ACROMEGALY

Herpes Zoster

Herpes Zoster in Different presentations ....

Rheumatoid nodules

Erythema marginatum

Erythema marginatum

Is described as the presence of pink rings on the trunk and inner surfaces of the arms and legs which come and go for as long as several months.

Causes

1. Infections
2. Bacteria: Escherichia coli , streptococcal infections
   
3. Fungi: Dermatophytes , Candida albicans and blue cheese Penicillium.
   
4. Mycobacteria: Mycobacterium tuberculosis.
   
5. Parasites: Ascaris lumbricoides
   
6. Viruses: (EBV) & was reported in an HIV-positive patient.
7. Drugs: In the cases of the antimalarials chloroquine and hydroxychloroquine, the eruptions took 5 months to a year to clear, and there are another many drugs ..
   
8. Neoplasms: Hodgkin disease, acute myelogenous leukemia (AML), and squamous cell carcinoma in a sebaceous cyst , and others …
9. Foods: Blue cheese and tomatoes have been reported to cause EAC.
   
10. Other causes
    

• Cholestatic liver disease
• Graves disease
  
• Hypereosinophilic syndrome
  
• Sjögren syndrome
  
• Sarcoidosis
  
• Osteoarthritis
  
• Stress
  
• Pregnancy

DDx

Cutaneous T-Cell Lymphoma Erythema Gyratum Repens Granuloma Faciale Lupus Erythematosus, Subacute Cutaneous

Management

Erythema annulare centrifugum (EAC) is usually self-limited. Topical steroids usually cause involution of the treated lesions, but they do not prevent the occurrence of new lesions or recurrence of the eruption.

SLE

Gout

N.B.
1-Gout usually presents as recurrent attacks of acute inflammatory arthritis (a red, tender, hot, swollen joint).
2-The joint that is most commonly affected is the first metatarsalphalangeal joint at the base of the big toe (approximately 75 % of first attacks) and when this occurs it is known as " podagra ".

DD :
1- Septic arthritis >> only can be ruled out by joint aspiration and culture .
2- Chondrocalcinosis " deposition of calcium pyrophosphate " .
3- Gouty tophi, particularly when not located in a joint, can be mistaken for basal cell carcinoma or other malignancies .


Prevention :
1- Life style modification "dietary modification " ...
2- Allopurinol ...
3- Probenecid ...
4- EDTA , as a chelating agent, ..


Management of the acute attacks :
1- Conservative by : Ice application ..
2-NSAIDs
3- Steroid ...
4- Colchicine ..

DM & PM

Dermatomyositis

Dermatomyositis (DM) is an idiopathic inflammatory myopathy (IIM) with characteristic cutaneous findings.


Classification :

1. 1ry idiopathic PM
2. 1ry idiopathic DM ( PM + Skin lesion )
3. PM or DM + Malignancy
4. Juvenile DM
5. PM or DM associated with other CT disorders ( Mixed CT diseases )

Yoy Must search for malignancy especially in old male patients .
"The onset of a rash in patients with pre-existing myositis requires investigation of the neoplastic possibility"

C/p :
1- Muscle :
- bilateral proximal " weakness, wasting but not tender " , facal and distal muscles are not affected .
" DD >> -MG : occular and face affection , increase with use and nocturnal
-Guan Barre : Distal affection > proximal . "
- Dysphagia
- Cardiomyopathy >> HF , arrhythmia

2- Skin :

• Heliotrope rash
• Gottron's sign
• shawl sign ... ?

3- Malignancy
4- Raynaud's phenomenon
5- ISP fibrosis
6- Arthralgia

Investigations :
1- EMG
2- Muscle biopsy , after MRI .. ??
3- CK level
4- ANA
5- Anti-jo-1 .. it is a myositis specific antibody (30%)

Treament :
1- Please search for neoplasms anywhere .
2- Steroids with the usual regimen .
3- Immunosuppressive therapy .
4- Pulse steroid ... ???

Pyoderma gangernosum

The common conditions associated with pyoderma gangrenosum are:

1- IBD

2-Arthritides:

• Rheumatoid arthritis
• Seronegative symmetrical polyarthritis

3-Haematological disease:

• Myelocytic leukaemia
• Hairy cell leukaemia
• Myelofibrosis
• Myeloid metaplasia
• Monoclonal gammopathy (IgA)

Scleroderma

Scleroderma

1- A disease depends on :
a- Vascular lesions >> endoth. damage >> .. >> obliterative arterial lesions >> ischaemia ...
b-Fibrotic lesions >>and internal organs .. ??

c- Autoimmune mechanism >> may precipitate the vascular lesions or activate the fibrotic mechanism , beside its own harming effect

2-C/P

- Skin ; ( edematous >> fibrotic >> atrophic )

• Non pitting edema >> and then become tight
• Skin tightness >> shiny , atrophy , ulceration
• "Fish mouth " and wrinkles
  
• " Salt and pepper " areas of hyperpigmentation and hypopigmentation
• Raynaud's phenomenon ( pallor>cyanosis>erythema) 2/3 .. What are the precipitating factors of raynaud's phenomenon ??
• Vasculitis infarction
  
• Atrophy and resorption

-MSK ^ Non erosive ^

• Sclerodermaomyositis ( sclerosis + DM )

- GIT

• Dysphagia ( lower dysphagia )
• Reflux " due to laxity of the lower eso. sphincter " >> aspiration pneumonia and hoarseness
• Malabsorption $ " due to over bacterial growth "
• Intestinal pseudo-obstruction ..... so , the patient presents with a long duration of constipation followed by a sever diarrhea .. so doctors prefer to give a prophylactic course of antibiotic every month ..

-IPF >>

• Pulmonary HTN ..

- Myocardial fibrosis >>

• Conduction and contraction defects

- ENT

• Sicca-like $
• Hoarseness of voice due to acid reflux

-Genetalia ( due to fibrosis )

• Erectile dysfunction in males
• Dysparonia in females

- Hypothyrodism ( due to fibrosis of the secretory acini )

- Scleroderma kidney ( also due to fibrosis )

• Malignant HTN
• Renal failure
• Scleroderma renal crisis ^abrupt onset

3- Investigations
- To detect the different affection ... ??
- Anti-Scl 70 ... Specific , but only in 20-30 %
- ANA +ve in 90% & Rh.f +ve in 30 % "sero +ve"

4- Treatment
- No specific satisfactory drug therapy
- symptomatic and life style modification ... ??
- Vasodilators

• ACEI from the start .. to prevent the Renal crisis .. and never stop if only produce cough >> shift to ARBs
• Viagra in winter , .. to females ??!!
• SSRI >> vasodilator + decrease TGF-Beta
• Iloprost " prostacyclin analogues substance "

-Mycophenolate : prevents internal organ fibrosis
-high dose CS " > 30 ".. is contra-indicaed as it can precipitate renal crisis ...