CPD SPOT DIAGNOSIS ,

Spot Dx — Mysterious rash, marks, macules, and a left-sided tongue loll

You can self-report this CPD/PDP activity by logging it online with the RACGP/ACRRM. The activity has been allocated 1 hour (0.5 hour EA and 0.5 hour RP). Certificates are not available for this CPD.

Test your clinical knowledge by taking the 6 quizzes below. If you select the wrong answer, have another go — you can try as many times as you like.

RACGP Activity Number: GPR004

ACRRM Activity Number: GPR004

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1. What’s causing these marks?

What is the most likely diagnosis?

<section data-block="SingleChoice"> <h3>What is the most likely diagnosis?</h3> <p><p><strong>Ned is a 14-year-old who presents with concerns about unsightly horizontal marks on his lower back for the past two months. He finds these very embarrassing when he swims.</strong></p><p><strong>Ned is otherwise well, with no past or family history of note, and takes no regular medications.</strong></p><p><strong>His height is 30th centile, weight 10th centile and BMI 20th centile for age, which is consistent with historical growth. Vital signs are normal and he appears generally well.</strong></p><p><strong>His skin and joint examinations are normal, apart from multiple horizontal, linear, erythematous-to-purpuric marks, on the lumbosacral region (see figure A) and wrinkled, atrophic, faint white lines on the knees (arrows, B).</strong></p><p><strong>He is Tanner stage 3-4 and has no endocrinological findings of note.</strong></p></p> <ul> <li>a. Cushing’s syndrome</li> <li>b. Marfan syndrome</li> <li>c. Ehlers-Danlos syndrome</li> <li>d. Adolescent striae</li> </ul> </section> <p> </p> <p></p>Photo: Reproduced from The BMJ, Hung Y, Chang Y, Chen W. A teenager with horizontal purple stripes on the lower back BMJ 2022; 378:e070642

Author

Author: Dr Kate Kelso is a GP and medical editor at Australian Doctor.

2. What’s causing these hypopigmented macules?

What is the most likely diagnosis?

<section data-block="SingleChoice"> <h3>What is the most likely diagnosis?</h3> <p><p><strong>Jamie, aged four, presents for his scheduled immunisations. He has no medical or family history of note, is of Caucasian descent and has never travelled overseas. He appears well and physical examination is unremarkable, apart from four hypopigmented macules on his knees and lower back, which measure 7-10mm in diameter. These have been present since birth and have not changed. His parents assumed they were birthmarks. Closer inspection does not reveal any associated scale. The lesions appear bright blue under Wood lamp examination and potassium hydroxide preparation is unremarkable.</strong></p></p> <ul> <li>a. Hansen’s disease (leprosy).</li> <li>b. Café au lait spots.</li> <li>c. Tinea versicolor.</li> <li>d. Tuberous sclerosis.</li> </ul> </section> <p></p>Photo: Dermnet NZ

Author

Author: Dr Paul Muthiah is a GP and a former medical co-editor of Australian Doctor.

3. What's behind this mysterious rash?

What is the most likely diagnosis?

<section data-block="SingleChoice"> <h3>What is the most likely diagnosis?</h3> <p><p><strong>Mac, a 30-year old man, presents after his first ever African safari. He complains of an itchy lesion around his elbow, which began 10 days after an insect bite while he was away. He returned from his trip six weeks ago. Over the past few days he has experienced malaise, daytime somnolence and fever. On examination, axillary and cervical lymphadenopathy is noted. His other system examinations are normal.</strong></p></p> <ul> <li>a. Malaria</li> <li>b. HIV</li> <li>c. Toxoplasmosis</li> <li>d. African trypanosomiasis</li> </ul> </section> <p></p>Photo: Dermnet NZ

Author

Author: Dr Paul Muthiah is a GP and a former medical co-editor of Australian Doctor.

4. What is causing this left-sided tongue loll?

What is the most likely diagnosis?

<section data-block="SingleChoice"> <h3>What is the most likely diagnosis?</h3> <p><p><strong>Jeremy is a 55-year-old public servant with a background of mild hypertension who presents with a one-month history of altered tongue movement and strength. He has also noticed the tongue deviates with protrusion (pictured). He is otherwise well, with no other associated symptoms. Neurological examination reveals weakness and wasting on the left half of the tongue and deviation to the left side, towards the outside of the mouth. The rest of the neurological examination is normal. His blood pressure is 145/95mmHg.</strong></p></p> <ul> <li>a. Glomus jugulare tumour</li> <li>b. Isolated hypoglossal nerve palsy</li> <li>c. Tumour at the base of the skull</li> <li>d. MS</li> </ul> </section> <p></p>Photo: Karsidag S, Ates MF. Emerg Med J 2021;38:307

Author

Author: Dr Kate Kelso is a GP and medical editor at Australian Doctor.

5. Can you spot the cause of this bruising?

What is the most likely diagnosis?

Author

Author: Dr Kate Kelso is a GP and medical editor at Australian Doctor.

6. What is causing this pruritic rash with associated weakness?

What is the most likely diagnosis?

Author

Author: Dr Paul Muthiah is a GP and a former medical co-editor of Australian Doctor.

References on request from kate.kelso@adg.com.au