A 29-year-old man comes to the office due to a 2-month history of a worsening nonpruritic skin rash. The patient also has had pain and stiffness of his hands for the past several days. He has no known medical issues and takes no medications.
Vital signs are within normal limits. Mild swelling and tenderness are present in several digits of both hands. Skin examination shows extensive scaly and erythematous plaques on the scalp, hands, arms, torso, and legs, as shown in the images.

Which of the following diagnostic studies is most appropriate in evaluation of this patient?

Question

A 29-year-old man comes to the office due to a 2-month history of a worsening nonpruritic skin rash.  The patient also has had pain and stiffness of his hands for the past several days.  He has no known medical issues and takes no medications.
Vital signs are within normal limits.  Mild swelling and tenderness are present in several digits of both hands.  Skin examination shows extensive scaly and erythematous plaques on the scalp, hands, arms, torso, and legs, as shown in the images.

Which of the following diagnostic studies is most appropriate in evaluation of this patient?

Quizplus · Accepted Answer

11ec193a_9795_899c_853d_755727a90af6_MD0002_00 This patient has skin lesions consistent with psoriasis, a common inflammatory skin disorder characterized by sharply demarcated, erythematous, scaly plaques. He likely also has psoriatic arthritis, which is seen in approximately one-third of patients with psoriasis and may precede the skin lesions. However, psoriasis usually has a gradual onset involving the scalp, knees, and extensor surface of the elbows, neck, and back. Abrupt onset of large, widespread psoriatic lesions is often seen in patients with HIV infection and may be the initial manifestation of the disease. Psoriasis in patients with HIV commonly affects intertriginous, rather than extensor, skin (inverse psoriasis) and can be associated with systemic symptoms (eg, fever). Rapid-onset severe psoriasis warrants screening for HIV. Other factors that can trigger atypical or widespread psoriasis include smoking, alcohol abuse, withdrawal from systemic glucocorticoid therapy, and streptococcal infections (guttate psoriasis). guttate psoriasis (Choice A) Anti-tissue transglutaminase antibody is an initial test for celiac disease. Celiac disease is associated with dermatitis herpetiformis, which presents with clusters of intensely pruritic papules and vesicles on the dorsal forearms, knees, and buttocks. papules and vesicles (Choice B) Dermal manifestations of hepatitis C include porphyria cutanea tarda (fragile, photosensitive skin with vesicles and bullae), leukocytoclastic vasculitis (palpable purpura), and lichen planus (pruritic, purple, polygonal plaques). fragile, photosensitive skin palpable purpura pruritic, purple, polygonal plaques (Choice C) Skin manifestations of inflammatory bowel disease include erythema nodosum (painful, erythematous nodules on the lower legs) and pyoderma gangrenosum (painful, enlarging, ulcerating nodules with violaceous borders). nodules ulcerating nodules (Choice D) Dermal manifestations of diabetes mellitus include acanthosis nigricans (velvety brown plaques in flexural regions), necrobiosis lipoidica (annular, yellowish brown lesions with central atrophy), and hidradenitis suppurativa (painful, inflamed nodules with hyperpigmentation and scarring in flexural areas). velvety brown plaques yellowish brown lesions inflamed nodules Educational objective: Abrupt onset of severe psoriasis is often seen in patients with HIV infection and may be the initial manifestation of the disease. Psoriasis in HIV commonly affects intertriginous, rather than extensor, skin and can be associated with systemic symptoms. Rapid onset of severe psoriasis warrants screening for HIV. __________ References: The skin and HIV: no superficial matter. (http://www.ncbi.nlm.nih.gov/pubmed/25398069) Ostraceous and inverse psoriasis with psoriatic arthritis as the presenting features of advanced HIV infection. (http://www.ncbi.nlm.nih.gov/pubmed/24763845)

A 29-Year-Old Man Comes to the Office Due to a 2-Month