MRCP revision battle 21.1: Erythema nodosum

I'm feeling a rather keen bean today so I've decided to slightly modify the way I serve your daily MRCP battles to you.  From now on, as well as battles and wars, I'll try to add 'further reading' links to some of the battles as a form of desert wine for the really keen/anally retentive. 

On that motivated note, today's battles will be:


MRCP revision battle 21.1: Erythema nodosum
MRCP revision battle 21.2: Glucagon and glucagonoma
MRCP revision battle 21.3: Wegener's Granulomatosis
MRCP revision battle 21.4: Rapidly progressive glomerulonephritis
MRCP revision battle 21.5: Achalasia
MRCP revision battle 21.6: Scabies
MRCP revision battle 21.7: Pre eclampsia and HELLP syndrome
MRCP revision battle 21.8: Cafe au lait spots




MRCP revision battle 21.1: Erythema nodosum


Erythema nodosum is inflammation of subcutaneous fat resulting in tender erythematous nodules, typically on the shins.

It usually resolves without scars in around 6 weeks.


It is associated with multiple conditions; below is a list of just a few that you really should remember:

• infection
• TB
• streptococcus
• viral infections
• systemic
• sarcoid
• IBD
• Behcets
• malignancy
• drugs
• OCP
• penicillin
• sulphonamides
• dapsone
• tetracycline
• pregnancy

Treatment is to treat the underlying condition and give NSAIDs for the pain of the nodules.

For the really keen:

Paper from the Dermatology Journal Online  

For everyone else, lets go to to battle 21.2!

MRCP revision battle 21.2: Glucagon and glucagonoma

Lets quickly recap glucagon from our med school days before we move on to the more exotic beast of glucagonoma...


Glucagon is a peptide hormone secreaed from the alpha cells of the islets of langerhans.


It results in raised blood glucose by:

• increasing gluconeogenesis in the liver
• increasing lipolysis

Glucagon is secreted in response to low blood glucose, raised catecholamines and raised plasma amino acids.
Glucagon secretion is inhibited by insulin, ketones in the blood, somatostatin and free fatty acids in the blood



A glucagonoma is a very rare tumour of the alpha cells of the islets of langerhans which secretes glucagon.


It results in:

• massively raised levels of glucagon
• diabetes mellitus
• hypoaminoacidaemia (as GNG is using up protein)
• anaemia
• necrolytic migratory erythema

Necrolytic migratory erythema is a red, blistering rash which is the presenting feature of a glucagonoma in 70% of cases.


Glucagonomas can be associated with MEN 1.


Treatment of a glucagonoma is ocreotide and surgery; prognosis is poor

For the really keen:

Link to the PDF of an article from the European Journal of Endocrinology 

For the rest of us, its onwards to battle 21.3!

MRCP revision battle 21.3: Wegener's Granulomatosis

Wegener's Granulomatosis is a small/medium vessel necrotising granulomatous vasculitis which tends to affect the upper respiratory tract, lungs and kidneys.


90% of cases present with respiratory symptoms.


Associated features to be aware of include:

• blood nasal discharge
• haemoptysis
• saddle-shaped nose

75% get crescentic glomerulonephritis.


cANCA is positive in 90%, pANCA is positive in 25%


CXR may show large shadows.  Pulmonary haemorrhage is also possible.


Treatment is with steroids, cyclophosphamide and possibly co-trimaoxazole to try and reduce risk of PCP.


I guess this is a good opportunity to reconfront a personal demon in the form of a renal battle...

MRCP revision battle 21.4: Rapidly progressive glomerulonephritis

Rapidly progressive glomerulonephritis, AKA crescentic glomerulonephritis (don't you just love the way that in renal medicine everything has multiple names just to make it even more complicated than it already is?!) is, as the name suggests, a particularly aggressive form of glomerulonephritis.  It often presents with acute renal failure, and can progress to end stage renal failure in a matter of days.


It causes crescent-shaped scarring of the glomeruli, hence its name.



Causes of rapidly progressive glomerulonephritis include:

• Wegeners 
• microscopic polyangiitis
• Goodpastures (a topic to be tackled tomorrow)
• transformation from other glomerulonephritis'

Treatment is with high dose steroids.


The prognosis is poor, especially if the initial creatinine is higher than 600.



Since I find anything renal hard to swallow, achalasia seemed an appropriate next battle...

MRCP revision battle 21.5: Achalasia

Achalasia is abnormal peristalsis and failure of relaxation of the lower oesophageal sphincter.


It causes dysphagia, regurgitation, chest pain and weight loss.


Females aged 30-50 are most commonly affected.


Investigation is with oesophageal manometry and barium swallow.
The barium swallow should show a characteristic 'birds beak' appearance (image below is from wiki commons):

Treatment is with balloon dilation or hellers cardiomyotomy.    Nifedipine may be temporarily helpful.


A rare and late complication of achalsia can be squamous carcinoma.


Now on to battle 21.6, which is short but sure to make you itch...

MRCP revision battle 21.6: Scabies

Scabies is an intensely itchy condition caused by sarcoptes scabei, an arachnid which burrows into skin.


In terms of MRCP the follow facts need to be committed to memory:

• first line treatment is 5% permethrin which must be applied over whole body, face and scalp and washed off after 8 to 12 hrs and repeated after 7 days
• second line treatment is 0.5% malatrion
• pruritus persists for up to 6 weeks post erradication.
• look out for pictures of lines (burrows) between web spaces of hands

Now you're itching nicely, lets attack the penultimate battle of the day, pre-eclampsia and HELLP syndrome.

MRCP revision battle 21.7: Pre eclampsia and HELLP syndrome

Pre-eclampsia is defined as:

• gestational hypertension
• proteinuria
• occurring after 20 weeks gestation

Oedema is often a feature.
Possible symptoms include blurred vision, headache and abdominal pain.


Treatment is to lower blood pressure but ultimately the only way to treat pre-eclampsia which is advancing towards eclampsia (=fit) is to deliver the baby.




HELLP syndrome is a severe form of pre-eclampsia characterised by:

• haemolysis
• elevated liver enzymes
• low platelets

It complicates 10-15% of cases of pre-eclapsia.
Mortality is 20-25%


The treatment for eclampsia is IV magnesium sulphate


Now to the final battle of the day

MRCP revision battle 21.8: Cafe au lait spots

Cafe au lait spots are light brown patches on the skin (see picture below from wiki commons):

Cafe au lait spots are associated with several conditions. 
The top 4 associations I remember for MRCP are:

• neurofibromatosis types I and II
• tuberous sclerosis
• Fanconi anaemia
• Mc Cure-Albright syndrome

Which serves as a teaser for conditions I will be covering tomorrow!  See you then.