Immuno/Rheum/OpthalSAQs

A76yearoldfemalewithahistoryofhypertensionpresentswithacuteonsetofpainanddecreasedvisual acuitytoherlefteye.Thereisnohistoryof trauma.Aphotoisattached:

1. List4positivefindingsonthephotographabove:(4marks)- Cloudycornea- Fixedpupilnotreactingtolight(whichcanbeseenshiningintoit)- Mid-dilated- Conjunctivalinjection

2. Whatisthediagnosis?(1mark)

- Acuteclosedangleglaucoma

3. Inthetablebelowlistthreedrugs,dosesandrationaleforprescriptioninthe

circumstance(3marks)

Drug Dose Rationale

Mannitol 1-2g/kgIV Reducesvolumeofaqueoushumor

Acetazolamide 250-500mgIV/PO Blocksproductionofaqueoushumor

Pilocarpine1-2% 1dropeveryq15mins Facilitatesoutflowofaqueoushumor

NB–otherexamplesoftreatmentareacceptable,butyouMUSThaveoneexampleofeachmechanismofactioninordertogainfullmarks

Question2

A58yearoldmanhasbeenreferredfromhisGPwithapainfulskinrashthatinitiallystartedasoralmucosalesionsseveralweeksprior.Hehasabackgroundofhypertensionandsmokingbutisotherwiseslimanddoesn’thaveanyothercomorbidities.Heisinsignificantdiscomfort,buthisvitalsignsarenormal.

Aphotographisbelow

Describethephotographabove(3marks)

Large,blisteringlesionserosionsoftheskin

Confluentinareas,isolatedinothers

Surroundingskinnormalincolourandappearance

Whatisthemostlikelydiagnosis?(1mark)

PemphigusVulgaris

Name2differentialdiagnosesandaclinicalfeaturethatmaydistinguishthemfromyourprovisionaldiagnosis(4marks)

Bullouspemphigoid–doesn’ttendtoinvolvetheoralmucosa,aren’tpainful(moreitchythanpainful),feverisveryrare.

Stevens-JohnsonSyndrome–Febrile,generalisedachesandpains(myalgia/arthralgia)andconjunctivitisismuchmorecommonthaninPV.Mucosalinvolvementismuchmoreprominentandmoresevere,affectingATLEASTtwomucsalareas–eyes,mouth,pharynx,genitals,UpperrespiratorytractorlowerGItract.

Howisthediagnosisconfirmed?(1mark)

Skinbiopsy

Outlinethemanagementprioritiesforthiscondition(3marks)

- Primaryaimoftreatmentistodecreaseblisterformation,preventinfectionsandpromotehealing.Systemiccorticosteroids,suchasoralprednisolone50mgdaily,orIVHydrocortisone100mgQIDifunabletoswallowduetomucosalinvolvement,arethemaintreatments.Otherimmunosuppressants,suchasazathioprineandcyclophosphamidecanbetrialledifsteroidsarecontraindicatedordiseaseprogressesdespitethis.

- Topicalemollientshelptoreducepainandpromotehealing- Woundcarewithappropriatedressings,suchasnon-adherentdressingsandabsorbent

ones,providesymptomaticreliefaswellQuestion3A65-year-oldmaleattendscomplainingoflossofvisioninhislefteye.Hehasnopainandisotherwisewell.Fundoscopyofhiseyeisshownbelow.

a)Listsixfeaturesyouwouldenquireaboutinthehistory(6marks)

- Visualacuity- Flashers/floaters- amaurosisfugax- trauma- headache/temporalpain- systemicupset- neurologicalsignsorsymptoms- eyepain- previousmedicalhistorye.g.AF,TIA

b)Name2abnormalitiesofthefundusphotographabove.(2marks)

- Venousengorgement- Widespreadhaemorrhage- Sunsetappearance

c)Whatisthediagnosis?(1marks)

- CentralRetinalVenousOcclusiond)Give4knownassociationsofthiscondition(4marks)

- Trauma–closedheadinjury- Vasculitis- Hypercoagulabilitystates- HTN- DM- Alcohol- Glaucoma

Question4A34yearoldmalepresentstotheEDwithawidespreadblisteringrash.Heissystemicallyunwellandtellsyouthatherecentlystartedanewmedicationforhighbloodpressure.

a) OtherStevens-JohnsonSyndrome,listsixdifferentialdiagnosisforarashinthispatient(6marks)

- Sunburn- Kawasakisyndrome- Toxicshocksyndrome- Staphylococcalscaldedskin- Erythemamultiforme- Pemphigoid(orbullouspemphigoid)- Pemphigus(orpemphigusvulgaris)- Subcornealpustulardermatosis- Insectbites- Mustardgas- Boricacidtoxicity- Herpessimplex- Herpeszoster

b) GivefourcausesofStevens-JohnsonSyndrome(4marks)

- Herpessimplex- Mycoplasma- CMV- Penicillins- Cephalosporins- Sulphonamides- Phenytoin- Carbamazepine- Allopurinol- Lamotrigine- NSAIDsespeciallyoxicams- Immunisations- Paracetamol(rarely)

c) DescribeNikolsky’ssign(1mark)

Epidermisdetachesfromthedermis/burnbedwithslightfrictionorrubbingoftheskinwithfinger