ETAS_MCQ_05 dermatopathology
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    ETAS_MCQ_05 dermatopathology ETAS_MCQ_05 dermatopathology Document Transcript

    • Dermatopathology1) Both mesenchymal and epithelial elements may be found in this tumor:A. Bednar tumorB. CylindromaC. Chondroid syringomaCorrect ChoiceD. Microcystic adnexal carcinomaE. Folliculosebaceous cystic hamartomaCutaneous mixed tumor, also known as Chondroid syringoma, represents an acquired hamartomawith folliculosebaceous-apocrine differentiation that has been generally interpreted as a form ofadnexal adenoma (neoplasm). It has both a mesenchymal and epithelial component2) What is the diagnosis?A. Papillary eccrine adenomaB. SyringomaCorrect ChoiceC. Adenoid cystic carcinomaD. TrichoadenomaE. Dermal duct tumorThis is a syringoma, in which there are small cords and strands of epithelial cells, some in a“tadpole” configuration. There are scattered lumens, often lined with clear cells, with a bluishsubstance within them. No horn cysts are present3) The diagnosis is:Image Link 1Image Link 2Image Link 3Image Link 4A. clear cell Bowens diseaseB. extramammary PagetsCorrect ChoiceC. epidermotropic sebaceous carcinomaD. epidermotropic Merkel cell carcinomaE. epidermotropic balloon-cell melanomaIn extramammary Paget’s disease, there are epidermotropic, large cells with a bluish cytoplasm. Attimes these cells can form “nests”, but in general, there is usually a compressed basal layer beneaththe “nests”.4) This is a desmoplakin:A. PlakophilinB. PlakoglobinC. BPAg1 Correct ChoiceD. Beta-catenin 1
    • E. DesmocollinDesmoplakins include desmoplakin 1, BPAg1, envoplakin, and periplakin5) Histologically, adenoma sebaceum represent which of the following lesions?A. AngiokeratomasB. Angiofibromas Correct ChoiceC. CollagenomasD. NeurofibromasE. Smooth muscle hamartomasAdenoma sebaceum, fibrous papules and pearly penile papules all have similar featureshistologically, presenting as angiofibromas. Features include atrophic epidermis with patchymelanocytic hyperplasia and hyperkeratosis, vertically oriented collagen, increased fibroblasts andblood vessels6) Lipomembranous change is seen in:A. Sclerosing panniculitis Correct ChoiceB. Sebaceous carcinomaC. Cystic sebaceous adenomaD. HibernomaE. MucoceleLipomembranous change is a non-specific histologic pattern that is most commonly seen inlipodermatosclerosis, which is also known as sclerosing panniculitis; this condition may besecondary to venous stasis7) The diagnosis is:Image Link 1Image Link 2A. sarcoidosisB. foreign bodyC. lupus miliaris et disseminataD. lichen nitidusCorrect ChoiceE. lymphocytoma cutis8) What is the diagnosis?A. PilomatrixomaB. Metastatic carcinomaC. TattooD. Wood splinterE. Calcinosis cutisCorrect ChoiceThis is calcinosis cutis, in which there is calcification (blue chunky material) in the dermis 2
    • 9) The diagnosis is:A. NeurilemmomaB. Granular cell tumorC. Xanthoma Correct ChoiceD. ReticulohistiocytomaE. NeuromaNEEDS EXPLANATIONS10) The diagnosis is:Image Link 1Image Link 2Image Link 3Image Link 4A. spiradenomaB. mastocytosisC. hidradenomaD. glomangiomaCorrect ChoiceE. KimurasIn glomangiomas, one sees multiple lumina lined by cells with pink cytoplasm and indisctinctborders with very round nuclei. Generally, the lumina are lined by one or two layers of glomus cells.11) 62-year old female with history of acute myeloid leukemia presents with multiple edematous,erythematous papules after starting G-CSF.A. Bowel bypass dermatosisB. Leukocytoclastic vasculitisC. Erythema multiformeD. Polymorphous light eruptionE. Sweets syndromeCorrect ChoiceSweets syndrome, or acute febrile neutrophilic dermatoses, is often associated with AML and G-CSF. Histologically, there is marked dermal edema with a prominent infiltrate composed ofneutrophils with leukocytoclasia. There is an absence of extensive vascular damage12) Multiple such lesions are seen in this syndrome:Image Link 1Image Link 2Image Link 3A. Nicolau and BalusB. AlagillesC. Rubinstein-TaybisD. Schopfs 3
    • E. Brooke-SpieglerCorrect ChoiceIn Brooke-Spiegler syndrome, there are multiple trichoepitheliomas, cylindromas, andspiradenomas. Nicolau and Balus’ syndrome has multiple eruptive syringomas, milia, andatrophoderma vermiculata. Alagille’s syndrome is the association of arteriohepatic dsyplasia withnevus comdonicus. Schopf’s syndrome associates multiple hidrocystomas with hypodontia,palmoplantar hyperkeratosis, and onychodystrophy. In Rubinstein-Taybi’s syndrome, patients areshort of stature with broad thumbs and multiple pilomatricomas13) This patient has multiple lesions showing the following histology. She has a family history ofsuch lesions. You check her for:Image Link 1Image Link 2Image Link 3A. fumarate hydrataseCorrect ChoiceB. transglutaminaseC. epoxide hydrolaseD. sulfataseE. urease14) The diagnosis is::Image Link 1Image Link 2Image Link 3A. incontinentia pigmentiCorrect ChoiceB. pemphigus vulgarisC. epidermal nevusD. bullous pemphigoidE. dermatitis herpetiformis15) The diagnosis is:Image Link 1Image Link 2Image Link 3A. adenoid cystic carcinomaCorrect ChoiceB. trichoepitheliomaC. dermal duct tumorD. syringomaE. tubular apocrine adenomaIn adenoid cystic carcinoma, there are cords and tubules of basaloid cells, arranged in a cribiformpattern. The cystic spaces contain a bluish material. Perineural invasion is common. The cells stainpositively for epithelial membrane antigen (EMA).15) The diagnosis is:Image Link 1 4
    • Image Link 2Image Link 3A. adenoid cystic carcinomaCorrect ChoiceB. trichoepitheliomaC. dermal duct tumorD. syringomaE. tubular apocrine adenomaIn adenoid cystic carcinoma, there are cords and tubules of basaloid cells, arranged in a cribiformpattern. The cystic spaces contain a bluish material. Perineural invasion is common. The cells stainpositively for epithelial membrane antigen (EMA16) For this patient, you request that the lab perform indirect immunofluorescence using whatsubstrate?A. Monkey esophagusB. Mouse epitheliumC. Rat bladderD. Guinea pig esophagusCorrect ChoiceE. Hep-2 cellsThis patient has pemphigus folicaceus, and indirect immunofluorescence works best on guinea pigesophagus17) This patient may need blood tests to check her:A. Renal functionB. White blood cell countC. Liver functionD. ThyroidCorrect ChoiceE. GlucoseHerpes gestationis is associated with an increased incidence of Graves’ disease.18) The diagnosis is:A. Wegener’s granulomatosisB. SyphilisC. Fixed drug reactionD. Granuloma faciale Correct ChoiceE. Angiolymphoid hyperplasia with eosinophiliaNEEDS EXPLANATIONS19) Multiple clear cell acanthomas are associated with: 5
    • A. ImmunosuppressionB. Ichthyosis Correct ChoiceC. Gastrointestinal polypsD. Breast cancerE. Cowden’sClear cell acanthoma is associated with ichthyosis20) The diagnosis is:Image Link 1Image Link 2Image Link 3A. metastatic carcinomaB. Merkel cell carcinomaC. pyogenic granulomaD. bacillary angiomatousE. glomus tumorCorrect ChoiceIn a glomus tumor, generally vascular spaces are not particularly prominent, and there are cords aswell as solid areas of uniform cells with very monomorphous rounded nuclei21) The diagnosis is:Image Link 1Image Link 2Image Link 3Image Link 4A. Large cell acanthomaB. Clear cell acanthomaCorrect ChoiceC. Hidroacanthoma simplexD. PoromaE. White sponge nevusIn a clear cell acanthoma, there is regular acanthosis, often with some parakeratotic scale withneutrophils overlying it. The keratinocytes making up the thickened epidermis are often clear, orpale, due to an increased glycogen content secondary to a deficiency of phosphorylase. There isoften a very abrupt demarcation at the margins of the acanthotic pale/clear cells and the normalepidermis22) The gene defect:Image Link 1Image Link 2Image Link 3A. DSG3B. ATP2A2C. ATP2C1Correct ChoiceD. SERCA2 6
    • E. CHRNA9In Hailey-Hailey disease, there is full-thickness acantholysis of the epidermis. The gene defect is inATP2C123) This tumor is vimentin+ and cytokeratin+:A. NeurothekeomaB. DermatofibromaC. AngiosarcomaD. Epithelioid sarcoma Correct ChoiceE. Nodular fasciitisCharacteristic immunohistochemistry of epithelioid sarcoma is vimentin- and cytokeratin- positivity24) The diagnosis is:Image Link 1Image Link 2Image Link 3A. argyriaCorrect ChoiceB. minocycline-induced pigmentationC. hemochromatosisD. ochronosisE. gold effectIn argyria, the silver deposits (black particles) are often seen around eccrine glands.25) The diagnosis is:Image Link 1Image Link 2Image Link 3A. traumatic neuromaB. acral angiofibromaC. accessory digitD. Koenens tumorE. acquired digital fibrokeratomaCorrect ChoiceThis is an acquired digital fibrokeratoma, with a thickened stratum corneum indicating an acrallocation and an absence of nerves in the dermis. Collagen is increased in the dermis26) With immunofluorescence, the most likely pattern would be:Image Link 1Image Link 2Image Link 3A. granular IgGB. granular IgACorrect Choice 7
    • C. linear IgG, IgM, C3, and IgAD. tubular IgGE. linear IgMIn dermatitis herpetiformis, there are characteristic clusters of neutrophils at the tips of dermalpapillae. Immunofluorescence will show granular IgA in the dermal papillae. Neutrophils at thedermo-epidermal junction of a bulla can also be seen in bullous systemic lupus erythematosus,linear IgA disease, neutrophilic bullous pemphigoid, and inflammatory epidermolysis bullosaacquisita27) The diagnosis is:Image Link 1Image Link 2Image Link 3A. epidermal nevusB. poromaCorrect ChoiceC. bowenoid papulosisD. large cell acanthomaE. verrucaIn a poroma, there is a down-growing epidermal proliferation composed of uniform cells, often withindistinct cytoplasmic borders that have rounded, monomorphous nuclei. Within this proliferation,there are often ducts lined by an eosinophilic cuticle28) Which immunohistochemical stain would be positive in eosinophilic granuloma?A. Congo redB. MucinC. Cytokeratin 20D. CD1aCorrect ChoiceE. HMB-45Eosinophilic granuloma is a form of Langerhans Cell Histocytosis (LCH), previously calledHistiocytosis X. Eosinophilic granuloma is a localized, benign form which is more common in malesand generally affects the bones. All forms of LCH are characterized by the infiltration of Langerhanscells on pathology, which staing for S-100, CD1a and contain cytoplasmic birbeck granules29) What is the diagnosis?A. Lichen nitidusCorrect ChoiceB. LupusC. Lichen planusD. Lichen planus-like keratosisE. Lichen striatusThe histologic features shown are indicative of lichen nitidus. Lichen nitidus has a very characteristic"claw clutching ball" appearance where the rete ridges extend downward around a lichenoidinfiltrate 8
    • 30) An increased number of miniaturized hairs are seen in:A. Lichen planopilaris and alopecia areataB. Alopecia areata Correct ChoiceC. TrichotillomaniaD. Lichen planopilarisE. Telogen effluviumIn alopecia areata, especially early stages, increased miniaturized catagen hairs can be seen inaddition to the finding of peribulbar lymphocytes resembling a “swarm of bees.” Lichen planopilarisis a scarring alopecia in which vertical tracts of fibrosis are seen in place of follicles. Trichotillomaniadisplays follicular plugging, trichomalacia, pigmented casts, hemorrhage, and increased catagenhairs on biopsy. Telogen effluvium is characterized by an increased number of telogen hairs31) The diagnosis is:Image Link 1Image Link 2Image Link 3A. Monsels reactionB. chrysiasisC. amalgam tattooD. minocycline-induced pigmentationE. ochronosisCorrect ChoiceIn ochronosis, there is slightly thickened banana-shaped collagen in the superficial dermis thatappears yellow-brown in color32) The diagnosis of this biopsy is:A. Erythema nodosumB. Polyarteritis nodosaCorrect ChoiceC. Granuloma annulareD. Leukocytoclstic vasculitisE. Reumatoid nodulePolyarteritis nodosa is a necrotizing vasculitis of medium-sized arteries in the derma-subcutaneousjunction. It is a septal panniculitis as a result of vasculitis. There is more fibrinous changes than inthrombophlebitis and less necrosis than erythema induratum33) What is the pathologic diagnosis of this lesion?A. Acanthosis nigricansB. Verruca planaCorrect ChoiceC. Seborrheic keratosisD. Normal skinE. Epidermal nevus 9
    • The histologic characteristics of verruca plana are presence of hyperkeratosis and acanthosis.Koilocytes appear in the upper one-third of the epidermis34) Similar follicles can be seen on skin from the:Image Link 1Image Link 2A. fiingerB. glans penisC. noseD. labia majoraE. eyelidCorrect ChoiceVellus hair follicles are seen commonly in accessory tragic and eyelid skin35) The diagnosis is:Image Link 1Image Link 2Image Link 3Image Link 4A. Bowens diseaseB. melanomaC. sebaceous carcinomaD. pagetoid reticulosisE. Pagets diseaseCorrect ChoiceIn Paget’s disease, there are epidermotropic cells in a variably acanthotic epidermis. Theepidermotropic cells have abundant cytoplasm that is often blue-gray in color. The cells are singleor in nests throughout the epidermis. There should be a compressed rim of basal cells beneathnests that are located near the dermoepidermal junction36) The diagnosis is::Image Link 1Image Link 2Image Link 3A. mixed tumorB. follicular mucinosisCorrect ChoiceC. alopecia areataD. lichen planopilarisE. pityrosporum folliculitis37) Eosinophils are typically found in each of the following except:A. Incontinentia pigmentiB. PlasmacytomaCorrect ChoiceC. Urticaria 10
    • D. Lichenoid drug reactionsE. Pemphigus vulgarisPlasmacytomas are characterized by the presence of monoclonal plasma cells. Plasmacytomas mayoccur from primary cutaneous focus or secondarily from myeloma38) The diagnosis is:Image Link 1Image Link 2Image Link 3Image Link 4Image Link 5A. Merkel cell carcinomaCorrect ChoiceB. neuroblastomaC. plasmacytomaD. LymphomaE. melanomaThis is a Merkel cell carcinoma, in which there is a dense collection of small blue cells with scantcytoplasm in the dermis. The cells are sometimes arranged in trabeculae and other times innodules. The cells appear very blue on low power, and on higher power have somewhat pale nucleithat have paler/darker foci within them in a salt-and-pepper pattern39) Which of the following lesions demonstrates a pseudo-Darier’s sign?A. MastocytomaB. Spitz nevusC. Smooth muscle hamartomaCorrect ChoiceD. PilomatricomaE. Bullous pemphigoidSmooth muscle hamartomas are benign tumors which arise from smooth muscle of the dermis.Pseudo-Dariers sign may be elicited due to transient piloerection after rubbing. Histologically, red-orange bundles and fascicles are present with blunt-ended nuclei40) The diagnosis is:Image Link 1Image Link 2Image Link 3A. apocrine adenomaB. amyloidosisC. Massons tumorCorrect ChoiceD. intravascular pyogenic granulomaE. papillary digital adenocarcinoma41) The most likely diagnosis for this painful neoplasm is: 11
    • A. Glomus tumorB. NeurilemmomaC. Cutaneous endometriosisCorrect ChoiceD. Blue rubber bleb nevusE. AngiolipomaCutaneous endometriosis usually occurs after gynecologic surgery. The rich, cellular stroma withregularly shaped channels and glandular structures are typical. Hemorrhage may also be present indeeper sections42) What infectious agent is most likely responsible for this reaction of fibrin and antibodies whichhelp to prevent phagocytosis?A. ActinomycosisCorrect ChoiceB. AnthraxC. Candida albicansD. Ricketsii speciesE. NocardiaHoeppli-Splendore reaction is characterized histologically by intensely eosinophilic materialconsisting of fibrin and antibodies. Causes of the phenomenon include Actinomycosis israelii, Staphaureus, Proteus, Pseudomonas and E. coli43) Goblet cells are seen in:A. Bronchogenic cyst Correct ChoiceB. SteatocystomaC. Cutaneous ciliated cystD. Dermoid cystE. EndometriosisBronchogenic cysts have a pseudostratified cuboidal or columnar lining that is ciliated; goblet cellsare found in the lining as well44) The diagnosis is:A. Metastatic carcinomaB. Mixed tumor Correct ChoiceC. Papillary eccrine adenomaD. Nodular hidradenomaE. Mucinous carcinomaNEEDS EXPLANATIONS45) The most common cause of this in the U.S. is:Image Link 1Image Link 2Image Link 3 12
    • A. Microsporum distortumB. Epidermophyton floccosumC. Trichophyton rubrumCorrect ChoiceD. Microsporum canisE. Trichophyton mentagrophytesTrichophyton rubrum is the most common cause of Majocchi’s granuloma, a type of folliculitis wherethe dermatophyte likely tracks down the follicle and creates a foreign-body-type inflammatoryreaction in the dermis46) This patient recently developed this rash. You decide to patch test her, but in the meanwhileyou tell her to avoid:A. PriminB. Abietic acidC. BenzocaineD. CinnamonCorrect ChoiceE. ChamomileThis patient likely has a fragrance allergy. Patients allergic to fragrances also need to avoid certainspices like cinnamon47) Multiple such lesions may be seen associated with:Image Link 1Image Link 2Image Link 3A. CowdensB. WermersCorrect ChoiceC. CowpersD. WernersE. BrookesMEN type I (Wermers Syndrome) is sometmes associated with multiple angiofibromas. Tuberoussclerosis is also associated with adenoma sebaceum (angiofibromas48) Turk cells are found in what infection?A. RubeolaB. MumpsC. RoseolaD. SyphilisE. RubellaCorrect ChoiceTurk cells are atypical lymphocytes found in rubella49) The diagnosis is:Image Link 1 13
    • Image Link 2Image Link 3A. MassonsB. bacillary angiomatosisC. hemangioendotheliomaD. fibrosing pyogenic granulomaCorrect ChoiceE. apocrine adenoma50) Which disease process best describes Texiers disease?A. Deposition disorderB. PanniculitisCorrect ChoiceC. Granulomatous diseaseD. Neutrophilic dermatosisE. Infectious processTexiers disease is a panniculitis secondary to vitamin K injections causing sclerotic lesions with lilacborders on the buttocks and thighs resembling a cowboy belt and holster51) A patient with dystrophic nails and multiple lesions with this histologic finding may have whatgene defect?A. PhosphorylaseB. Keratin 6b/17Correct ChoiceC. Beta-cateninD. Keratin 6a/16E. Keratin 1/10Pachonychia congenita type II (also known as Jackson-Lawler) is a autosomal dominant disordercharacterized by natal teeth, steatocystoma multiplex, and pincer nails. Steatocystomas have cystwalls that are intricately folded or crenulated. Sebaceous glands are present within the cyst wall52) What is the diagnosis?A. Warty dyskeratomaB. Molluscum contagiosumCorrect ChoiceC. TrichilemmomaD. Ecthyma contagiosumE. OrfThis is a lesion of Molluscum contagiosum, in which there is a lobulated down-growth (cup-shaped)of keratinocytes; centrally towards the surface, the keratinocytes are enlarged with cytoplasmicpink inclusions (Henderson-Patterson bodies53) Multiple such lesions can be associated with:Image Link 1 14
    • Image Link 2Image Link 3A. GauchersB. SipplesC. fucosidosisCorrect ChoiceD. Louis-BarrE. Bournevillesmultiple angiokeratomas in a bathing trunk distribution may be associated with Fabrys disease(angiokeratoma corporis diffusum) or fucosidosis as well as some other storage diseases as well aspossibly being a normal finding. There has been a recent report of angiokeratomas in a bathingtrunk distribution in a woman with no other signs of a storage disorder54) What is the diagnosis?A. Lipoid protinosisB. Erythrpoietic protoporphyriaC. Lichen sclerosus et atrophicusCorrect ChoiceD. Lichen amyolidosusE. MorpheaThis is lichen sclerosus et atrophicus in which there is hyperkeratosis overlying an atrophicepidermis. Underlying the epidermis is a layer of homogenized light pink collagen. Beneath that,there is a somewhat band-like inflammatory infiltrate of predominantly lymphocytes, but alsohistiocytes and plasma cells55) What is the diagnosis?A. Seborrheic keratosisB. Hidroacanthoma simplexC. Epidermal nevusD. Fibroepithelioma of PinkusCorrect ChoiceE. Nevus sebaceusFibroepithelioma of Pinkus is a form of basal cell carcinoma. Histology shows long, thin,anastomosing strans of basal cell embedded in fibrous stroma with many connections to theepidermis56) A newborn infant presents with bullous lesions. Based upon the pathology, what is the mostlikely gene defect causing her skin condition?A. Keratin 1 and 10B. PAX3C. NEMOCorrect ChoiceD. Keratin 5 and 14E. SPINK5 15
    • Incontinentia pigmenti is an X_linked dominant genodermatosis which presents in the newbornperiod with vesicles in a Blaschkoid distribution. A biopsy would show eosinophilic spongiosis withdyskeratotic keratinocytes and pigment incontinence. A gene defect in NEMO has been identified asthe cause for the constellation of fingings57) The most common location for this lesion would be:A. Upper lipB. Sole of footCorrect ChoiceC. ButtockD. FingerE. GroinEccrine poroma is a benign, solitary tumor arsing in the lower portion of the epidermis. It ischaracterized by small, uniformly cuboidal cells with deeply basophilic nuclei. The tumor mass isassembled in broad anastomosing bands and may have narrow ductal lumina lined by eosinophiliccuticle58) The diagnosis is:Image Link 1Image Link 2Image Link 3A. microcystic adenexal carcinomaB. breast carcinomaCorrect ChoiceC. neuroendocrine carcinomaD. tubular apocrine adenomaE. infiltrative basal cell carcinomaThe diagnosis is metastatic breast carcinoma. In this example, there is a dense collection of cellsthroughout the ermis. On closer examination, tehre are strands/cords of cells as well as some cellsarranged around lumina infiltrating through the dermis59) Steatocystoma multiplex is associated with:A. Jackson-Lawler Correct ChoiceB. Jadassohn-LewandowskyC. Zinsser-Engman-ColeD. Schaufer-BrunauerE. Touraine-Solente-GoleJackson-Lawler (Jackson-Sertoli) is known as pachyonychia congenital type 2. Multiple steatocystscan be seen in this condition60) Weibel-Palade bodies are seen in:A. Spitz NeviB. Endothelial cells Correct ChoiceC. Cells infected with MCV 16
    • D. Plasmacytoid CellsE. MalakoplakiaWeibel-Palade bodies are seen in endothelial cells and are therefore found in vascular lesions.Kamino bodies are found in Spitz nevi. Henderson Patterson bodies are seen in molluscum. Dutcherbodies are intranuclear inclusions seen in plasmacytoid cells. Michaelis Gutmann bodies are partiallydigested bacteria seen in malakoplakia61) Eosinophilia-Myalgia syndrome is caused by:A. Norwegian salt-petterB. Unadultered Spanish grapeseed oilC. Excessive anaerobic exerciseD. L-Tryptophan Correct ChoiceE. Pb intoxicationThe eosinophilia myalgia syndrome is characterized by marked peripheral eosinophilia with a clinicalspectrum of signs and symptoms, including generalized myalgias, pneumonitis, myocarditis,neuropathy, encephalopathy and fibrosis. Many patients progress to a clinical picture clinicallyindistinguishable from eosinophilic fasciitis. The disease is caused by the ingestion of certain lots ofL-tryptophan62) Blue-gray pigmentation on the legs secondary to minocycline on biopsy stains with:A. Fontana Masson and Perls Correct ChoiceB. All of these answers are correctC. Sudan blackD. Fontana MassonE. PerlsThere are three types of pigmentary change that are caused by minocycline. The blue-graypigmentation on the legs and the blue pigment in scars is thought to be secondary to a drug-proteincomplex deposited in the dermis. The blue-gray pigment on the legs stains with Perls and Fontana-Masson. The blue in scars (often on the face) stains with Perls. The muddy-brown discoloration onsun-exposed areas shows increased basilar pigment and melanin incontinence on biopsy. It is likelysecondary to phototoxicity.63) The diagnosis is:Image Link 1Image Link 2Image Link 3A. Artecoll reactionB. goutCorrect ChoiceC. mucinous carcinomaD. Urbach-WiethesE. HuntersIn gout, there are characteristic amorphous light pink masses of material within which it issometimes possible to see outlines of needle-like spaces. The urate crystals can only be seen if 17
    • alcohol fixation is used. The amorphous material is generally surrounded by histiocytes and foreign-body giant cells64) The histologic finding of "shoulder parakaratosis", parakeratosis with prediliection for thefollicular ostia, is characteristic of pityriasis rubra pilaris as well as:A. Stasis dermatitisB. Atopic dermatitisC. Seborrheic dermatitisCorrect ChoiceD. Nummular dermatitisE. Allergic contact dermatitisParakeratosis refers to pyknotic keratinocyte nuclei in the stratum corneum, where nuclei are notusually present. It is common in diseases with changes in the epidermis. Histologically seborrheicdermatitis can shows "shoulder parakeratosis" with epidermal spongiosis. Histologically atopic,nummular and contact dermatitis present with spongiosis with or without vesicles. Stasis dermatitispresents with more dilated papillary dermal small blood vessels and hemosiderin65) The diagnosis is:Image Link 1Image Link 2Image Link 3Image Link 4Image Link 5Image Link 6A. scleroderma, earlyB. erythema induratumC. sarcoidosisD. erythema nodosumCorrect ChoiceE. subcutaneous granuloma annulareIn erythema nodoosum, one sees a predominantly septal panniculitis with some septal thickeningand fibrosis and an inflammatory infiltrate within the septae composed of lymphocytes, histiocytes,eosinophils, and giant cells66) The diagnosis is:A. PsoriasisB. Bowens diseaseC. Clear cell acanthoma Correct ChoiceD. TrichilemmomaE. PoromaNEEDS EXPLANATIONS67) Which type of artifact is shown here?A. Electrodessication 18
    • B. DessicationC. Gel foamCorrect ChoiceD. Microtome knife chatterE. FreezeThe presence of deeply basophilic, wavy, angulated foreign material characteristic of gel foamartifact68) This is associated with MEN IIa:A. Malignant peripheral nerve sheath tumorB. Macular amyloidosis Correct ChoiceC. MucoceleD. NeurothekeomaE. Chondroid syringomaMacular amyloidosis is associated with MEN IIa69) The diagnosis is:A. LymphomaB. Small cell melanomaC. Glomus tumorD. Merkel cell carcinoma Correct ChoiceE. RhabdomyosarcomaNEEDS EXPLANATIONS70) The diagnosis is:Image Link 1Image Link 2Image Link 3A. acrospiromaB. reticulated seborrheic keratosisC. fibroepithelioma of PinkusCorrect ChoiceD. syringofibroadenomaE. tumor of the follicular infundibulumIn fibroepithelioma of Pinkus, there is a reticulated network of basaloid cells coming off of theepidermis in a plate-like fashion. There is some peripheral palisading of cells. The cells areembedded in a fibrotic stroma71) Paraproteinemia is associated with all except:A. Plane xanthomaB. Necrobiotic xanthogranuloma 19
    • C. ScleromyxedemaD. Sclerosing panniculitis Correct ChoiceE. ScleredemaSclerosing panniculitis (lipodermatosclerosis) displays characteristic changes in the fat(lipomembranous change); it is not associated with paraproteinemia. Generalized plane xanthomas,scleromyxedema, necrobiotic xanthogranuloma, scleredema, erythema elevatum diutinum,xanthoma disseminatum, and pyoderma gangrenosum have all been associated with aparaproteinemia72) The diagnosis is:A. CylindromaB. TrichoblastomaC. HidradenomaD. AcrospiromaE. Spiradenoma Correct ChoiceNEEDS EXPLANATIONS73) All of the following are true of reticulohistiocytoma except:A. Trauma is precipitating factorB. Rare occurrence in childrenC. Association with arthritisCorrect ChoiceD. Immunostaining is positive for OKM1E. Giant cells with “ground-glass” cytoplasmReticulohistiocytomas, also called giant cell reticulohistiocytomas, occur almost exclusively in adults.They are generally solitary, and unlike the multicentric type, are not associated with mutilatingarthritis or predisposition for malignancy74) What is the diagnosis?A. SpiradenomaB. CylindromaCorrect ChoiceC. Dermal duct tumorD. Syringocystadenoma papilliferumE. TrichoblastomaThis is a cylindroma, in which there is a jigsaw puzzle type arrangement of islands of basaloid cellswith intervening fibrous, pink stroma. The basaloid cells are sometimes rimmed by a thick, pinkbasement membrane75) Mulberry cells contain increased:A. Mitochondria Correct ChoiceB. Phagolysosomes and mitochondria 20
    • C. PhagolysosomesD. GolgiE. RibosomesHibernomas commonly arise in the neck, axillae, and posterior shoulder. The cells aremultivacuolated and resemble mulberries; the cells are filled with mitochondria, as are the cells innormal brown fat76) The endemic form of this disease may be transmited by:Image Link 1Image Link 2Image Link 3A. GlossinaB. SimuliumCorrect ChoiceC. LutzomyiaD. PhlebotomusE. TriatomaTriatoma (reduviid bug) species transmit American trypanosomiasis. Glossina is the genus of tsetseflies that transmit African trypanosomiasis. Simulium is the genus of the black fly that can tranmitOnchocerciasis and possibly the endemic form of pemphigus foliceus (fogo selvagem). Phlebotomusand Lutzomyia are types of sandflies that can transmit Leishmaniasis, Carrion’s disease, and viralsandfly fever77) Which of the following hitologic features would be most helpful in differentiating lichenoid drugeruption from lichen planus?A. Squamatization of the basal layerB. Band-like infiltrate with “Saw-tooth” rete ridgesC. Parakeratosis and eosinophilsCorrect ChoiceD. Presence of pruritusE. Civatte bodiesLichenoid drug eruptions share clinical and histopathologic features with lichen planus. Sometimesdifferentiation is not possible; however, eosinophil, parakeratosis, and a deeper perivascularinfiltrate is more suggestive of lichenoid drug. Implicated medications include captopril,penicillamine, and chloroquine78) In this patient, this test will be helpful in making the diagnosis:A. Direct immunofluorescenceCorrect ChoiceB. Tissue cultureC. Fluorescent antibody test for herpesD. Patch testE. KOH examThis patient has penicillamine-induced pemphigus foliaceus. Direct immunofluorescence testing willbe very helpful as it should reveal intercellular antibodies within the epidermis 21
    • 79) This patient says the rash is spreading and not controlled with topical therapy. You give him acourse of oral treatment that lasts:A. 1 weekB. 3 weeksCorrect ChoiceC. 5 weeksD. 4 weeksE. 2 weeksGenerally, for poison ivy dermatitis, if patients are given a course of oral steroids, the course shouldbe at least 3 weeks long, as if the duration is shorter, patients may develop a rapid rebound80) Langerhans cells express or are characterized by all of the following except:A. HLA-DRB. ChromagraninCorrect ChoiceC. Birbeck granulesD. CD1aE. S-100Chromagranin stain neuroendocrine cells, Merkel cellcarcinomas and eccrine glands. They do notstain Langerhans cells81) What is the diagnosis?A. DermatomyofibromaB. LeiomyosarcomaC. Palisaded encapsulated neuromaCorrect ChoiceD. LeiomyomaE. Traumatic neuromaThis is a palisaded encapsulated neuroma, in which there are small bundles of cells that have wavy,thin (elongated) nuclei and pink cytoplasm. The cells are separated by artifactual clefting. Thebundles are often located very superficially. Encapsulation is often incomplete/not obvious82) This woman should have a workup for:A. NephrolithiasisB. HemochromatosisCorrect ChoiceC. LymphomaD. ThalassemiaE. Pancreatic cancerPorphyria cutanea tarda has been shown to be associated with hemochromatosis. Patients withporphyria cutanea tarda have mutations in the HFE gene, and early detection of mutations canimprove life expectancy for these patients 22
    • 83) The diagnosis is:Image Link 1Image Link 2Image Link 3A. myxedemaB. digital mucous cystCorrect ChoiceC. reticulated erythematous mucinosisD. mucinous granuloma annulareE. papular mucinosisIn a digital mucous cyst, one sees a collection of mucin in the dermis beneath acral skin. This entityis not a true cyst as there is no epithelial lining to the cyst. The mucin is largely composed ofhyaluronic acid84) The diagnosis is:Image Link 1Image Link 2Image Link 3Image Link 4Image Link 5A. neurothkeomaB. palisaded encapsualted neuromaCorrect ChoiceC. amelanotic blue nevusD. dermatofibromaE. leiomyomaIn palisaded encapsulated neuroma, there are broad fascicles of spindle cells set in a clear matrix.The fascicles of spindle cells are sometimes clearly separated from the surrounding normal dermisby a capsule, but other times blend into the dermis. The spindle cells have elongated, thin/taperednuclei. Palisading of nuclei is often not obvious85) The diagnosis is:Image Link 1Image Link 2Image Link 3A. granuloma facialeB. pigmented purpuraC. leukocytoclastic vasculitisCorrect ChoiceD. mastocytosisE. acrodermatitis of MaliIn leukocytoclastic vasculitis, on low power there is an inflammatory infiltrate generally clusteredaround the vessels (although sometimes more dense and interstitial). There is extravasation oferythrocytes around vessels with predominantly neutrophils around vessels and often within thewalls of the vessels. There is fragmentation of neutrophilic nuclei (“nuclear dust”) with fibrin (pinkamorphous material) within the walls of vessels and sometimes frank destruction of vessels86) Which type of artifact is illustrated here? 23
    • A. ElectrodessicationCorrect ChoiceB. Gel foamC. Knife chatterD. DessicationE. FreezeThe elogation of cells and spindling of nuclei with typical "string bean" appearance are characteristicof electrodessication artifact87) This patient’s biopsy will likely show:A. Mononuclear cells with abundant cytoplasm around superficial vesselsB. Eosinophils at the dermoepidermal junctionC. Leukocytoclasia around superficial vesselsD. Lymphocytes at the dermoepidermal junctionCorrect ChoiceE. Neutrophils at the dermoepidermal junctionThis patient has erythema multiforme, and biopsy should show a lichenoid infiltrate of lymphocytesat the dermoepidermal junction88) The promontory sign is seen in:A. Tufted angiomaB. Acroangiodermatitis of MaliC. Kaposi’s sarcoma Correct ChoiceD. Glomeruloid hemangiomaE. Spindle cell hemangioendotheliomaThe promontory sign refers to the formation of new vessels around existing vessels and adnexalstructures. This is seen in Kaposi’s89) What is the diagnosis?A. Lupus erythematosusB. Mycosis fungoidesC. PoromaD. PorokeratosisE. PsoriasisCorrect ChoiceThis is psoriasis, in which there is parakeratosis with entrapped neutrophils overlying a regularlyacanthotic epidermis. There is hypogranulosis of the epidermis with increased mitoses in the basallayer. There are thinned suprapapillary plates with dilated vessels in the superficial dermal papillae.There is a lympho-histiocytic infiltrate around superficial vessels. Occasionally, clusters ofneutrophils can be seen in the stratum spinosum (spongiform pustules of Kogoj90) What is the diagnosis?A. Melanoma 24
    • B. Extramammary Paget’sCorrect ChoiceC. Sebaceous carcinomaD. Bowen’sE. CondylomaThis is an example of extramammary Paget’s, in which there are atypical cells singly and in groupswithin the epidermis. The cells have abundant bluish cytoplasm91) This is secondary to:Image Link 1Image Link 2A. paraproteinemiaB. a dull bladeC. silicone injectionsD. gel foamCorrect ChoiceE. metastatic carcinomaGel foam in tissue sections is a characteristic wavy material that stains bluish-gray92) The predominant location of the cleft in transient neonatal pustular melanosis is:A. SuprabasalB. Basement membrane zoneC. Subcorneal/granularCorrect ChoiceD. DermalE. Basal keratinocytesTransient neonatal pustular melanosis is an idiopathic pustular eruption of newborns, mostly on thechest, that heals with hyperpigmentation. It is most common on pigmented individuals.Histologically it presents as subcorneal pustules with eosinophils and neutrophils93) What is the diagnosis?A. ChondrodermatitisCorrect ChoiceB. Granular cell tumorC. BromodermaD. Lichen simplex chronicusE. Actinic keratosisThis is chondrodermatitis nodularis helices, in which there is hyperkeratosis and parakeratosisoverlying an altered/thickened epidermis. Beneath that area, in the dermis, there is often fibrosis.Flanking the fibrosis on either side, there is a proliferation of vessels and inflammation (resemblinggranulation tissue94) A lichenoid infiltrate that surrounds eccrine glands is seen in:A. Lichen planus 25
    • B. Lichenoid purpuraC. Lichen striatusCorrect ChoiceD. Lichenoid drug rectionE. Lichen planopilarisLichen striatus is an uncommon inflammatory dermatitis seen most commonly in children aged 5 to15. It presents unilaterally along Blaschkos lines as raised, slightly scaly, erythematous papules,which are often pruritic. These lesions typically regress spontaneously within a year. Thehistopathologic features of lichen striatus include a superficial perivascular inflammatorylymphohistiocytic infiltrate with rare plasma cells and eosinophils. There is a focal lichenoid infiltratein the papillary dermis with basilar vacuolar alteration and necrotic keratinocytes. Spongiosis withexocytosis of lymphocytes can be seen in the epidermis. A specific and distinctive feature of lichenstriatus is the presence of an inflammatory infiltrate that surrounds hair follicles and eccrine glands95) Similar follicles can be seen on skin from the:A. EyelidCorrect ChoiceB. NoseC. FingerD. Glans penisE. Labia majoraVellus hair follicles are seen commonly in accessory tragic and eyelid skin96) What is the diagnosis?A. Incontinentia pigmentiB. Lichen striatusC. Lichen simplex chronicusD. Lichen planusCorrect ChoiceE. Pityriasis lichenoides et varioliformis acutaThis is lichen planus, in which there is hyperkeratosis (and no parakeratosis), irregular acanthosis ofthe epidermis, hypergranulosis (often in wedge shapes), saw-toothing of the basal layer, and aband-like inflammatory infiltrate of predominantly lymphocytes (usually no eosinophils) at thedermoepidermal junction. Occasionally, artifactual clefting can be seen at the dermoepidermaljunction (Max-Joseph space). Colloid bodies/Civatte bodies (amorphous pink material in globs) mayalso be seen near the dermoepidermal junction97) This reaction is most likely secondary to:Image Link 1Image Link 2A. nicotinamideB. tetracyclineC. mycophenolic acidD. captoprilCorrect ChoiceE. cyclosporine 26
    • Bullous pemphigoid can be drug-induced and a common inciting drug is captopril. Other causesinclude lasix, nalidixic acid, penicillamine, antibiotics (penicillin, amoxicillin, ampicillin), and PUVA98) All have been associated with increased risk of breast cancer except:A. Birt-Hogg-Dube Correct ChoiceB. ataxia telangiectasiaC. Multicentric reticulohistiocytosisD. Peutz-JeghersE. Cowden’sBirt-Hogg-Dube is associated with renal cancer and thyroid cancer. Female carriers of a mutatedATM (homozygous mutations ATM cause ataxia telangiectasia) have an increased risk of breastcancer99) The diagnosis is:Image Link 1Image Link 2Image Link 3A. microcystic adnexal carcinomaB. mixed tumorCorrect ChoiceC. syringofibroadenomaD. mucinous carcinomaE. papillary eccrine adenomaSome authors separate mixed tumors into eccrine and apocrine types. In the eccrine mixed tumor(pictured here), there are cords, clusters, and strands of basaloid cells forming lumina, some linedby eosinophilic cuticles. These clusters of cells are embedded in a bluish myxoid/cartilaginousstroma100) The predominant location of the cleft in acropustulosis of infancy is:A. DermalB. Basment mebrane zoneC. Subcorneal/granularCorrect ChoiceD. SuprabasalE. Basal keratinocytesAcropustulosis of infancy presents as idiopathic pustules on acral skin. Diagnosis is made only afterother causes of pustules have been ruled out, and it usually resolves in a few years. The cleft inacropustulosis of infancy is subcorneal/granular with neutrophils101) Cicatricial pemphigoid antibodies directed against this are associated with high frequency ofmalignancy:A. Laminin 5 Correct ChoiceB. Beta4-integrinC. BPAg2 27
    • D. Laminin 6E. All of these answers are correctAnti-laminin 5 cicatricial pemphigoid (CP) is also known as anti-epiligrin CP. Anti-epiligrin CP isassociated with an increased frequency of internal adenocarcinomas. Laminin 5 is composed ofthree chains (heterotrimer), alpha3, beta3, gamma2. Antibodies are frequently directed against thealpha3 chain, and so cross-reactivity can be observed with laminin 6, as laminin 6(alpha3beta1gamma1) has the alpha3 chain as well. Beta4-integrin antibodies have been associatedwith ocular CP. BPAg2 antibodies are seen in CP patients that have mucosal as well as skin disease102) This patient may have antibodies to:Image Link 1Image Link 2Image Link 3A. metalloproteinaseB. transglutaminaseC. myeloperoxidaseCorrect ChoiceD. proteinase-3E. aminotransferaseThe figures are consitent with polyarteritis nodosa. Patients with polyarteritis nodosa may haveantibodies to p-ANCA or myeloperoxidase103) The diagnosis is:Image Link 1Image Link 2Image Link 3Image Link 4A. malignant fibrous histiocytomaB. nodular fascitisCorrect ChoiceC. epithelioid sarcomaD. neurofibromaE. dermatofibrosarcoma protuberansIn nodular fasciitis, there is a ill-defined deep (often extending into fat) proliferation of plumpspindle cells that on higher power resemble “tissue-culture fibroblasts” with elongated cytoplasmoften set in a background of many small vessels and extravasated erythrocytes. The spindle cellsare arranged haphazardly, and the stroma is often myxoid. Mitoses are common104) What is the diagnosis?A. PsoriasisB. Granular parakeratosisCorrect ChoiceC. Lichen nitidusD. DermatophyteE. Lichen planus 28
    • Granular parakeratosis results from abnormal keratinization which generally occurs in the flexuralareas. Histologically, the thick parakeratotic layer with retention of keratohyaline granules. Inaddition, the granular layer is preserved with relatively normal epidermis105) What is the diagnosis?A. MastocytosisB. LeprosyC. SarcoidD. Lichenoid actinic keratosisE. Lichen nitidusCorrect ChoiceThis is lichen nitidus, in which there is a “ball” of lymphocytes and histiocytes in the superficialdermis abutting the epidermis surrounded on both sides by “claws” of the epidermis (rete106) Which of the following drugs has been known to cause pyogenic granuloma?A. CapecitabineCorrect ChoiceB. PaclitaxelC. IsosfamideD. DaunorubicinE. MithramycinSystemic retinoids, indinavir and capecitabine have all been describe to cause pyogenic granulomas107) Which of the following histologic features is seen in aging skin?A. Increased sebum productionB. Increased number of terminal hairsC. Thickened dermal-epidermal junctionD. Fewer Langerhans cellsCorrect ChoiceE. Increased mast cellsHistologic features of aging epidermis include flattened dermo-epidermal junction, occasionalnuclear atypia, decrease in the number of melanocytes and Langerhans cells. Changes that arepresent in the dermis include atrophy, decrease in fibroblasts, mast cells and blood vessels108) In this patient, this test will be helpful in making the diagnosis:A. Patch testB. Fluorescent antibody test for herpesCorrect ChoiceC. Tissue cultureD. KOH examE. Indirect immunofluorescenceThis patient has herpes zoster. A direct fluorescent antibody test for the varicella zoster virus can beperformed to confirm the diagnosis. 29
    • 109) This patient also has anemia. He needs screening for::Image Link 1Image Link 2Image Link 3A. malignancyCorrect ChoiceB. liver cirrhosisC. diabetesD. pulmonary firbrosisE. immunosuppressionThe histology shows numerous neutrophils in the dermis with a lack of vasculitis, consistent withSweet’s syndrome. In a patient with Sweet’s syndrome, the presence of anemia is associated withan internal malignancy.110) Multiple such lesions are associated with::Image Link 1Image Link 2A. CowdensCorrect ChoiceB. GorlinsC. WernersD. BloomsE. SipplesMultiple sclerotic fibromas are seen in Cowden’s syndrome.111) The diagnosis is:A. DermatofibrosarcomaB. Angiolipoma Correct ChoiceC. Epithelioid sarcomaD. Nodular fasciitisE. LiposarcomaNEEDS EXPLANATIONS112) Cellular neurothekeoma stains with:A. Low molecular weight keratinB. Stromelysin-3C. DesminD. PGP-9.5 Correct ChoiceE. S-100PGP-9.5 and S100-a6 stains cellular neurothekeoma. Stromelysin-3 is positive in dermatofibromasand negative in dermatofibrosarcoma protuberans. Desmin stains rhabdomyosarcoma. S-100 stainsneural tumors and melanocytic tumors among other things, but cellular neurothekeomas aregenerally S100-negative 30
    • 113) What stain may be used to differentiate this entity from metastatic oat cell carcinoma of thelung?A. HMB 45B. CEAC. PASD. Cytokeratin 20Correct ChoiceE. S-100Merkel cell carcinoma is a neuroendocrine cancer, usually of the head and neck. The tumor stainwith cytokeratin 20 which is expressed in a paranuclear dot-like pattern. This stain helps todifferentiate Merkel cell carcinoma from metastatic oat cell carinoma of the lung.114) The diagnosis is:Image Link 1Image Link 2Image Link 3A. Epithelioid sarcomaB. AngiosarcomaC. Epithelioid hemangioendotheliomaD. Kaposis sarcomaCorrect ChoiceE. Aneurismal dermatofibromaIn nodular Kaposi’s sarcoma, one sees a proliferation of spindle cells, often arranged in nodulesseparated by fibrous bands. On higher power examination of the spindle cells, numerousextravasated erythrocytes can be seen between the cells. Often, hemosiderin-filled macrophagesand plasma cells can be seen as well. The spindle cells are packed closely together and often willhave intracytoplasmic pink inclusions (erythrophagolysosomes115) The diagnosis is:A. PsoriasisB. Pityriasis rubra pilarisCorrect ChoiceC. Inflammatory linear verrucous epidermal nevusD. Prurigo nodularisE. IchthyosisNEEDS EXPLANATION116) What is the diagnosis?A. Dilated poreCorrect ChoiceB. FibrofolliculomaC. Pilar sheath acanthomaD. Keratosis pilaris 31
    • E. TrichoadenomaThis is a dilated pore, in which there is an invagination lined by epidermis that is slightly acanthotic117) These cells should stain with:Image Link 1Image Link 2Image Link 3A. S100B. factor XIIIaC. cytokeratinD. CD34E. actinCorrect ChoiceThis is a dermatomyofibroma. Dermatomyofibromas are often found over the scapula of women.The spindle cells are oriented parallel to the epidermis, and stain with vimentin and non-specificmuscle actin. The spinde cells do not stain with desmin, S100, CD34, or Factor XIIIa118) What is the diagnosis?A. ImpetigoB. Bullous pemphigoidCorrect ChoiceC. Subcutaneous lupus erythematosusD. Dermatitis herpetiformisE. Polymorphous light eruptionThis is bullous pemphigoid, in which a subepidermal bullae/vesicle displays numerous eosinophilslining up at the dermo-epidermal junction119) This developed in a patient with a history of breast cancer s/p surgical excision/radiation. Herdiagnosis is:Image Link 1Image Link 2Image Link 3A. HornersB. Stewart-TrevesCorrect ChoiceC. Parkes-WeberD. KettlesE. Klippel-TrenaunayAngiosarcoma can develop in a lymphedematous extremity. When it develops in the upperextremity after surgical treatment of breast cancer, it is referred to as Stewart-Treves syndrome.When it develops in the lower extremity after lymph node dissection for a melanoma, it is referredto as Kettles syndrome120) What is the diagnosis?A. Trichofolliculoma 32
    • B. SpiradenomaC. TrichilemmomaD. Mixed tumorE. TrichoepithliomaCorrect ChoiceThis is a trichoepithelioma, in which there are islands of basaloid cells in a somewhat fibrous stromawith no retraction between the islands and the stroma. Often horn cysts are seen (not shown).121) The inclusions in infantile digital fibromatosis stain for trichrome and:A. Thioflavin TB. Pentahydroxy flavanolC. Osmium tetroxideD. Phosphotungstic acid hematoxylin Correct ChoiceE. BodianOsmium tetroxide stains fat. Thioflavin T stains amyloid. The Bodian stain is for nerves.Pentahydroxy flavanol is a fluorescent stain for calcium122) The diagnosis is:Image Link 1Image Link 2Image Link 3Image Link 4A. myofibromatosisB. schwannomaC. Kaposis sarcomaD. neurofibromaCorrect ChoiceE. leiomyomaThis is a plexiform neurofibroma. There are discrete nodules of spindle cells within the dermis. Onhigher power, the cells have wavy nuclei with pink cytoplasm123) What is the diagnosis?A. Carbon tattooCorrect ChoiceB. Monsel’s reactionC. Blue nevusD. Postinflammatory hyperpigmentationE. Minocycline-induced hyperpigmentationThis is a carbon tattoo, in which there are extracellular and intracellular particles of black material inthe superficial dermis124) What is the diagnosis?A. Deep penetrating nevus 33
    • B. Recurrent nevusC. Congenital nevusCorrect ChoiceD. Epithelioid blue nevusE. Nevoid melanomaThis is a congenital nevus, in which there are nests of nevomelanocytic cells at the dermoepidermaljunction and extending deep into the dermis. In the deeper dermis, the cells infiltrate throughcollagen bundles and extend around adnexal structures. There is hyperkeratosis, acanthosis, andpapillomatosis of the surface epidermis125) The green color in chloroma is secondary to:A. StromelysinB. Myeloperoxidase Correct ChoiceC. FumaraseD. ChloracetateE. Alkaline phosphataseChloromas are greenish tumor grossly secondary to involvement of the skin in acute granulocyticleukemia. The green color is secondary to myeloperoxidase126) Supporting evidence for the diagnosis of mycosis fungoides is CD4+ lymphocytes with loss ofCD7 as well as loss ofA. CD20B. CD2C. CD30D. CD5 Correct ChoiceE. CD3CD5 as well as CD7 are sometimes lost on the surface of epidermotropic T cells in mycosisfungoides. CD2, CD3, and CD5 are T cell markers. CD20 is a B cell marker. CD30 is positive inanaplastic large cell lymphoma cells, Hodgkin’s lymphoma, and lymphomatoid papulosis. Reactiveinfiltrates can also have some CD30-positive cells127) Clinically, a nondescript hyperkeratotic papule on the ulnar side of the base of the fifth fingeris most likely:A. Cutaneous hornB. Accessory digit Correct ChoiceC. Digital fibromatosisD. Acquired digital fibrokeratomaE. Glomus tumorAccessory digits (supernumerary digits) are usually found at the base of the fifth finger, oftenbilaterally128) Multiple trichoepitheliomas are seen in all except: 34
    • A. Brooke-Fordyce syndromeB. Rombo syndromeC. Gorlins syndrome Correct ChoiceD. Brooke-Spiegler syndromeE. Bazexs syndromeGorlins syndrome is nevoid basal cell carcinoma syndrome; multiple trichoepitheliomas are notseen. Several syndromes have been associated with multiple trichoepitheliomas: Basex, Brooke-Fordyce, Brooke-Spiegler, Rombo, and possibly Rasmussen. (Rasmussen described one family in1975 with autosomal dominant inheritance of multiple trichoepitheliomas, milia, and cylindromas.)Basex syndrome (follicular atrophoderma, hypotrichosis, occasional trichoepitheliomas, basal cellcarcinomas, and localized or generalized hypohidrosis) is inherited in an X-linked dominant manner.Brooke and Fordyce both described multiple trichoepitheliomas concurrently in 1892, and thereforemultiple familial trichoepitheliomas are sometimes called “Brooke-Fordyce” sydrome. Spieglerdescribed patients with multiple cylindromas in 1899 and also noted that many of these patientshad mutiple trichoepitheliomas; more recently it has been noted that multiple spiradenomas may beseen in patients with multiple trichoepitheliomas and cylinidromas; this co-occurrence of tumors hasbeen referred to as “Brooke-Spiegler” syndrome. (Brooke-Fordyce and Brooke-Spiegler are likelythe same syndrome.) Rombo syndrome is characterized by vermiculate atrophoderma, multipleBCCs, multiple trichoepitheliomas, cyanosis and peripheral vasodilation129) The diagnosis is::Image Link 1Image Link 2Image Link 3Image Link 4A. hypertrophic scarCorrect ChoiceB. leiomyomaC. dermatomyofibromaD. neurofibromaE. dermatofibroma130) What is the diagnosis?A. Adenoid cystic carcinomaB. TrichoblastomaC. Microcystic adnexal carcinomaD. TrichodiscomaE. Morpheaform basal cell carcinomaCorrect ChoiceThis is a morpheaform basal cell carcinoma, in which there are very infiltrative islands of basaloidcells, extending deep into the dermis. Around some of the basaloid islands, there is new, pinkcollagen. The basaloid proliferation off of the surface of the epidermis is more typical of a superficialmulticentric basal cell carcinoma and aids in the diagnosis131) This patient should be examined for::Image Link 1Image Link 2Image Link 3Image Link 4 35
    • A. photosensitivityB. keratoacanthomasCorrect ChoiceC. pigmentary anomaliesD. odontogenic cystsE. arsenical keratosesThe figures show a sebaceous adenoma. Sebaceous adenomas are associated with Muir-Torresyndrome, in which patients can have an internal malignancy and multiple keratoacanthomas132) The most likely diagnosis for this lesion would be:A. VerrucaB. AcrochordonC. Acquired digital fibrokeratomaCorrect ChoiceD. Amputation neuromaE. Supernumery digitThe diagnosis of this acral lesion is an acquired digital fibrokeratoma which shows a small, exophyticcircumscribed lesions. Collagen bundles are oriented perpendicularly to the skin surface. The lesionlacks nerve twigs and bone, which may be present in supernumery digit or amputation neuroma133) Clear cell syringomas are associated with:A. SarcoidosisB. MalignancyC. Diabetes Correct ChoiceD. Lichen myxedematosisE. ArgyriaClear cell syringomas are associated with diabetes. Syringomas are associated with Down’ssyndrome134) The diagnosis is:Image Link 1Image Link 2Image Link 3A. tubular apocrine adenomaB. dermal duct tumorC. syringomaD. trichoepitheliomaE. adenoid cystic carcinomaCorrect ChoiceIn adenoid cystic carcinoma, there are cords and tubules of basaloid cells, arranged in a cribiformpattern. The cystic spaces contain a bluish material. Perineural invasion is common. The cells stainpositively for epithelial membrane antigen (EMA).135) What is the cause of this pigmentary condition? 36
    • A. HemochromatosisB. Post-inflammatory hyperpigmetationC. Minocycline ingestionD. ArgyriaCorrect ChoiceE. ChrysiasisThe characteristic feature of argyria is the presence of black granules in the eccrine glands. Itdifferentiates this condition from other pigmentary disorders136) The diagnosis is:Image Link 1Image Link 2Image Link 3Image Link 4A. Erythropoietic protoporphyriaB. Lipoid proteinosisC. Radiation dermatitisD. Colloid miliumE. Lichen sclerosus et atrophicusCorrect ChoiceIn lichen sclerosus et atrophicus, there is often an atrophic epidermis with overlying orthokeratosisthat is thicker than the stratum spinosum, with some follicular plugging. There is sometimes asubepidermal separation. The upper dermis is homogenized and pink/pale. Sometimes underlyingthe homogenized zone, there is a band-like infiltrate (not seen here137) A patient with a blue-red discoloration of the nail plate reports that the same finger becomesvery tender when exposed to the cold. You suspect a:A. Pyogenic granulomaB. Glomus tumorCorrect ChoiceC. Periungual verrucaD. Mucous cystE. PterygiumGlomus tumors are tumors of the arterio-venous anastamosis of the digital dermis. They occur mostfrequently in the nail bed. The commonly have a bluish-red discoloration and may be tender orpainful with exposure to heat or cold138) Verruciform xanthoma is seen most commonly on:A. Distal extremitiesB. Mucosal surfaces and trunk/proximal extremitiesC. Oral mucosae and genital areas Correct ChoiceD. Nail bed and periungual areasE. Head and neckNEEDS EXPLANATION 37
    • 139) This patient developed an acute vesicular rash after eating a mango. She has returned for aroutine follow-up. She needs to be careful of exposure to:A. All of these answers are correctB. Ginkgo fruitCorrect ChoiceC. CrotonD. RagweedE. Tea tree oilPatients allergic to the peel of a mango can also be allergic to other plants/products of theAnacardiaceae family. Cross-reactions can occur with exposure to any plants of the genusToxicodendron, to the oil from the cashew nut shell, to the Brazilian pepper tree, to lacquer fromthe Japanese lacquer tree, to ink from the Indian marking nut, and to the fruit pulp of the ginkgotree, and others140) The diagnosis is:Image Link 1Image Link 2Image Link 3Image Link 4A. BlastomycosisB. CryptococcosisC. HistoplasmosisD. ToxoplasmosisE. LeishmaniaisisCorrect ChoiceThe diagnosis is Leishmaniasis. In this condition, the epidermis is often ulcerated (not seen in thiscase) with a dense infiltrate is seen within the dermis. There are numerous macrophages(Leishman-Donovan bodies) within the infiltrate that have intracellular amastigotes within them. Onclose examination of the parasites, a kinetoplast is evident. In contrast to histoplasmosis, a discretehalo is not seen around the amastigotes141) Caterpillar bodies are seen in:A. Dyskeratosis congenitalB. Porphyria cutanea tarda Correct ChoiceC. AmyloidosisD. Lipoid proteinosisE. MucoceleCaterpillar bodies are thought to be type IV collagen142) A healthy 6 month old girl has a subcutaneous nodule above her right eyebrow. A skin biopsydemonstrates a cystic lesion with adnexal structures in the wall. Your diagnosis is:A. Nevus sebaceousB. Epidermal inclusion cystC. Steatocystoma 38
    • D. Pilar cystE. Dermoid cystCorrect ChoiceDermoid cysts present along lines of embryonic closure. The are most commonly found on the head(around the eyes) and the neck. They are lined by an epidermis that contains various epidermalappendages that are usually fully matured143) The diagnosis is:Image Link 1Image Link 2Image Link 3A. basaloid squamous cell carcinomaB. malignant acrospiromaC. poroid squamous cell carcinomaD. porocarcinomaE. basosquamous carcinomaCorrect ChoiceIn basosquamous carcinomas, there are areas that appear typical of basal cell carcinoma (withbasaloid cells coming off the epidermis in buds with peripheral palisading) as well as areas typical ofsquamous cell carcinoma (with atypical keratinocytes that are more pink and angular than basaloidcells). Often, ulcerated basal cell carcinomas have squamous differentiation at the base of the ulcerand this is not to be confused with a basosquamous carcinoma, in which there are areas of bothbasal cell carcinoma and squamous cell carcinoma144) The diagnosis is:A. Dermatofibroma Correct ChoiceB. DermatomyofibromaC. NeurofibromaD. Plexiform fibrohistiocytic tumorE. Infantile digital fibromatosisNEEDS EXPLANATIONS 39