Quiz

The Diagnosis: Disseminated Erythema Chronicum Migrans 

Empiric treatment with doxycycline 100 mg twice daily for 14 days was initiated for suspected early disseminated Lyme disease manifesting as disseminated multifocal erythema chronicum migrans (Figure). Lyme screening immunoassay and confirmatory IgM Western blot testing subsequently were found to be positive. The clinical history of recent travel to an endemic area and tick bite combined with the recent onset of multifocal erythema migrans lesions, systemic symptoms, elevated erythrocyte sedimentation rate, and positive Lyme serology supported the diagnosis of Lyme disease.

The appropriate clinical context and cutaneous morphology are key when considering the differential diagnosis for multifocal annular lesions. Several entities comprised the differential diagnosis considered in our patient. Sweet syndrome is a neutrophilic dermatosis that can present with fever and varying painful cutaneous lesions. It often is associated with certain medications, underlying illnesses, and infections.¹ Our patient’s lesions were not painful, and she had no notable medical history, recent infections, or new medication use, making Sweet syndrome unlikely. A fixed drug eruption was low on the differential, as the patient denied starting any new medications within the 3 months prior to presentation. Erythema multiforme is an acute-onset immunemediated condition of the skin and mucous membranes that typically affects young adults and often is associated with infection (eg, herpes simplex virus, Mycoplasma pneumoniae) or medication use. Cutaneous lesions typically are self-limited, less than 3 cm targets with 3 concentric distinct color zones, often with central bullae or erosions. Although erythema multiforme was higher on the differential, it was less likely, as the patient lacked mucosal lesions and did not have symptoms of underlying herpetic or mycoplasma infection, and the clinical picture was more consistent with Lyme disease. Lastly, the failure for individual skin lesions to resolve within 
 24 hours excluded the diagnosis of urticaria.

Lyme disease is a tick-borne illness caused by 3 species of the Borrelia spirochete: Borrelia burgdorferi, Borrelia afzelii, and Borrelia garinii.² In the United States, the disease predominantly is caused by B burgdorferi that is endemic in the upper Midwest and Northeast regions.3 There are 3 stages of Lyme disease: early localized, early disseminated, and late disseminated disease. Early localized disease typically presents with a characteristic single erythema migrans (EM) lesion 3 to 30 days following a bite by the tick Ixodes scapularis.² The EM lesion gradually can enlarge over a period of several days, reaching up to 12 inches in diameter.² Early disseminated disease can occur weeks to months following a tick bite and may present with systemic symptoms, multiple widespread 
EM lesions, neurologic features such as meningitis or facial nerve palsy, and/or cardiac manifestations such as atrioventricular block or myocarditis. Late disseminated disease can present with chronic arthritis or encephalopathy after months to years if the disease is left untreated.⁴

Early localized Lyme disease can be diagnosed clinically if the characteristic EM lesion is present in a patient who visited an endemic area. Laboratory testing and Lyme serology are neither required nor recommended in these cases, as the lesion often appears before adequate time has lapsed to develop an adaptive immune response to the organism.5 In contrast, Lyme serology should be ordered in any patient who meets all of the following criteria: (1) patient lives in or has recently traveled to an area endemic for Lyme disease, (2) presence of a risk factor for tick exposure, and (3) symptoms consistent with early disseminated or late Lyme disease. Patients with signs of early or late disseminated disease typically are seropositive, as IgM antibodies can be detected within 2 weeks of onset of the EM lesion and IgG antibodies within 2 to 6 weeks.⁶ The Centers for Disease Control and Prevention recommends a 2-tiered approach when testing for Lyme disease.⁷ A screening test with high sensitivity such as an enzyme-linked immunosorbent assay or an immunofluorescence assay initially should be performed.⁷ If results of the screening test are equivocal or positive, secondary confirmatory testing should be performed via IgM, with or without IgG Western immunoblot assay.⁷ Biopsy with histologic evaluation can reveal nonspecific findings of vascular endothelial injury and increased mucin deposition. Patients with suspected Lyme disease should immediately be started on empiric treatment with doxycycline 100 mg twice daily for a minimum of 10 days (14–28 days if there is concern for dissemination) to prevent post-Lyme sequelae.⁵ Our patient’s cutaneous lesions responded to oral doxycycline. 

The Diagnosis: Disseminated Erythema Chronicum Migrans 

Empiric treatment with doxycycline 100 mg twice daily for 14 days was initiated for suspected early disseminated Lyme disease manifesting as disseminated multifocal erythema chronicum migrans (Figure). Lyme screening immunoassay and confirmatory IgM Western blot testing subsequently were found to be positive. The clinical history of recent travel to an endemic area and tick bite combined with the recent onset of multifocal erythema migrans lesions, systemic symptoms, elevated erythrocyte sedimentation rate, and positive Lyme serology supported the diagnosis of Lyme disease.

The appropriate clinical context and cutaneous morphology are key when considering the differential diagnosis for multifocal annular lesions. Several entities comprised the differential diagnosis considered in our patient. Sweet syndrome is a neutrophilic dermatosis that can present with fever and varying painful cutaneous lesions. It often is associated with certain medications, underlying illnesses, and infections.¹ Our patient’s lesions were not painful, and she had no notable medical history, recent infections, or new medication use, making Sweet syndrome unlikely. A fixed drug eruption was low on the differential, as the patient denied starting any new medications within the 3 months prior to presentation. Erythema multiforme is an acute-onset immunemediated condition of the skin and mucous membranes that typically affects young adults and often is associated with infection (eg, herpes simplex virus, Mycoplasma pneumoniae) or medication use. Cutaneous lesions typically are self-limited, less than 3 cm targets with 3 concentric distinct color zones, often with central bullae or erosions. Although erythema multiforme was higher on the differential, it was less likely, as the patient lacked mucosal lesions and did not have symptoms of underlying herpetic or mycoplasma infection, and the clinical picture was more consistent with Lyme disease. Lastly, the failure for individual skin lesions to resolve within 
 24 hours excluded the diagnosis of urticaria.

Lyme disease is a tick-borne illness caused by 3 species of the Borrelia spirochete: Borrelia burgdorferi, Borrelia afzelii, and Borrelia garinii.² In the United States, the disease predominantly is caused by B burgdorferi that is endemic in the upper Midwest and Northeast regions.3 There are 3 stages of Lyme disease: early localized, early disseminated, and late disseminated disease. Early localized disease typically presents with a characteristic single erythema migrans (EM) lesion 3 to 30 days following a bite by the tick Ixodes scapularis.² The EM lesion gradually can enlarge over a period of several days, reaching up to 12 inches in diameter.² Early disseminated disease can occur weeks to months following a tick bite and may present with systemic symptoms, multiple widespread 
EM lesions, neurologic features such as meningitis or facial nerve palsy, and/or cardiac manifestations such as atrioventricular block or myocarditis. Late disseminated disease can present with chronic arthritis or encephalopathy after months to years if the disease is left untreated.⁴

Early localized Lyme disease can be diagnosed clinically if the characteristic EM lesion is present in a patient who visited an endemic area. Laboratory testing and Lyme serology are neither required nor recommended in these cases, as the lesion often appears before adequate time has lapsed to develop an adaptive immune response to the organism.5 In contrast, Lyme serology should be ordered in any patient who meets all of the following criteria: (1) patient lives in or has recently traveled to an area endemic for Lyme disease, (2) presence of a risk factor for tick exposure, and (3) symptoms consistent with early disseminated or late Lyme disease. Patients with signs of early or late disseminated disease typically are seropositive, as IgM antibodies can be detected within 2 weeks of onset of the EM lesion and IgG antibodies within 2 to 6 weeks.⁶ The Centers for Disease Control and Prevention recommends a 2-tiered approach when testing for Lyme disease.⁷ A screening test with high sensitivity such as an enzyme-linked immunosorbent assay or an immunofluorescence assay initially should be performed.⁷ If results of the screening test are equivocal or positive, secondary confirmatory testing should be performed via IgM, with or without IgG Western immunoblot assay.⁷ Biopsy with histologic evaluation can reveal nonspecific findings of vascular endothelial injury and increased mucin deposition. Patients with suspected Lyme disease should immediately be started on empiric treatment with doxycycline 100 mg twice daily for a minimum of 10 days (14–28 days if there is concern for dissemination) to prevent post-Lyme sequelae.⁵ Our patient’s cutaneous lesions responded to oral doxycycline. 

The Diagnosis: Disseminated Erythema Chronicum Migrans 

Empiric treatment with doxycycline 100 mg twice daily for 14 days was initiated for suspected early disseminated Lyme disease manifesting as disseminated multifocal erythema chronicum migrans (Figure). Lyme screening immunoassay and confirmatory IgM Western blot testing subsequently were found to be positive. The clinical history of recent travel to an endemic area and tick bite combined with the recent onset of multifocal erythema migrans lesions, systemic symptoms, elevated erythrocyte sedimentation rate, and positive Lyme serology supported the diagnosis of Lyme disease.

The appropriate clinical context and cutaneous morphology are key when considering the differential diagnosis for multifocal annular lesions. Several entities comprised the differential diagnosis considered in our patient. Sweet syndrome is a neutrophilic dermatosis that can present with fever and varying painful cutaneous lesions. It often is associated with certain medications, underlying illnesses, and infections.¹ Our patient’s lesions were not painful, and she had no notable medical history, recent infections, or new medication use, making Sweet syndrome unlikely. A fixed drug eruption was low on the differential, as the patient denied starting any new medications within the 3 months prior to presentation. Erythema multiforme is an acute-onset immunemediated condition of the skin and mucous membranes that typically affects young adults and often is associated with infection (eg, herpes simplex virus, Mycoplasma pneumoniae) or medication use. Cutaneous lesions typically are self-limited, less than 3 cm targets with 3 concentric distinct color zones, often with central bullae or erosions. Although erythema multiforme was higher on the differential, it was less likely, as the patient lacked mucosal lesions and did not have symptoms of underlying herpetic or mycoplasma infection, and the clinical picture was more consistent with Lyme disease. Lastly, the failure for individual skin lesions to resolve within 
 24 hours excluded the diagnosis of urticaria.

Lyme disease is a tick-borne illness caused by 3 species of the Borrelia spirochete: Borrelia burgdorferi, Borrelia afzelii, and Borrelia garinii.² In the United States, the disease predominantly is caused by B burgdorferi that is endemic in the upper Midwest and Northeast regions.3 There are 3 stages of Lyme disease: early localized, early disseminated, and late disseminated disease. Early localized disease typically presents with a characteristic single erythema migrans (EM) lesion 3 to 30 days following a bite by the tick Ixodes scapularis.² The EM lesion gradually can enlarge over a period of several days, reaching up to 12 inches in diameter.² Early disseminated disease can occur weeks to months following a tick bite and may present with systemic symptoms, multiple widespread 
EM lesions, neurologic features such as meningitis or facial nerve palsy, and/or cardiac manifestations such as atrioventricular block or myocarditis. Late disseminated disease can present with chronic arthritis or encephalopathy after months to years if the disease is left untreated.⁴

Early localized Lyme disease can be diagnosed clinically if the characteristic EM lesion is present in a patient who visited an endemic area. Laboratory testing and Lyme serology are neither required nor recommended in these cases, as the lesion often appears before adequate time has lapsed to develop an adaptive immune response to the organism.5 In contrast, Lyme serology should be ordered in any patient who meets all of the following criteria: (1) patient lives in or has recently traveled to an area endemic for Lyme disease, (2) presence of a risk factor for tick exposure, and (3) symptoms consistent with early disseminated or late Lyme disease. Patients with signs of early or late disseminated disease typically are seropositive, as IgM antibodies can be detected within 2 weeks of onset of the EM lesion and IgG antibodies within 2 to 6 weeks.⁶ The Centers for Disease Control and Prevention recommends a 2-tiered approach when testing for Lyme disease.⁷ A screening test with high sensitivity such as an enzyme-linked immunosorbent assay or an immunofluorescence assay initially should be performed.⁷ If results of the screening test are equivocal or positive, secondary confirmatory testing should be performed via IgM, with or without IgG Western immunoblot assay.⁷ Biopsy with histologic evaluation can reveal nonspecific findings of vascular endothelial injury and increased mucin deposition. Patients with suspected Lyme disease should immediately be started on empiric treatment with doxycycline 100 mg twice daily for a minimum of 10 days (14–28 days if there is concern for dissemination) to prevent post-Lyme sequelae.⁵ Our patient’s cutaneous lesions responded to oral doxycycline. 

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[polldaddy:10665862]

[polldaddy:10665862]

Q2. Correct answer: D  
 
Rationale  
Episodic hepatic encephalopathy is usually precipitant-induced in over 80% of cases and includes dehydration, infections, over diuresis, gastrointestinal bleeding, constipation, and the use of narcotics and sedatives. Key is to identify and treat the precipitant. A diagnostic workup to rule out other disorders that can alter brain function and mimic hepatic encephalopathy should also be performed.  
 
Reference  
1. Viltstrup H et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology. 2014;60(2):715-35. 
 
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Q2. Correct answer: D  
 
Rationale  
Episodic hepatic encephalopathy is usually precipitant-induced in over 80% of cases and includes dehydration, infections, over diuresis, gastrointestinal bleeding, constipation, and the use of narcotics and sedatives. Key is to identify and treat the precipitant. A diagnostic workup to rule out other disorders that can alter brain function and mimic hepatic encephalopathy should also be performed.  
 
Reference  
1. Viltstrup H et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology. 2014;60(2):715-35. 
 
[email protected]

Q2. Correct answer: D  
 
Rationale  
Episodic hepatic encephalopathy is usually precipitant-induced in over 80% of cases and includes dehydration, infections, over diuresis, gastrointestinal bleeding, constipation, and the use of narcotics and sedatives. Key is to identify and treat the precipitant. A diagnostic workup to rule out other disorders that can alter brain function and mimic hepatic encephalopathy should also be performed.  
 
Reference  
1. Viltstrup H et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology. 2014;60(2):715-35. 
 
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Q1. Correct answer: A  
 
Rationale  
In the United States, pigmented stones (black and brown) are less common than cholesterol gallstones. Both types of pigmented stones contain an excess of unconjugated bilirubin and are composed of calcium hydrogen bilirubinate, which is oxidized and polymerized in the hard black stones but unpolymerized in softer brown stones. Black pigmented gallstones are frequently radiopaque and form in sterile bile. Risk factors for black pigmented stones include hemolysis (example, sickle cell disease), cirrhosis, cystic fibrosis, and diseases affecting the ileum (example, Crohn's disease). In contrast, brown stones are more likely to occur in the bile ducts, are radiolucent, and form secondary to biliary stasis (example, biliary stricture) and infection (example, Clonorchis sinensis).  
Obesity, female sex, and hyperlipidemia are risk factors for cholesterol gallstone formation. Octreotide decreases gallbladder motility and long-term use can increase the risk of cholelithiasis.  
 
References  
1. Stinton LM, Myers RP, Shaffer EA. Epidemiology of gallstones. Gastroenterol Clin N Am. 2010;39:157-69.  
2. Vitek L, Carey MC. New pathophysiological concepts underlying pathogenesis of pigment gallstones. Clin Res Hepatol Gastroenterol. 2012;36:122-9.

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Q1. Correct answer: A  
 
Rationale  
In the United States, pigmented stones (black and brown) are less common than cholesterol gallstones. Both types of pigmented stones contain an excess of unconjugated bilirubin and are composed of calcium hydrogen bilirubinate, which is oxidized and polymerized in the hard black stones but unpolymerized in softer brown stones. Black pigmented gallstones are frequently radiopaque and form in sterile bile. Risk factors for black pigmented stones include hemolysis (example, sickle cell disease), cirrhosis, cystic fibrosis, and diseases affecting the ileum (example, Crohn's disease). In contrast, brown stones are more likely to occur in the bile ducts, are radiolucent, and form secondary to biliary stasis (example, biliary stricture) and infection (example, Clonorchis sinensis).  
Obesity, female sex, and hyperlipidemia are risk factors for cholesterol gallstone formation. Octreotide decreases gallbladder motility and long-term use can increase the risk of cholelithiasis.  
 
References  
1. Stinton LM, Myers RP, Shaffer EA. Epidemiology of gallstones. Gastroenterol Clin N Am. 2010;39:157-69.  
2. Vitek L, Carey MC. New pathophysiological concepts underlying pathogenesis of pigment gallstones. Clin Res Hepatol Gastroenterol. 2012;36:122-9.

[email protected]

Q1. Correct answer: A  
 
Rationale  
In the United States, pigmented stones (black and brown) are less common than cholesterol gallstones. Both types of pigmented stones contain an excess of unconjugated bilirubin and are composed of calcium hydrogen bilirubinate, which is oxidized and polymerized in the hard black stones but unpolymerized in softer brown stones. Black pigmented gallstones are frequently radiopaque and form in sterile bile. Risk factors for black pigmented stones include hemolysis (example, sickle cell disease), cirrhosis, cystic fibrosis, and diseases affecting the ileum (example, Crohn's disease). In contrast, brown stones are more likely to occur in the bile ducts, are radiolucent, and form secondary to biliary stasis (example, biliary stricture) and infection (example, Clonorchis sinensis).  
Obesity, female sex, and hyperlipidemia are risk factors for cholesterol gallstone formation. Octreotide decreases gallbladder motility and long-term use can increase the risk of cholelithiasis.  
 
References  
1. Stinton LM, Myers RP, Shaffer EA. Epidemiology of gallstones. Gastroenterol Clin N Am. 2010;39:157-69.  
2. Vitek L, Carey MC. New pathophysiological concepts underlying pathogenesis of pigment gallstones. Clin Res Hepatol Gastroenterol. 2012;36:122-9.

[email protected]

[polldaddy:10586792]

[polldaddy:10586792]

[polldaddy:10586792]

[polldaddy:10527068]

[polldaddy:10527068]

[polldaddy:10527068]

[polldaddy:10424906]

[polldaddy:10424906]

[polldaddy:10424906]