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Dermatology - Lentigo maligna melanoma (LMM)
LMM, or lentigo maligna melanoma, is a melanoma subtype that is quite uncommon, affecting less than 5% of light-skinned individuals. It primarily affects older adults, with a median age of beginning at 65 years. LMM typically appears on the portions of the body that are most exposed to the sun, such as the face and forearms.
LMM initially manifests as lentigo maligna (LM), which is a flat neoplasm located inside the epidermis. It is important to note that LM is not a precursor but rather a developing lesion of melanoma. Papular and nodular lesions indicate a transition from radial to vertical growth, indicating an infiltration into the dermis.
The process of LMM gradually transitions from LM over a span of many years, occasionally lasting as long as two decades.
Dermatoheliosis is almost always present in the background.
The lesions in question are flat and uniform macules, ranging in size from 0.5 cm to 20 cm. They often have well-defined borders, although they may occasionally exhibit fuzzy or extremely uneven edges, frequently with a notch. These lesions often have a "geographic" appearance, resembling inlets and peninsulas. Initial lesions appear tan, but more developed lesions exhibit a brown and black (speckled) appearance. These mature lesions resemble irregular networks of black markings on a brown backdrop, lacking any shades of red or blue.
Lentigo maligna melanoma LMM is characterized by the presence of red, white, and blue patches, bumps, or lumps, similar to LM but with a varied appearance. Occasionally, LMM may lack pigmentation, have a skin-colored appearance, and exhibit patchy redness, requiring a biopsy for diagnosis.
The diagnosis is established through clinical examination using dermoscopy and subsequently confirmed through histological analysis. The differential diagnosis includes seborrheic keratosis, which can be distinguished by the presence of scaling upon excoriation, and solar lentigo, which lacks the same level of intensity or variation in brown, dark brown, and black colors as found in LM.
Administer imiquimod to address first lesions promptly. Remove advanced lesions by excising tissue down to the fascia, ensuring 1-cm margins beyond the apparent lesion or biopsy scar. However, if the eyelids or critical organs are affected, smaller margins can be used. Utilize a Woods light and dermoscopy to delineate the boundaries of the lesion. Perform a biopsy on the sentinel nodes if the lesion measures more than 1 millimeter in thickness. Utilize skin flaps or grafts to achieve closure and restoration. Following the complete eradication of all identifiable tumors, it is advisable to contemplate the use of additional therapy based on the stage of the disease.
LMM, or lentigo maligna melanoma, is a melanoma subtype that is quite uncommon, affecting less than 5% of light-skinned individuals. It primarily affects older adults, with a median age of beginning at 65 years. LMM typically appears on the portions of the body that are most exposed to the sun, such as the face and forearms.
LMM initially manifests as lentigo maligna (LM), which is a flat neoplasm located inside the epidermis. It is important to note that LM is not a precursor but rather a developing lesion of melanoma. Papular and nodular lesions indicate a transition from radial to vertical growth, indicating an infiltration into the dermis.
The process of LMM gradually transitions from LM over a span of many years, occasionally lasting as long as two decades.
Dermatoheliosis is almost always present in the background.
The lesions in question are flat and uniform macules, ranging in size from 0.5 cm to 20 cm. They often have well-defined borders, although they may occasionally exhibit fuzzy or extremely uneven edges, frequently with a notch. These lesions often have a "geographic" appearance, resembling inlets and peninsulas. Initial lesions appear tan, but more developed lesions exhibit a brown and black (speckled) appearance. These mature lesions resemble irregular networks of black markings on a brown backdrop, lacking any shades of red or blue.
Lentigo maligna melanoma LMM is characterized by the presence of red, white, and blue patches, bumps, or lumps, similar to LM but with a varied appearance. Occasionally, LMM may lack pigmentation, have a skin-colored appearance, and exhibit patchy redness, requiring a biopsy for diagnosis.
The diagnosis is established through clinical examination using dermoscopy and subsequently confirmed through histological analysis. The differential diagnosis includes seborrheic keratosis, which can be distinguished by the presence of scaling upon excoriation, and solar lentigo, which lacks the same level of intensity or variation in brown, dark brown, and black colors as found in LM.
Administer imiquimod to address first lesions promptly. Remove advanced lesions by excising tissue down to the fascia, ensuring 1-cm margins beyond the apparent lesion or biopsy scar. However, if the eyelids or critical organs are affected, smaller margins can be used. Utilize a Woods light and dermoscopy to delineate the boundaries of the lesion. Perform a biopsy on the sentinel nodes if the lesion measures more than 1 millimeter in thickness. Utilize skin flaps or grafts to achieve closure and restoration. Following the complete eradication of all identifiable tumors, it is advisable to contemplate the use of additional therapy based on the stage of the disease.
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Symptoms and Signs – Differential Diagnosis of Cloudy Urine
• Use of multivitamin supplements
• Urinary tract infection
• Pyuria
• Phosphaturia
• Lipiduria
• Hyperoxaluria
• Diet high in purine-rich foods
• Concentrated urine
• Chyluria
• Use of multivitamin supplements
• Urinary tract infection
• Pyuria
• Phosphaturia
• Lipiduria
• Hyperoxaluria
• Diet high in purine-rich foods
• Concentrated urine
• Chyluria
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Symptoms and Signs – Differential Diagnosis of Clubbing
• Celiac disease
• Chronic liver disease, cirrhosis (particularly biliary and juvenile)
• Chronic trauma (jackhammer operators, machine workers)
• Cyanotic congenital heart disease
• Cystic fibrosis
• Endocrine (Graves’ disease, hyperparathyroidism)
• Extrapulmonary infectious process (subacute bacterial endocarditis, intestinal TB, bacterial or amebic dysentery, arterial graft sepsis)
• Hereditary (pachydermoperiostitis)
• Idiopathic
• Inflammatory bowel disease (IBD)
• Other neoplasm (GI, liver, Hodgkin’s disease, thymus, osteogenic sarcoma)
• Pneumoconiosis
• Pulmonary arteriovenous (AV) malformations
• Pulmonary infectious process (empyema, abscess, bronchiectasis, TB, chronic pneumonitis)
• Pulmonary neoplasm (lung, pleura)
• Sarcoidosis
• Thyroid acropachy
• Celiac disease
• Chronic liver disease, cirrhosis (particularly biliary and juvenile)
• Chronic trauma (jackhammer operators, machine workers)
• Cyanotic congenital heart disease
• Cystic fibrosis
• Endocrine (Graves’ disease, hyperparathyroidism)
• Extrapulmonary infectious process (subacute bacterial endocarditis, intestinal TB, bacterial or amebic dysentery, arterial graft sepsis)
• Hereditary (pachydermoperiostitis)
• Idiopathic
• Inflammatory bowel disease (IBD)
• Other neoplasm (GI, liver, Hodgkin’s disease, thymus, osteogenic sarcoma)
• Pneumoconiosis
• Pulmonary arteriovenous (AV) malformations
• Pulmonary infectious process (empyema, abscess, bronchiectasis, TB, chronic pneumonitis)
• Pulmonary neoplasm (lung, pleura)
• Sarcoidosis
• Thyroid acropachy
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Symptoms and Signs – Differential Diagnosis of Cobalamin Deficiency
NUTRITIONAL COBALAMIN DEFICIENCY (I.E., INSUFFICIENT COBALAMIN INTAKE)
• Vegetarians, poverty-imposed near-vegetarians, breast-fed infants of mothers with pernicious anemia
ABNORMAL INTRAGASTRIC EVENTS (I.E., INADEQUATE
PROTEOLYSIS OF FOOD COBALAMIN)
• Atrophic gastritis, partial gastrectomy with hypochlorhydria, proton pump inhibitors, H2 blockers
LOSS OR ATROPHY OF GASTRIC OXYNTIC MUCOSA (I.E., DEFICIENT INTRINSIC FACTOR [IF] MOLECULES)
• Total or partial gastrectomy, pernicious anemia, caustic
destruction (lye)
ABNORMAL EVENTS IN SMALL BOWEL LUMEN
• Inadequate pancreatic protease (e.g., R-cobalamin not degraded, cobalamin not transferred to IF)
• Insufficient pancreatic protease (i.e., pancreatic insufficiency)
• Inactivation of pancreatic protease (i.e., Zollinger-Ellison syndrome)
• Usurping of luminal cobalamin (i.e., inadequate cobalamin binding to IF)
• By bacteria; during stasis syndromes (e.g., blind loops, pouches of diverticulosis, strictures, fistulas, anastomosis); impaired bowel motility (e.g., scleroderma); hypogammaglobulinemia
• By Diphyllobothrium latum (fish tapeworm)
DISORDERS OF ILEAL MUCOSA/IF-COBALAMIN RECEPTORS (I.E., IF-COBALAMIN NOT BOUND TO IFCOBALAMIN RECEPTORS)
• Diminished or absent IF-cobalamin receptors (e.g., ileal bypass, resection, fistula)
• Abnormal mucosal architecture/function (e.g., tropical or nontropical sprue, Crohn’s disease, tuberculous ileitis, infiltration by lymphomas, amyloidosis)
• IF/post IF–cobalamin receptor defects (e.g., Imerslund-Graesbeck syndrome, transcobalamin II [TC II] deficiency)
• Drug effects (e.g., Slow-K, metformin, cholestyramine, colchicine, neomycin)
DISORDERS OF PLASMA COBALAMIN TRANSPORT (I.E., TC II–COBALAMIN NOT DELIVERED TO TC II RECEPTORS)
• Congenital TC II deficiency, defective binding of TC II–cobalamin to TC II receptors (rare)
METABOLIC DISORDERS (I.E., COBALAMIN NOT USED BY CELLS)
• Inborn enzyme errors (rare)
• Acquired disorders (e.g., cobalamin functionally inactivated by irreversible oxidation, N2O inhalation)
NUTRITIONAL COBALAMIN DEFICIENCY (I.E., INSUFFICIENT COBALAMIN INTAKE)
• Vegetarians, poverty-imposed near-vegetarians, breast-fed infants of mothers with pernicious anemia
ABNORMAL INTRAGASTRIC EVENTS (I.E., INADEQUATE
PROTEOLYSIS OF FOOD COBALAMIN)
• Atrophic gastritis, partial gastrectomy with hypochlorhydria, proton pump inhibitors, H2 blockers
LOSS OR ATROPHY OF GASTRIC OXYNTIC MUCOSA (I.E., DEFICIENT INTRINSIC FACTOR [IF] MOLECULES)
• Total or partial gastrectomy, pernicious anemia, caustic
destruction (lye)
ABNORMAL EVENTS IN SMALL BOWEL LUMEN
• Inadequate pancreatic protease (e.g., R-cobalamin not degraded, cobalamin not transferred to IF)
• Insufficient pancreatic protease (i.e., pancreatic insufficiency)
• Inactivation of pancreatic protease (i.e., Zollinger-Ellison syndrome)
• Usurping of luminal cobalamin (i.e., inadequate cobalamin binding to IF)
• By bacteria; during stasis syndromes (e.g., blind loops, pouches of diverticulosis, strictures, fistulas, anastomosis); impaired bowel motility (e.g., scleroderma); hypogammaglobulinemia
• By Diphyllobothrium latum (fish tapeworm)
DISORDERS OF ILEAL MUCOSA/IF-COBALAMIN RECEPTORS (I.E., IF-COBALAMIN NOT BOUND TO IFCOBALAMIN RECEPTORS)
• Diminished or absent IF-cobalamin receptors (e.g., ileal bypass, resection, fistula)
• Abnormal mucosal architecture/function (e.g., tropical or nontropical sprue, Crohn’s disease, tuberculous ileitis, infiltration by lymphomas, amyloidosis)
• IF/post IF–cobalamin receptor defects (e.g., Imerslund-Graesbeck syndrome, transcobalamin II [TC II] deficiency)
• Drug effects (e.g., Slow-K, metformin, cholestyramine, colchicine, neomycin)
DISORDERS OF PLASMA COBALAMIN TRANSPORT (I.E., TC II–COBALAMIN NOT DELIVERED TO TC II RECEPTORS)
• Congenital TC II deficiency, defective binding of TC II–cobalamin to TC II receptors (rare)
METABOLIC DISORDERS (I.E., COBALAMIN NOT USED BY CELLS)
• Inborn enzyme errors (rare)
• Acquired disorders (e.g., cobalamin functionally inactivated by irreversible oxidation, N2O inhalation)
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Symptoms and Signs – Differential Diagnosis of Cocaine Overdose
• Methylenedioxyamphetamine (“ecstasy”) abuse
• Methamphetamine (“speed”) abuse
• Lysergic acid diethylamide (LSD) abuse
• Hyperthyroidism, panic disorder, pheochromocytoma
• Cathinone (“khat”) abuse
• Methylenedioxyamphetamine (“ecstasy”) abuse
• Methamphetamine (“speed”) abuse
• Lysergic acid diethylamide (LSD) abuse
• Hyperthyroidism, panic disorder, pheochromocytoma
• Cathinone (“khat”) abuse
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Symptoms and Signs – Differential Diagnosis of Coccidioidomycosis
• Acute pulmonary coccidioidomycoses: community-acquired pneumonias caused by Mycoplasma and Chlamydia; granulomatous diseases, such as Mycobacterium tuberculosis and sarcoidosis; other fungal diseases, such as Blastomyces dermatitidis and Histoplasma
capsulatum
• Coccidioidomas: true neoplasms
• Acute pulmonary coccidioidomycoses: community-acquired pneumonias caused by Mycoplasma and Chlamydia; granulomatous diseases, such as Mycobacterium tuberculosis and sarcoidosis; other fungal diseases, such as Blastomyces dermatitidis and Histoplasma
capsulatum
• Coccidioidomas: true neoplasms
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Symptoms and Signs – Differential Diagnosis of Acute Abdominal Colic
• Acute gastroenteritis
• Food poisoning
• Nonspecific causes, anxiety disorder
• Constipation
• Gastric outlet obstruction
• Chronic peptic ulceration
• Gastric cancer
SMALL BOWEL OBSTRUCTION
Adhesions
• Postsurgical
• Inflammatory (e.g., diverticular)
• Radiation
• Meckel’s diverticulum
• Metastatic
Stricture
• Ischemic
• Radiation
• Inflammatory (e.g., Crohn’s disease)
Volvulus
Intussusception
• Tumor (e.g., Peutz-Jeghers syndrome)
Superior Mesenteric Artery Syndrome
Intraluminal Bolus
• Gallstone
• Bezoar
Hernia
• Abdominal wall
• Internal
Neoplasm
• Benign (e.g., leiomyoma)
• Malignant (e.g., carcinoid tumor, adenocarcinoma)
• Large bowel obstruction
• Colon cancer
• Diverticular disease
• Volvulus
• Uterine
• Missed abortion
• Parturition
• Period pain
• Acute gastroenteritis
• Food poisoning
• Nonspecific causes, anxiety disorder
• Constipation
• Gastric outlet obstruction
• Chronic peptic ulceration
• Gastric cancer
SMALL BOWEL OBSTRUCTION
Adhesions
• Postsurgical
• Inflammatory (e.g., diverticular)
• Radiation
• Meckel’s diverticulum
• Metastatic
Stricture
• Ischemic
• Radiation
• Inflammatory (e.g., Crohn’s disease)
Volvulus
Intussusception
• Tumor (e.g., Peutz-Jeghers syndrome)
Superior Mesenteric Artery Syndrome
Intraluminal Bolus
• Gallstone
• Bezoar
Hernia
• Abdominal wall
• Internal
Neoplasm
• Benign (e.g., leiomyoma)
• Malignant (e.g., carcinoid tumor, adenocarcinoma)
• Large bowel obstruction
• Colon cancer
• Diverticular disease
• Volvulus
• Uterine
• Missed abortion
• Parturition
• Period pain
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Symptoms and Signs – Differential Diagnosis of Cutaneous Color Changes
BROWN
• Generalized: pituitary, adrenal, liver disease; adrenocorticotropic hormone (ACTH) producing tumor (e.g., oat cell lung carcinoma)
• Localized: nevi, neurofibromatosis
WHITE
• Generalized: albinism
• Localized: vitiligo, Raynaud’s syndrome
RED (ERYTHEMA)
• Generalized: fever, polycythemia, urticaria, viral exanthems
• Localized: inflammation, infection, Raynaud’s syndrome
YELLOW
• Generalized: liver disease, chronic renal disease, anemia
• Generalized (except sclera): hypothyroidism, increased intake of vegetables containing carotene
• Localized: resolving hematoma, infection, peripheral vascular insufficiency
BLUE
• Lips, mouth, nail beds: cardiovascular and pulmonary diseases, Raynaud’s syndrome
BROWN
• Generalized: pituitary, adrenal, liver disease; adrenocorticotropic hormone (ACTH) producing tumor (e.g., oat cell lung carcinoma)
• Localized: nevi, neurofibromatosis
WHITE
• Generalized: albinism
• Localized: vitiligo, Raynaud’s syndrome
RED (ERYTHEMA)
• Generalized: fever, polycythemia, urticaria, viral exanthems
• Localized: inflammation, infection, Raynaud’s syndrome
YELLOW
• Generalized: liver disease, chronic renal disease, anemia
• Generalized (except sclera): hypothyroidism, increased intake of vegetables containing carotene
• Localized: resolving hematoma, infection, peripheral vascular insufficiency
BLUE
• Lips, mouth, nail beds: cardiovascular and pulmonary diseases, Raynaud’s syndrome
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Symptoms and Signs – Differential Diagnosis of Colorado Tick Fever
• Cytomegalovirus (CMV) infection
• Endocarditis
• Hepatitis
• Idiopathic thrombocytopenic purpura (ITP)
• Infectious mononucleosis
• Influenza
• Kawasaki’s disease
• Leptospirosis
• Lyme disease
• Measles
• Meningitis
• Pneumonia
• Rocky Mountain spotted fever
• Rubella
• Scarlet fever
• Thrombotic thrombocytopenic purpura (TTP)
• Toxic shock syndrome
• Typhus
• Vasculitis
• Cytomegalovirus (CMV) infection
• Endocarditis
• Hepatitis
• Idiopathic thrombocytopenic purpura (ITP)
• Infectious mononucleosis
• Influenza
• Kawasaki’s disease
• Leptospirosis
• Lyme disease
• Measles
• Meningitis
• Pneumonia
• Rocky Mountain spotted fever
• Rubella
• Scarlet fever
• Thrombotic thrombocytopenic purpura (TTP)
• Toxic shock syndrome
• Typhus
• Vasculitis
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Symptoms and Signs – Differential Diagnosis of Charcot’s Joint
• Rheumatoid and other inflammatory arthritides
• Osteomyelitis, cellulitis, abscess
• Osteoarthritis
• Infectious arthritis
• Rheumatoid and other inflammatory arthritides
• Osteomyelitis, cellulitis, abscess
• Osteoarthritis
• Infectious arthritis
