Topics covered in this Tutorial
Hypothyroidism in different Age Groups
Macroglossia causes
Amyloidosis
Localised red papules
Hand granulomas
Cutaneous TB
Gardner's syndrome
Bechet's disease
What are some of the features of hypothyroidism at different age groups?
Answer
In infants it causes a big tongue. In younger children it causes big lips and livedo and in juveniles it causes hypertrichosis on the shoulders. In adults you can get punctate telangiectasia on the extensor arms, leg ulcers and carotenemia.
In practical terms you consider hypothyroidism when you have a patient with sudden onset of dry skin, pruritus, weight gain, dry brittle hair and hair loss. They have a typical facies. There is infiltration of tissues with mucopolysaccharides giving the large tongue and carpal tunnel syndrome. Infiltration of the dermis gives non pitting oedema of the hands, feet and eyelids.
The Differential Diagnosis of Macroglossia
Congenital, - Down’s syndrome, Hurler’s syndrome and cretinism.
Tumours-Namely neurofibromatosis, lymphangioma and haemangioma.
Infiltrates--Namely amyloid, lipoid proteinosis and rarely sarcoid.
Angioedema--From superior vena cava obstruction, congestive heart failure or renal oedema.
Hormonal--Due to acromegaly, cretinism
Granulomatous--From the Melkerson Rosenthal syndrome,
Infections-- mainly syphilis, leprosy and Actinomycosis.
Also see Riga Fede disease
Image below is amyloid macroglossia in myeloma
Nodular amyloidosis on the legs is like hypertrophic lichen planus. Primary systemic amyloidosis involves the face, the fingers and the flexures.
View this case of systemic amyloidosis
View these other images of amyloidosis for some other clinical presentations
Nodular amyloidosis is also commonly seen on the scalp as a red brown nodule with central thinning revealing the underlying fat. Some patients have isolated clinical disease while in others it is part of systemic amyloidosis.
Image below is lichen amyloidosis
Vertical lines in the face causing leonine faces can be due to leprosy, mycosis fungoides, Sezary’s syndrome, leukemia, systemic amyloidosis and scleromyxedema.
Question
What is the differential diagnosis of granulomas of the hand?
Answer
They include atypical mycobacterial infection, Leishmaniasis, sporotrichosis and the scarring types of sarcoidosis which tend to be annular and papular. Always check the eyes in early suspected sarcoidosis.
Dorsal hand nodules + trauma → foreign‑body granuloma
Sporotrichoid pattern → M. marinum or sporotrichosis
Palisading necrobiotic granulomas → GA or rheumatoid nodule
Non‑caseating granulomas → sarcoidosis
Chalky deposits → gouty tophus
Bone involvement → LCH
Question
What types of cutaneous tuberculosis do you know?
Answer
There is primary inoculation TB, there is tuberculosis cutis verrucosum, there is tuberculosis cutis orificialis, lupus vulgaris, scrofuloderma and miliary TB.
Id Reactions
Include papulonecrotic tuberculid, erythema induratum and lichen scrofulosorum.
Image below is cutaneous TB
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| Lichen scrofulosorum |
What is the differential diagnosis of localised red papules?
Answer
Generally the diagnosis will come into the categories of embolic, bites , adnexal particularly miliaria and Grover’s disease, folliculitis, vasculitis or drugs. Look out for frictional lichenoid papules on the elbows.
The image below is Grover's
This is an inherited autosomal dominant disorder with large bowel polyps and osteomas. They also develop desmoids, epidermoid and pilar cysts. Osteomas are often in the skull and facial bones. Polyps develop in early childhood or early adult life. 100% subsequently develop malignancy. There can be a need for colectomy and surgery in a case like this. They can also develop fibrosarcomas, dental cysts and have supernumary and un-erupted teeth.
Compare Gardner’s syndrome to Steatocystoma multiplex and keratinised cysts.
In Gardner’s the cysts are of early onset. There are multiple different lesions and they have osteomas. Steatocystoma multiplex tends to develop at puberty and may have associated vellus hair cysts. They leak an oily fluid if burst. Keratin cysts such as epidermoid or pilar cysts can develop at any age. They are usually in the scalp.
The image below is eruptive vellus hair cysts
In Bechet’s disease ulcers never start as vesicles or bullae. Aphthae when they occur are larger and last longer and note that aphthae do not affect the gingivae.
Image below is of Sutton's apthous ulcers
