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1. Biopsy of the scalp lesions
Biopsy of the scalp lesions represents the easiest, most direct route to obtain potentially useful information regarding the accuracy of the diagnosis of TSC-LAM in this patient. Bronchoscopy with transbronchial biopsy could be potentially useful in this regard, and thoracoscopic lung biopsy could establish the correct diagnosis, but both are needlessly invasive in light of a more accessible alternative. In fact, material from an outside thoracoscopic lung biopsy, from the right middle lobe, was subsequently obtained and showed only “emphysematous changes with bullae and blebs, and fibrinous pleuritis", the latter consistent with the history of previous pneumothorax. Repeat thoracic CT using high-resolution technique is not required- the imaging obtained thus far is adequate. Renal ultrasound could be of benefit should angiomyolipomas- the characteristic fat-containing lesion seen in the kidneys of patients with TSC and TSC-LAM- be detected, but angiomyolipomas may occur sporadically (unassociated with TSC-LAM), and the lack of their demonstration would not exclude the diagnosis of TSC-LAM.
The patient subsequently underwent biopsy of the scalp lesions, which showed trichodiscoma (aka fibrofolliculoma).
Which of the following entities are associated with trichodiscomas? (Click on the correct answer to proceed to the eighth and final panel)