic ulcer c. histoplasmosis d. no cause identified e. all of the above 24. Histoplasmosis is a serious opportunistic infection that occurs in the setting of immunosuppression. Each of the following statements is true except a. cutaneous histoplasmosis occurs in 11 % of AIDS patients with disseminated infection. b. cutaneous histoplasmosis occurs in 25% to 50% of AIDS patients with disseminated infection. c. cutaneous histoplasmosis lesions are diverse in nature. d. histoplasmosis capsulatum is best demonstrated by silver stain of a biopsy specimen . e. histoplasmosis may resemble psoriasis or seborrheic dermatitis in patients with HIV infection. 25. " N onbullous pemphigoid" can persist without vesicles or bullae for as long as a. I week b. 1 month c. 1 year d. 2 years e. 3 years 26 . Which statement is true with regard to methotrexate and reproduction in men? a. Contraception should be used for at least 3 months or longer than one spermatogenic cycle after discontinuation of the drug. b. In contrast to the teratogenic effect in women, there is no concern for a mutagenic effect of
CME examination for volume 29 31A methotrexate on spermatogenesis, and no precautions are necessary. c. Methotrexate interferes with early events in spermatogenesis, accounting for the rapid decrease in sperm count 2 to 3 weeks after initiation of the drug. d. The alteration of testicular stem cell chromosomes by methotrexate results in a high risk of fetal damage. e. Amn iocentesis and other methods of prenatal diagnosis are effectively used to detect new dominant mutations related to methotrexate exposure in the father. 27 . Each of the following statements regarding Ka wasaki syndrome in an adult is true except a. it has not been reported in the context of HIV infection. b. anti cardiolipin antibodies can be present. c. a perineal erup tion can be present. d. strawberry tongue can be present. e. it may be associated with multiple immunologic abnormalities. 28. The venoarteriolar reflex of the leg a. is activated when changing from the supine to the standing position b. can be blocked by local anesthesia or local heating c. causes constriction of the precapillary arterioles d. is mediated by an axon reflex e. all of the above
29. The main clue to the diagnosis of graft-versus-host disease after liver transplantation is a. fever b. diarrhea c. pancytopenia d. liver dysfunction e. skin rash 30. Microcystic adnexal carcinoma of the skin a . frequently metastasizes b. has characteristic histologic features that allow easy diagnosis c. rarely recurs, even if incompletely excised d. can be distinguished from benign adnexal neoplasms by a variety of stains, including type IV collagen, p53 and proliferating cell nuclear antigens e. commonly shows cysts with compact keratin or shadow cells, consistent with follicular differentiation 31. Lymphomas that occur after renal allograft transplantation a. are more commonly T cell than B cell in origin b. tend to be more benign if they consist of a clonal population of lymphocytes
Continued on page 32A
32A
CME examination for volume 29
c. tend to be more benign in their course if T cell in origin d. may he triggered by Epstein-Barr virus infection e. often involve the lungs as well as the skin 32. In Merkel cell carcinoma of the skin all of the following immunocytochemical studies are usually positive except a. neuron-specific enolase b. cytokeratin c. S~ 100 protein
Journal of the American Academy of Dermatology June 1994
d. epithelial membrane antigen e. neurofiiament 33. In a recent prospective study of 724 HIV-l-positive patients, all of the following malignant neoplasms were observed except a. basal cell carcinoma b. squamous cell carcinoma c. Kaposi's sarcoma d. malignant melanoma e. angiosarcoma
AI11eRlCaN Acaoemy OF
DerMaTOLOGY In the June and December issues each year, CME questions based on articles in the preceding volume of the JOURNAL appear. Two hours of Category I CME credit can be earned by reading the text material, reporting the answerson the perforated answer sheet, and following instructions for Category I CME credit.-Editor
CME examination for volume 29* Identification No. 894-306
Instructionsfor CategoryI CME credit and answers to this examination appear in the front advertisingsection.See last page of Contents for page number.
Directions for questions 1-33: Give single best response. 1. Prolidase deficiency is characterized by all of the following except a. skin ulcers b. eczematous eruptions c. mental retardation d. x-linked inheritance, with clinical disease only in male patients e. susceptibility to infections 2. Which of the following therapies has not been reported to be effective in the treatment of solar urticaria?
a. Hj-antagonists b. Antimalarials c. Light hardening d. Melatonin e. PUVA 3. Features that suggest a role for neuropeptides in the pathophysiology of psoriasis include all of the following except a. pruritus b. symmetry c. exacerbation by topical capsaicin d. exacerbation by stress e. remission after surgical denervation 4. The most diagnostic feature of paraneoplastic pemphigus is a. autoantibodies that bind to a subset of epidermal proteins denoted desmoplakin I (250 kd) and II (210 kd) b. the classic appearance of a bullous eruption only in patients with malignancy who are undergoing radiotherapy *Includes entire volume with the exception of CME article.
c. the absence of oral involvement in otherwise typical clinical appearance of pemphigus d. a bullous eruption localized to the site of an underlying abdominal malignancy e. the rapid response of clinical lesions to dapsone therapy 5. Which of the following skin lesions has been described in association with histiocytosis X (Langerhans cell histiocytosis)? a. Bronze pigmentation b. Purpura c. Lipid infiltration of the eyelids d. Granuloma annulate-like plaques e. All of the above 6. Chronic bullous disease of childhood can be distinguished from bullous pemphigoid in children by a. a subepidermal bulla detected by routine histologic examination b. deposition of predominantly IgA in a linear pattern c. deposition of predominantly IgG in a granular pattern d. a characteristic annular pattern of blisters, which has not been described in bullous pemphigoid e. good response to dapsone therapy 7. Which of the following statements regarding {3-carotene is correct? a. It is an essential precursor to vitamin D. b. The U.S. Department of Agriculture and the National Cancer Institute recommend a diet including 5 to 6 mg/day. c. It does not inhibit chemically induced or UV light-induced skin cancers in mice. d. It cannot function as a free radical scavenger. e. It cannot function as an antioxidant.
8. Which of the following organisms can cause tinea capitis in an adult?
a. Microsporum audouini b. Trichophyton mentagrophytes c. Epidermophyton fioccosum d. Trichophyton tonsurans e. Pityrosporum orbiculare 9. Acquired ichthyosis may be a sign of a. internal malignancy
Continued on page 28A 26A
June 1994
Journal of the American Academy of Dermatology June 1994
28A CME examination for volume 29 b. HN-1 infection c. concomitant HIV-1 and HTLV-II infection more frequently than HIV-1 infection alone d. leprosy e. all of the above 1O. Each of the following foods has a high nickel content
except a. shellfish b. chocolate milk c. spinach d. raspberries e. alcoholic beverages 11. HIV-1 infection predisposes patients to a. aggressive B-celllymphoma with extranodal presentation b. indolent Hodgkin's disease c. cutaneous T-cell lymphoma d. undifferentiated lymphomas with a benign course e. no increase in the incidence of lymphoma 12. Which of the following organisms causes erythema
infectiosum? a. Coxsackievirus b. Cytomegalovirus c. Human paravirus Bl9 d. Epstein-Barr virus e. Human herpesvirus type 6 13. When compared with acquired ichthyosis seen in most other patients, acquired ichthyosis in patients with AIDS is a. the same clinically b. more likely associated with pterygium formation c. associated with scales that are larger, more rhomboidal, more coarse, and more generalized in distribution, almost resembling lamellar ichthyosis d. more likely associated with Mees' lines e. less likely associated with pterygium formation 14. Each of the following statements regarding delusions of parasitosis is true except a. the typical patient is a middle-aged or elderly woman who appears frustrated or exhausted. b. evaluation of an affected patient requires a search for a true infestation or organic cause. c. the "matchbox sign" is pathognomonic for the disease. d. an appropriate laboratory evaluation or the affected patient should include skin scrapings, skin biopsies for histologic examination and direct immunofluorescence, chest x-ray, and electrocardiography e. the therapeutic drug of choice is pimozide. 15. Which of the following may be associated with balanitis xerotica obliterans? a. Bulla formation
b. c. d. e.
Urethral meatal stenosis Squamous cell carcinoma Stricture of the foreskin All of the above
16. Diseases that have been reported to occur in association with lymphomatoid papulosis include each of the following except a. Hodgkin's disease b. cutaneous T-cell lymphoma c. follicular small-cleaved lymphoma d. notalgia paresthetica e. diffuse large-cell lymphoma 17. Clonal rearrangements ofimmunoglobulins or T-cell receptor genes may be found in a. pseudolymphoma b. angiolymphoid hyperplasia with eosinophilia c. cutaneous lymphoma, localized to the skin d. cutaneous lymphoma, with systemic disease e. all of the above 18. Each of the following statements regarding atypical mole syndrome CAMS) or dysplastic nevus syndrome is true except a. the AMS phenotype is characterized by many nevi, clinically atypical nevi, and nevi in unusual sites. b. the AMS phenotype is a potent risk factor for melanoma. c. melanoma patients with AMS phenotype are likely to be at increased risk of additional primary tumors. d. the presence of the AMS phenotype in a patient with melanoma merits screening for the first-degree relatives, even in the absence of a family history of melanoma. e. data suggest that only a small percentage of patients with melanoma have the AMS phenotype. 19. Proximal white subungual onychomycosis is an unusual pattern of superficial infection. Its presence suggests a. insufficient treatment b. clinical relapse of previously treated onychomycosis c. underlying HIV infection d. dermatophytosis because it is the most common pattern e. candidal infection 20. Ecthyma gangrenosum is a cutaneous sign of a. hypersensitivity to aspartame b. fiberglas dermatitis c. Osler-Weber-Rendu syndrome d. frostbite e. Pseudomonas septicemia
Continued on page 31A
Journal of the American Academyof Dermatology Volume 30, Number 6
21. Organic illnesses associated with delusional parasitosis include a. cocaine abuse b. dementia c. systemic corticosteroid use d . diabetes mellitus e. all of the above 22. Each of the following statements characterizes lichenoid drug eruptions (LDEs) except a . LDEs wax and wane despite continuation of the offending drug. b. follicular involvement may result in severe alopecia. c. oral mucosal lesions occur more frequentl y in LDEs than in idiopathic lichen planus. d. skin lesions commonly show a pattern of photodistribution. e. common inducers of LDEs include penicillamine, antimalarials, a nd ,B-adrenergic blocking agents. 23. Possible causes for oral ulcerations in HIV infected patients include a. herpes simplex b. eosinophilic ulcer c. histoplasmosis d. no cause identified e. all of the above 24. Histoplasmosis is a serious opportunistic infection that occurs in the setting of immunosuppression. Each of the following statements is true except a. cutaneous histoplasmosis occurs in 11 % of AIDS patients with disseminated infection. b. cutaneous histoplasmosis occurs in 25% to 50% of AIDS patients with disseminated infection. c. cutaneous histoplasmosis lesions are diverse in nature. d. histoplasmosis capsulatum is best demonstrated by silver stain of a biopsy specimen . e. histoplasmosis may resemble psoriasis or seborrheic dermatitis in patients with HIV infection. 25. " N onbullous pemphigoid" can persist without vesicles or bullae for as long as a. I week b. 1 month c. 1 year d. 2 years e. 3 years 26 . Which statement is true with regard to methotrexate and reproduction in men? a. Contraception should be used for at least 3 months or longer than one spermatogenic cycle after discontinuation of the drug. b. In contrast to the teratogenic effect in women, there is no concern for a mutagenic effect of
CME examination for volume 29 31A methotrexate on spermatogenesis, and no precautions are necessary. c. Methotrexate interferes with early events in spermatogenesis, accounting for the rapid decrease in sperm count 2 to 3 weeks after initiation of the drug. d. The alteration of testicular stem cell chromosomes by methotrexate results in a high risk of fetal damage. e. Amn iocentesis and other methods of prenatal diagnosis are effectively used to detect new dominant mutations related to methotrexate exposure in the father. 27 . Each of the following statements regarding Ka wasaki syndrome in an adult is true except a. it has not been reported in the context of HIV infection. b. anti cardiolipin antibodies can be present. c. a perineal erup tion can be present. d. strawberry tongue can be present. e. it may be associated with multiple immunologic abnormalities. 28. The venoarteriolar reflex of the leg a. is activated when changing from the supine to the standing position b. can be blocked by local anesthesia or local heating c. causes constriction of the precapillary arterioles d. is mediated by an axon reflex e. all of the above
29. The main clue to the diagnosis of graft-versus-host disease after liver transplantation is a. fever b. diarrhea c. pancytopenia d. liver dysfunction e. skin rash 30. Microcystic adnexal carcinoma of the skin a . frequently metastasizes b. has characteristic histologic features that allow easy diagnosis c. rarely recurs, even if incompletely excised d. can be distinguished from benign adnexal neoplasms by a variety of stains, including type IV collagen, p53 and proliferating cell nuclear antigens e. commonly shows cysts with compact keratin or shadow cells, consistent with follicular differentiation 31. Lymphomas that occur after renal allograft transplantation a. are more commonly T cell than B cell in origin b. tend to be more benign if they consist of a clonal population of lymphocytes
Continued on page 32A
32A
CME examination for volume 29
c. tend to be more benign in their course if T cell in origin d. may he triggered by Epstein-Barr virus infection e. often involve the lungs as well as the skin 32. In Merkel cell carcinoma of the skin all of the following immunocytochemical studies are usually positive except a. neuron-specific enolase b. cytokeratin c. S~ 100 protein
Journal of the American Academy of Dermatology June 1994
d. epithelial membrane antigen e. neurofiiament 33. In a recent prospective study of 724 HIV-l-positive patients, all of the following malignant neoplasms were observed except a. basal cell carcinoma b. squamous cell carcinoma c. Kaposi's sarcoma d. malignant melanoma e. angiosarcoma