(BMJ)—A 55-yo woman w/ a 13-yr hx of psoriasis (treated w/ cyclosporin for 12y and then secukinumab for the past 12mo) presented w/ a shin lesion that had been present for 6mo. She denied increased sun exposure or tanning bed use. Exam: 5x4-cm exophytic mass. No popliteal/inguinal nodes. Thin red plaques on legs/trunk suggestive of treated psoriasis. What is the dx?
Buruli ulcer
Primary cutaneous squamous cell carcinoma
Merkel cell carcinoma
Pyogenic granuloma
Mycobacterium leprae infection
You are correct. Excisional bx revealed moderately differentiated invasive cutaneous squamous cell carcinoma. Cutaneous squamous cell carcinomas are observed more frequently in pts w/ severe (vs mild) psoriasis, esp when managed w/ immunosuppressive tx. This pt had complete excision w/ healthy margins. Lymph node U/S showed no other abnormalities. She was followed up weekly for the 1st month and opted to continue tx w/ secukinumab after being informed about the lack of long-term safety data for pts w/ hx of malignancies. She also received advice to avoid radiation (sun, phototherapy), to use sunscreen, and to follow up w/ a dermatologist q6mo for the next 2y, and then yearly for life.

BMJ 2019;366:l4822
(BMJ)—A 46-yo woman who had sustained L-sided closed head injury during a traffic accident 1y prior presented w/ a 1-mo hx of L eye redness, w/o vision changes. Exam: mild L eye protrusion, esp on bowing her head; dilated episcleral vessels; fundoscopy: retinal vein engorgement. Imaging confirmed dx. What is it?
Thyroid orbitopathy
Superior vena cava syndrome
Chronic angle-closure glaucoma
Carotid-cavernous sinus fistula
Radius‐Maumenee syndrome
You are correct. CT angiography confirmed the dx as trauma-induced L-sided carotid-cavernous sinus fistula (communication between the carotid arterial system and the cavernous sinus). Following her accident, the pt had persistent intracranial bruit x5mo. Ultrasound showed a pulsating engorged L orbital vessel.

BMJ 2019;366:l4960
(BMJ)—An otherwise healthy, nonsmoking 18-yo man presented w/ a 7-day hx of gradually increasing sore throat, malaise, nausea/vomiting, odynophagia, and fever. No wt loss, travel, night sweats. Exam: bilateral tender neck nodes, hoarse voice, bilateral enlarged tonsils w/ white exudate. What is the dx?
Lymphoma
Gonococcal pharyngitis
Peritonsillar abscess
Infectious mononucleosis
Ludwig angina
You are correct. Extensive lymphadenopathy, pharyngitis, and thick white exudate is pathognomonic for infectious mononucleosis. Approximately 90% of cases are caused by Epstein-Barr virus, and the rest by CMV. It is most common in adolescents and young adults. Other s/sx can include petechiae on the palate, and liver and/or spleen enlargement. It is transmitted primarily by saliva, and the incubation period is 4-8wk. A positive monospot can confirm the dx; however, a false negative occurs in up to 25% of pts during the 1st week of s/sx.

BMJ 2019;366:l4361