Question of the Week # 321

321)  A 45 – year-old obese woman presents to your office complaining of a skin lesion on her left shin. This lesion started spontaneously 3 weeks ago and appeared like a small bruise. Over the past two weeks, the lesion has enlarged and the overlying skin has become hardened and raised with reddish border. There is no pain or itching. She denies any recent trauma. She lives in  Texas but one month ago, she traveled to New England region to visit a friend. She is sexually active with one partner and occasionally, uses condoms.. Her past medical history is unremarkable. On physical examination, there is an oval shaped  lesion on her left shin. The border is indurated and red in color with yellowish, atrophic appearance in the center. An image of the lesion is shown below:

Which of the following investigations should be ordered next?

A) Lyme serology

B)  Hemoglobin A1C

C)  Anti-Myeloperoxidase ( P-ANCA)

D)  Colonoscopy

E)  Herpes Simplex Virus (HSV) Serology

22 Responses

  1. Lyme serology
    Erythema chronicum migrans ?

  2. bbbbbbbbbb

  3. a

  4. Travel to the NE. Lyme serology.

  5. a

  6. A as she has Target lesion ideal incubation period and H/o travel to NE

  7. C

  8. diabeitis atrophic center i guess if tick would have bitten her she would have given the history

  9. what is the correct answer??

  10. I think I would check for a tick bite hx and lymes would be a first differential.

  11. B) Hemoglobin A1C

    Its Necrobius Lipoidica

  12. B) Hemoglobin A1C

    Its Necrobiosis Lipoidica

  13. B……….
    A degenerative disease of the dermal connective tissue characterized by the development of erythematous papules or nodules in the pretibial area. The papules form plaques covered with telangiectatic vessels. More than half of the affected patients have diabetes.
    The average age of onset for necrobiosis lipoidica is 30 years, but it can occur at any age. The age of onset ranges from infancy to the eighth decade. The disease tends to develop at an earlier age in patients with diabetes. It also shows a sex predilection, being 3 times more common in women than in men.

    Necrobiosis lipoidica has been described in about 0.3% of diabetic patients. In one study, necrobiosis lipoidica was shown to precede the onset of diabetes mellitus in 15% of patients. In addition, 60% of patients had the diagnosis of diabetes mellitus prior to the onset of necrobiosis lipoidica, while 25% of patients had lesions that appeared with the onset of diabetes mellitus. The presence or progression of necrobiosis lipoidica does not correlate with how well diabetes is controlled.

  14. is colonoscopy the solution? is this indurated inflammatory lesion 2/2 to chron’s dz –> erythema nodosum? if the other choice said asca abd abca Ab’s i might have picked that solution b4 colonoscopy. i don’t think its lyme i haven’t seen erythema nodosum lesion in person but i have seen lyme and it was more of a rash this looks far to nasty…may b is right i’m not familiar with that. i would love the answer. i think the trip to new england is a distractor most pt’s don’t recall tick bite so sometimes not in hx. ahh i would have guessed EN tho and i guess would have been wrong.

  15. b necrobiosis lipoidica diabeticorum

  16. B

  17. Lyme serology

  18. Colonoscopy – for UC
    Looks like pyoderma gangrenosum

  19. c)
    Pyoderma Gangrenosum and Erythema nodosum – both are painful.

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