[vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][ultimate_heading main_heading=”Candidate brief” main_heading_color=”#000000″ sub_heading_color=”#000000″ main_heading_style=”font-weight:bold;” main_heading_font_size=”desktop:36px;”]

“This patient has been referred to clinic on account of shortness of breath.  Please examine him and present your findings to the examiners.”

[/ultimate_heading][vc_empty_space image_repeat=”no-repeat”][vc_video link=”https://vimeo.com/150791665″][vc_empty_space image_repeat=”no-repeat”][vc_row_inner row_type=”row” type=”full_width” use_row_as_full_screen_section_slide=”no” text_align=”left” css_animation=””][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Station Time” counter_value=”20″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Time for this encounter” counter_value=”10″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Maximum time to examine your patient” counter_value=”6″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Minimum time for discussion and questions” counter_value=”4″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][/vc_row_inner][vc_empty_space image_repeat=”no-repeat”][/vc_column][/vc_row][vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][vc_accordion style=”accordion”][vc_accordion_tab title=”Common examiner questions”][vc_column_text]Common examiner questions include the following:

  1. What do you think this patient has?
  2. How would you like to investigate this patient next?
  3. What do you think the underlying cause of this patient’s signs is?

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Diagnosis and clinical signs”][vc_column_text]This patient has sarcoidosis.

The clinical signs exhibited in this video include:

  • Bibasal crepitations;
  • Lupus pernio;
  • Erythema nodosum.

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Discussion”][vc_column_text]Lupus Pernio is a sarcoidosis cuatneous variant that presents with symmetric erythematous nodules and plaques over ears, nose, cheeks and digits [1].  It is pathognomonic of sarcoidosis. The lesion is:

  • Typically red to purple due to increased vasculature
  • Swollen
  • Accompanied with shiny skin changes on the affected part.
  • Lesions may have an appearance of small beads along the edge, especially in case of nose rim lesions.

Lupus Pernio if present is highly predictive of involvement of pulmonary parenchyma, nasal and oral mucosa, pharynx, larynx, tongue, tonsils and salivary glands. As mentioned it is a cuatneous manifestation of chronic multi system sarcoidosis, which itself has an obscure etiology, with the following pre-disposing factors:

  • Genetic pre-disposition triggered by:
    • Bacteria
    • Viruses
    • Dust or chemicals
  • Female gender
  • African-American ancestry
  • Family history

While clinical presentation helps in differentiating it from other lesions, biopsy provides a definitive diagnosis. Being highly correlated with sarcoidosis, patients presenting with this lesion must be evaluated and assessed for sarcoidosis. Investigations include:

  • Chest x-ray
  • Liver function tests
  • Renal tests
  • Serum Calcium
  • Tuberculin skin testing
  • ECG
  • Ophthalmologic evaluation
  • Pulmonary function testing

Although a variety of therapeutic options are available for sarcoid, there is still debate on the best therapy for cuatneous manifestations. Management of skin lesions includes;

  • Avoiding exposure to natural light
  • Systemic glucocorticoids
  • Intra lesional injections of triamcinolone acetonide (limited skin disease)
  • Chloroquine
  • Hydroxychloroquine
  • Methotrexate
  • Azathioprine
  • Cyclophosphamide
  • Thalidomide
  • TNF inhibitors
  • Pulsed dye and CO2 laser are used for debulking of granulamotus lesions.

References

[1] Gopikrishnan Anjaneyan, Rita Vora. Lupus pernio without systemic involvement. Indian Dermatol Online Journal. 2013 Oct-Dec; 4(4): 314–317.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Specimen case presentation”][vc_column_text]”This gentleman has sarcoidosis.  He has a combination of lupus pernio on the nose and fine bibasal crepitations in keeping with a complication of pulmonary fibrosis.  I’d like to investigate further with a chest x-ray and pulmonary function tests.  I’d also consider arranging a skin biopsy.”[/vc_column_text][/vc_accordion_tab][/vc_accordion][/vc_column][/vc_row]