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To claim CME credit, complete this case-based posttest online at http://www.aad.org/JAAD/. Note:CME quizzes are available after the first of themonth in which the article is published. Aminimum scoreof 70% must be achieved to claim CME credit. If you have any questions, please contact the MemberResource Center of the American Academy of Dermatology at toll-free (866) 503-SKIN (7546), (847)240-1280 (for international members), or by e-mailing mrc@aad.org.

CME examination

Identification No. JB0213

February 2013 issue of the Journal of the American Academy of Dermatology.

Questions 1-5, Thrash B, Patel M, Shah KR, Boland CR, Menter A. J Am Acad Dermatol 2013;68:211-43.

Directions for questions 1-5: Choose the single bestresponse.

A 7-year-old boy is brought to the office by his mother forevaluation of a rash of 3 days’ duration. Before the devel-opment of the rash, she had taken the child to thepediatrician’s office for an intensely painful upset stomachof several days’ duration and was given an antibiotic thathe began taking that afternoon. She says that he has beenscratching and not sleeping well. She believes that he ishaving an allergic drug reaction to the antibiotic and wantshim placed on steroids. The physical examination revealsmultiple small, nonblanching papules with associatedpurpura most pronounced on the buttocks, below theknees, and around the ankles. When the child’s ankle isgrabbed, he winces. ‘‘He’s been hobbling around thehouse. I think he twisted his ankle at soccer practice,’’themother says. A complete blood cell count and completemetabolic panel are normal. However, the urine shows atrace hematuria without proteinuria.

1. If you begin a course of prednisone 1 mg/kg/day for

2 weeks, which of the child’s symptoms is most likelyto respond?a. Insomniab. Rashc. Gastrointestinal complaintsd. Hematuriae. Anal pruritis

2. When discussing the finding of hematuria in thiscondition with the mother, which of the following ismost accurate?a. Most children with this condition have blood in

their urineb. The hematuria is harmless and should not be

considered relevantc. Her son is most likely going to require dialysis at

some pointd. Hematuria is common, but it rarely progresses to

more serious renal diseasee. Prednisone will lower the risk of her son’s hema-

turia, progressing to end stage renal disease

A 34-year-old woman with an 8-month history of ex-tremely pruritic lesions on her arms and legs presents toyour office. She was diagnosed with ‘‘eczema’’ by herprimary care physician, but despite the use of multiplesteroid creams, there has been little improvement in hersymptoms. She states that she is so uncomfortable that shefinds it difficult to concentrate at work and she wakes up atnight scratching. The physical examination reveals multi-ple erythematous, excoriated papules on the elbows andknees and the small of her back and buttocks. Her ante-cubital and popliteal fossae are spared of lesions, as are herfinger webs, umbilicus, and wrists. On direct questioning,she states that there are frequently ‘‘water blisters’’ in thearea of the itching.

3. What is the next step in confirming the diagnosis in

this patient?a. Obtain a skin biopsy specimen to include direct

immunofluorescence of immunoglobulin A anti-bodies to epidermal transglutaminase

b. Obtain a biopsy specimen of the small bowelc. Scraping of the lesion for microscopic evaluationd. An enzyme-linked immunosorbent assay for

antiepidermal transglutaminase in the serume. Begin a gluten-free diet

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VOLUME 68, NUMBER 2CME examination 245

4. What should be the initial step in treatment of thepatient’s disease?a. Topical dapsone and initiation of a gluten-free dietb. Oral dapsone and initiation of gluten-free dietc. Sulfasalazined. Potent topical steroidse. PUVA

5. In counseling the patient regarding her disease, whichof the following is accurate?a. A strict gluten-free diet will most likely result in

resolution of her lesions within 6 weeksb. She is at a significantly increased risk for

non-Hodgkin lymphomac. A biopsy specimen of the small bowel would most

likely reveal villous atrophyd. Treatment with dapsone generally takes 6 weeks

to demonstrate an improvement in the prurituse. Other than celiac disease, there are no known

associated conditions from which her diagnosisplaces her at increased risk