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CME examination for volume 39
Joumal of the American Academy 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 answers on the perforated answer sheet, and following instructions for Category I CME credit.--Editor
CME examination for volume 39* Identification No. 899-306
Instructions for Category I CME credit and answers to this examination appear in the front advertising section. See last page of Contents for page number.
Directions for questions 1-29: Give single best response. 1. The most characteristic histopathologic feature of arthropod bite lesions in patients with chronic lymphocytic leukemia is a. intraepidermal neutrophils b. vasculitis c. epidermal necrosis d. atypical lymphoid nodules e. eosinophils in the dermis 2. Which of the following physician groups is most likely to prescribe a corticosteroid/antifungal combination topical agent to their patients? a. Family/general practitioners b. General internist c. Pediatricians d. Dermatologists e. Neurosurgeons 3. White and Winkelmann recently questioned the existence of Weber-Christian disease as a distinct entity. What final diagnosis was most common in their group? a. Erythema nodosum b. Histolytic cytophagic panniculitis c. Lupus panniculitis d. Pancreatic panniculitis e. Cold-panniculitis 4. Urticarial vasculitis has been associated with the following diseases except a. IgM gamrnopathy b. hepatitis C c. serum sickness d. lupus erythematosus e. scleroderma 'Includes entire volume with the exception of the CME articles.
June, Part 1, 1999
5. Cyclosporine levels are reduced by a. ketoconazole b. cimetidine c. rifampin d. allopurinol e. erythromycin 6. Which of the following laboratory values is most likely to be abnormal in patients with melanoma that has metastasized to the liver? a. Serum lactate dehydrogenase b. Complete blood cell count c. Antinuclear antibody d. Serum potassium e. Blood urea nitrogen 7. Antinuclear antibody seropositivity is not induced by a. procainamide b. interferon alfa c. dermatomyositis d. cutaneous T-cell lymphoma e. ultraviolet light
8. The results of a study of 227 patients followed up for an average of 6.7 years with congenital nevi between 1.5 and 20 cm suggest that medium-sized congenital nevi witho)lt unusual clinical features a. have a high risk bf malignant degeneration b. may be followed clinically c. should be removed when on the trunk d. have twice the risk of malignant degeneration as small congenital nevi e. have twice the risk of malignant degeneration as large congenital nevi 9. Diffuse plane xanthoma may be associated with a. diabetes mellitus b. hyperlipidemia a. alcoholic liver disease d. monoclonal gamrnopathy e. chronic renal disease 10. Alizarin red, initially derived from the madder plant, stains a. elastic fibers
33A
34A CME examination for volume 39 b. c. d. e.
muscle fibers sebaceous gland dermal collagen dermal calcium deposits
11. In assessing the response of plaque psoriasis to treatment with the combination tazarotene and topical steroids, which one of the following statements is correct? a. There is no clinical difference between the combination of tazarotene and high-potency corticosteroid cream versus tazarotene plus lowpotency corticosteroid cream. b. Ninety-five percent of patients using tazarotene plus high-potency corticosteroid cream showed more than 50% improvement over the 12-week treatment period. c. The median time for initial treatment success with tazarotene plus mid-potency corticosteroid cream was slower than with tazarotene plus high-potency corticosteroid cream. d. Pruritus peaked at 3 weeks of the treatment period with the combination of tazarotene and corticosteroid cream. e. Combining corticosteroid creams with tazarotene reduced the posttreatment sustained effect of tazarotene. 12. Sentinel node biopsy in patients with melanoma a. shows a false-negative result rate of 14% to 15% b. utilizes technetium 99m-Iabeled sulfa colloid to identify primary lymph node basin-draining melanoma in lymphoscintigraphy studies c. has been shown to be associated with metastases in lymph node basins initially negative by lymphoscintigraphy. d. must be followed by lymph node dissection with the patient under general anesthesia in all patients e. is of no benefit in identifying patients for adjuvant therapy with interferon alfa 13. Each of the following is true of retinoids except they a. reduce malignant cell growth b. suppress the expression of epidermal transglutaminase c. suppress the immune system d. produce changes in keratin content of keratinocytes e. increase angiogenesis 14. In phase III studies of men with androgenetic alopecia treated with finasteride, the following was shown to be true: a. Global photographic improvement reached a plateau at 1 year.
Journal of the American Academy of Dermatology June 1999
b. Finasteride lowered serum dehydrotestosterone by 25% from baseline. c. Finasteride minimally increased serum prostatespecific antigen. d. Fewer than 2% of men receiving finasteride had a decrease in libido or erectile function. 15. Which of the following is true regarding lymphatic mapping and sentinel node biopsy in patients with melanoma? a. The lymphatics from body sites above Sappey's line drain to the ipsilateral groin. b. Colloidal gold is the current standard material for lymphoscintigraphy. c. Metastases have not been found in basins initially determined negative by lymphoscintigraphy. d. Metastases to higher level nodes in the absence of sentinel lymph node involvement occurs in 25% of cases. 16. Regarding vitamin E, each of the following statements is true except a. vitamin E is regenerated from its radical form by vitamin C. b. vitamin E is the most important antioxidant in extracellular fluids. c. patients receiving anticoagulant therapy should avoid doses of vitamin E of more than 4000 IV/day. d. vitamin E, 800 IV/day, appears to confer a partial protective effect against dapsone-induced hemolysis. 17. The organism that most commonly causes fungemia in patients after bone marrow transplantation is a. Fusarium b. Candida albicans c. Paecilomyces lilacinus d. Malassezia fuifur e. Aspergillus 18. Wooly hair can be associated with epidermal nevi and with an epidermolytic form of palmoplantar keratoderma. Cutaneous findings in patients with wooly hair and palmoplantar keratoderma include keratotic streaks and accentuation at pressure points on the palms and soles, lichenoid keratoses of flexural areas, and follicular keratoses. In addition to these cutaneous changes, what other system is involved in most patients? a. Heart, possibly leading to congestive heart failure b. Kidneys, possibly leading to renal failure c. Bone, with severe osteoporosis and increased risk of fracture
Journal of the American Academy of Dermatology Volume 40, Number 6, Part I
d. Central nervous system, with a high risk of seizures e. No other noncutaneous involvement occurs in most patients 19. At diagnosis, patients with diffuse plane xanthomas are most likely to have the following associated condition: a. reticuloendothelial disease, such as monoclonal gammopathy, leukemia, or multiple myeloma b. hypertriglyceridemia c. hypercholesterolemia d. diabetes mellitus e. no associated underlying condition 20. Transverse overcurvature of the nails in association with erythema, edema, and purulent exudate of the nailfolds has been described as a reversible complication of therapy with which drug? a. Penicillins b. Erythromycin c. Retinoids d. ~-Blockers e. Furosemide 21. Delayed-type hypersensitivity reactions to tattoo dyes may occur within days after tattoo application or up to 17 years later. The dye color most commonly implicated in causing reactions is a. red b. purple c. yellow d. blue e. green 22. Mycophenolate mofetil has been used successfully as a steroid-sparing agent to treat psoriasis, vasculitis, nodular panniculitis, and autoimmune disorders, such as pemphigus vulgaris and bullous pemphigoid. Mycophenolate mofetil is rapidly metabolized to its active metabolite, mycophenolic acid, which acts by a. suppressing RNA transcription, thereby limiting hyperproliferative processes b. specifically suppressing Th2 cells and activates Thl cell pathways c. inhibiting phosphodiesterase, thus limiting cyclic adenosine monophosphate activation d. inhibiting a key enzyme in the de novo pathway of purine synthesis e. suppressing the chemotactic activity of neutrophils 23. Leukonychia can range from complete nail whitening to discrete white punctata or striae. Congenital leukonychia a. is the most common form of leukonychia
CME examination for volume 39 35A b. is a hereditary disorder of males, probably Xlinked recessive c. results from a defect in the nail matrix that leads to premature keratination, so that the entire nail is opaque d. usually involves local areas of opacification rather than the entire nail e. can be diagnosed by histologic analysis of nail clippings, which show parakeratosis and immature keratinocytes with large nuclei and keratohyalin granules
24. A 51-year-old black man presents with an 8-week history of generalized desquamative lichenoid erythroderma. In addition, 4 weeks earlier tense bullae developed on his chest and limbs; erosions of the oral cavity also developed. Histologic examination reveals liquefaction degeneration of the basal cell layer associated with linear granular IgG and C3 deposits along the basement membrane zone. Antibodies exhibit BPAG 1 and BPAG2 specificities and ultrastructurally are located in the lamina lucida and hemidesmosomes. His haplotype is HLA-DRIO. Which of the following is most likely the diagnosis? a. Bullous lupus erythematosus b. Bullous lichen planus c. Lichenoid erythrodermic bullous pemphigoid d. Graft-versus-host disease e. Paraneoplastic pemphigus 25. A 30-year-old man presents with tender erythematous nodular lesions on his legs and malaise. A biopsy specimen from a skin lesion reveals subcutaneous infiltrates of pleomorphic lymphocytes and cytophagic histiocytes. In situ hybridization studies for Epstein-Barr virus show strong nuclear positivity in the atypical cells of the subcutaneous infiltrate. A bone marr6~ biopsy specimen reveals hemophagocytic histiocytes. Which of the following is the most likely diagnosis? a. Lupus panniculitis b. Cytophagic histiocytic panniculitis c. Erythema induratum d. Kikuchi's syndrome e. Subcutaneous panniculitic T-cell lymphoma 26. Long-term occupational exposure to tar causes a shift in the ratio of squamous cell to basal cell carcinomas toward squamous cell carcinomas (1. 7: 1) and a marked increase in the incidence (18.7% of workers) and decrease of the average patient age at presentation of which of the following tumor types? a. Melanoma b. Merkel cell tumor
36A CME examination for volume 39 c. Bowen's disease d. Keratoacanthoma e. Atypical fibroxanthoma 27. Bacterial infection occurring after laser skin resurfacing a. is usually initiated by a herpes simplex infection b. is of little consequence and heals without treatment c. occurs frequently despite the use of prophylactic oral antibodies d. is most often due to Staphylococcus aureus e. is most likely related to postoperative use of topical antibiotics 28. Melanomas associated with large congenital melanocytic nevi a. arise from both epidermal and nonepidermal origins b. generally appear during young adulthood c. have an incidence rate ranging from 10% to 15% d. usually arise in satellite congenital nevi e. rarely occur if there is associated leptomeningeal melanosis
Journal of the American Academy of Dermatology June 1999
29. Condylomata acuminata a. rarely regress spontaneously b. are usually caused by human papillomaviruses (HPV) 6 and 8 c. result within a month of contact with the causative HPV d. occur in approximately 5% of the adult population e. result in mucosal carcinoma when HPV 1 or 2 is the causative virus
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 answers on the perforated answer sheet, and following instructions for Category I CME credit.--Editor
CME examination for volume 39* Identification No. 899-306
Instructions for Category I CME credit and answers to this examination appear in the front advertising section. See last page of Contents for page number.
Directions for questions 1-29: Give single best response. 1. The most characteristic histopathologic feature of arthropod bite lesions in patients with chronic lymphocytic leukemia is a. intraepidermal neutrophils b. vasculitis c. epidermal necrosis d. atypical lymphoid nodules e. eosinophils in the dermis 2. Which of the following physician groups is most likely to prescribe a corticosteroid/antifungal combination topical agent to their patients? a. Family/general practitioners b. General internist c. Pediatricians d. Dermatologists e. Neurosurgeons 3. White and Winkelmann recently questioned the existence of Weber-Christian disease as a distinct entity. What final diagnosis was most common in their group? a. Erythema nodosum b. Histolytic cytophagic panniculitis c. Lupus panniculitis d. Pancreatic panniculitis e. Cold-panniculitis 4. Urticarial vasculitis has been associated with the following diseases except a. IgM gamrnopathy b. hepatitis C c. serum sickness d. lupus erythematosus e. scleroderma 'Includes entire volume with the exception of the CME articles.
June, Part 1, 1999
5. Cyclosporine levels are reduced by a. ketoconazole b. cimetidine c. rifampin d. allopurinol e. erythromycin 6. Which of the following laboratory values is most likely to be abnormal in patients with melanoma that has metastasized to the liver? a. Serum lactate dehydrogenase b. Complete blood cell count c. Antinuclear antibody d. Serum potassium e. Blood urea nitrogen 7. Antinuclear antibody seropositivity is not induced by a. procainamide b. interferon alfa c. dermatomyositis d. cutaneous T-cell lymphoma e. ultraviolet light
8. The results of a study of 227 patients followed up for an average of 6.7 years with congenital nevi between 1.5 and 20 cm suggest that medium-sized congenital nevi witho)lt unusual clinical features a. have a high risk bf malignant degeneration b. may be followed clinically c. should be removed when on the trunk d. have twice the risk of malignant degeneration as small congenital nevi e. have twice the risk of malignant degeneration as large congenital nevi 9. Diffuse plane xanthoma may be associated with a. diabetes mellitus b. hyperlipidemia a. alcoholic liver disease d. monoclonal gamrnopathy e. chronic renal disease 10. Alizarin red, initially derived from the madder plant, stains a. elastic fibers
33A
34A CME examination for volume 39 b. c. d. e.
muscle fibers sebaceous gland dermal collagen dermal calcium deposits
11. In assessing the response of plaque psoriasis to treatment with the combination tazarotene and topical steroids, which one of the following statements is correct? a. There is no clinical difference between the combination of tazarotene and high-potency corticosteroid cream versus tazarotene plus lowpotency corticosteroid cream. b. Ninety-five percent of patients using tazarotene plus high-potency corticosteroid cream showed more than 50% improvement over the 12-week treatment period. c. The median time for initial treatment success with tazarotene plus mid-potency corticosteroid cream was slower than with tazarotene plus high-potency corticosteroid cream. d. Pruritus peaked at 3 weeks of the treatment period with the combination of tazarotene and corticosteroid cream. e. Combining corticosteroid creams with tazarotene reduced the posttreatment sustained effect of tazarotene. 12. Sentinel node biopsy in patients with melanoma a. shows a false-negative result rate of 14% to 15% b. utilizes technetium 99m-Iabeled sulfa colloid to identify primary lymph node basin-draining melanoma in lymphoscintigraphy studies c. has been shown to be associated with metastases in lymph node basins initially negative by lymphoscintigraphy. d. must be followed by lymph node dissection with the patient under general anesthesia in all patients e. is of no benefit in identifying patients for adjuvant therapy with interferon alfa 13. Each of the following is true of retinoids except they a. reduce malignant cell growth b. suppress the expression of epidermal transglutaminase c. suppress the immune system d. produce changes in keratin content of keratinocytes e. increase angiogenesis 14. In phase III studies of men with androgenetic alopecia treated with finasteride, the following was shown to be true: a. Global photographic improvement reached a plateau at 1 year.
Journal of the American Academy of Dermatology June 1999
b. Finasteride lowered serum dehydrotestosterone by 25% from baseline. c. Finasteride minimally increased serum prostatespecific antigen. d. Fewer than 2% of men receiving finasteride had a decrease in libido or erectile function. 15. Which of the following is true regarding lymphatic mapping and sentinel node biopsy in patients with melanoma? a. The lymphatics from body sites above Sappey's line drain to the ipsilateral groin. b. Colloidal gold is the current standard material for lymphoscintigraphy. c. Metastases have not been found in basins initially determined negative by lymphoscintigraphy. d. Metastases to higher level nodes in the absence of sentinel lymph node involvement occurs in 25% of cases. 16. Regarding vitamin E, each of the following statements is true except a. vitamin E is regenerated from its radical form by vitamin C. b. vitamin E is the most important antioxidant in extracellular fluids. c. patients receiving anticoagulant therapy should avoid doses of vitamin E of more than 4000 IV/day. d. vitamin E, 800 IV/day, appears to confer a partial protective effect against dapsone-induced hemolysis. 17. The organism that most commonly causes fungemia in patients after bone marrow transplantation is a. Fusarium b. Candida albicans c. Paecilomyces lilacinus d. Malassezia fuifur e. Aspergillus 18. Wooly hair can be associated with epidermal nevi and with an epidermolytic form of palmoplantar keratoderma. Cutaneous findings in patients with wooly hair and palmoplantar keratoderma include keratotic streaks and accentuation at pressure points on the palms and soles, lichenoid keratoses of flexural areas, and follicular keratoses. In addition to these cutaneous changes, what other system is involved in most patients? a. Heart, possibly leading to congestive heart failure b. Kidneys, possibly leading to renal failure c. Bone, with severe osteoporosis and increased risk of fracture
Journal of the American Academy of Dermatology Volume 40, Number 6, Part I
d. Central nervous system, with a high risk of seizures e. No other noncutaneous involvement occurs in most patients 19. At diagnosis, patients with diffuse plane xanthomas are most likely to have the following associated condition: a. reticuloendothelial disease, such as monoclonal gammopathy, leukemia, or multiple myeloma b. hypertriglyceridemia c. hypercholesterolemia d. diabetes mellitus e. no associated underlying condition 20. Transverse overcurvature of the nails in association with erythema, edema, and purulent exudate of the nailfolds has been described as a reversible complication of therapy with which drug? a. Penicillins b. Erythromycin c. Retinoids d. ~-Blockers e. Furosemide 21. Delayed-type hypersensitivity reactions to tattoo dyes may occur within days after tattoo application or up to 17 years later. The dye color most commonly implicated in causing reactions is a. red b. purple c. yellow d. blue e. green 22. Mycophenolate mofetil has been used successfully as a steroid-sparing agent to treat psoriasis, vasculitis, nodular panniculitis, and autoimmune disorders, such as pemphigus vulgaris and bullous pemphigoid. Mycophenolate mofetil is rapidly metabolized to its active metabolite, mycophenolic acid, which acts by a. suppressing RNA transcription, thereby limiting hyperproliferative processes b. specifically suppressing Th2 cells and activates Thl cell pathways c. inhibiting phosphodiesterase, thus limiting cyclic adenosine monophosphate activation d. inhibiting a key enzyme in the de novo pathway of purine synthesis e. suppressing the chemotactic activity of neutrophils 23. Leukonychia can range from complete nail whitening to discrete white punctata or striae. Congenital leukonychia a. is the most common form of leukonychia
CME examination for volume 39 35A b. is a hereditary disorder of males, probably Xlinked recessive c. results from a defect in the nail matrix that leads to premature keratination, so that the entire nail is opaque d. usually involves local areas of opacification rather than the entire nail e. can be diagnosed by histologic analysis of nail clippings, which show parakeratosis and immature keratinocytes with large nuclei and keratohyalin granules
24. A 51-year-old black man presents with an 8-week history of generalized desquamative lichenoid erythroderma. In addition, 4 weeks earlier tense bullae developed on his chest and limbs; erosions of the oral cavity also developed. Histologic examination reveals liquefaction degeneration of the basal cell layer associated with linear granular IgG and C3 deposits along the basement membrane zone. Antibodies exhibit BPAG 1 and BPAG2 specificities and ultrastructurally are located in the lamina lucida and hemidesmosomes. His haplotype is HLA-DRIO. Which of the following is most likely the diagnosis? a. Bullous lupus erythematosus b. Bullous lichen planus c. Lichenoid erythrodermic bullous pemphigoid d. Graft-versus-host disease e. Paraneoplastic pemphigus 25. A 30-year-old man presents with tender erythematous nodular lesions on his legs and malaise. A biopsy specimen from a skin lesion reveals subcutaneous infiltrates of pleomorphic lymphocytes and cytophagic histiocytes. In situ hybridization studies for Epstein-Barr virus show strong nuclear positivity in the atypical cells of the subcutaneous infiltrate. A bone marr6~ biopsy specimen reveals hemophagocytic histiocytes. Which of the following is the most likely diagnosis? a. Lupus panniculitis b. Cytophagic histiocytic panniculitis c. Erythema induratum d. Kikuchi's syndrome e. Subcutaneous panniculitic T-cell lymphoma 26. Long-term occupational exposure to tar causes a shift in the ratio of squamous cell to basal cell carcinomas toward squamous cell carcinomas (1. 7: 1) and a marked increase in the incidence (18.7% of workers) and decrease of the average patient age at presentation of which of the following tumor types? a. Melanoma b. Merkel cell tumor
36A CME examination for volume 39 c. Bowen's disease d. Keratoacanthoma e. Atypical fibroxanthoma 27. Bacterial infection occurring after laser skin resurfacing a. is usually initiated by a herpes simplex infection b. is of little consequence and heals without treatment c. occurs frequently despite the use of prophylactic oral antibodies d. is most often due to Staphylococcus aureus e. is most likely related to postoperative use of topical antibiotics 28. Melanomas associated with large congenital melanocytic nevi a. arise from both epidermal and nonepidermal origins b. generally appear during young adulthood c. have an incidence rate ranging from 10% to 15% d. usually arise in satellite congenital nevi e. rarely occur if there is associated leptomeningeal melanosis
Journal of the American Academy of Dermatology June 1999
29. Condylomata acuminata a. rarely regress spontaneously b. are usually caused by human papillomaviruses (HPV) 6 and 8 c. result within a month of contact with the causative HPV d. occur in approximately 5% of the adult population e. result in mucosal carcinoma when HPV 1 or 2 is the causative virus