Lupoid cutaneous leishmaniasis: a report of 16 cases

BACKGROUND

Lupoid cutaneous leishmaniasis (CL) is known as the chronic form of CL. However, keeping its clinical presentation in view, there is a need to revisit this form of disease.

AIMS

To redefine/describe lupoid CL in view of clinical features.

METHODS

It was a case series seen in Muzaffarabad (Pakistan) from Jan 2006 to May 2008. All patients clinically suggestive and consistent with laboratory diagnosis of CL were registered. Patients of all age groups and either sex having cutaneous lesions resembling lupus vulgaris or lupus erythematosus on the face or elsewhere were included in the study. Those having chronic fluctuating/relapsing course or scarring within the lesions were also included. Various demographic features of the patients and clinical patterns were recorded. Descriptive statistics were used for analysis.

RESULTS

Of 254 registered patients of CL, 16 (6.3%) were diagnosed as lupoid CL. None of the patients had scarred lesions. Age ranged from 38 to 75 (55 + 15.11) years and duration of lesions varied from 4 to 32 (14.25 + 07.59) weeks. All patients had lesions over the face. Thirteen (81.25%) had a large solitary plaque extending over the nose and a large part of the cheeks and three (18.75%) had multiple lesions. Lesions were central/nasal in two (12.5%), unilateral/asymmetrical in four (25%) and bilateral/symmetrical in 10 (62.5%). Morphological patterns included erythematous/infiltrated (7), psoriasiform (6), ulcerated/crusted (2) and Discoid lupus erythematosus (DLE)[G1] like (1).

CONCLUSION

Lupoid CL is not strictly a chronic form of disease, which presents on the face from the very onset and shows no scarring or recurrence.

Treatment of toxic epidermal necrolysis (TEN) with low dose intravenous immunoglobulin in child

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN, Lyell's disease) are severe, episodic, acute mucocutaneous reaction that may be caused by various factors particularly drugs. Treatment is primarily supportive care and there are no specific therapy regimens. Intravenous immunoglobulin (IVIG) has recently been shown to be a useful and safe therapy in paediatric patients with SJS/TEN, though no such case has so far been reported from Pakistan. The authors report the experience with low dose IVIG (0.1 g/kg/day for four consecutive days for treating a 3 years old boy with toxic epidermal necrolysis with favourable outcome without early complications.

A clinicopathological study of urethritis in males

OBJECTIVE

To determine the etiology and frequency of different types of urethritis in adult males.

STUDY DESIGN

A case series.

PLACE AND DURATION OF STUDY

The Dermatology Department of PNS Shifa Hospital, Karachi, from June 2004 to December 2007.

METHODOLOGY

One hundred male patients having complaints of urethral discharge and dysuria reporting in the skin OPD were included in the study. Patients who had received systemic treatment for their complaints and those who had other systemic infections were excluded. A detailed history including history of sexual contact was taken. Dermatological examination including examination of external genitalia was also performed. All these patients were subjected to complete physical examination, complete urine examination, urethral pus for gram staining and culture, endo-urethral swab with urethral loop for seeing Chlamydia antigen by fluorescent microscopy, cultures for ureaplasma and Wet mount specimen microscopy for trichomonas along with HIV (serum ELISA) test. Non-gonococcal urethritis was diagnosed on the presence of more than five polymorphonuclear leucocytes per high power field in at least five fields of Gram stained urethral smear, in the absence of Gram negative diplococci.

RESULTS

The mean age was 29.2 + or - 5.8 years. Seventy (70%) cases were diagnosed as gonococcal urethritis and 30 (30%) cases as non-gonococcal urethritis (NGU). History of illicit sexual exposure was available in 25 (25%) patients. The interval period between initiation of symptoms and reporting of patient in gonococcal urethritis was 4 to 30 days (mean 12.8 days) and 4 days to 2 months (mean 20.7 days) in non-gonococcal urethritis. The patients with gonococcal urethritis presented with purulent discharge in 66 (84%) cases, and dysuria in 49 (70%) cases. In the NGU group, 25 (80%) cases had mucoid discharge and 18 (65%) had dysuria. in 70%, Neisseria gonorrhoeae was isolated, Chlamydia trachomatis in 16%, ureaplasma in 8%, and Trichomonas vaginalis in 4%. No organism could be detected in 2% cases. HIV test was negative in all cases.

CONCLUSION

Gonococcal urethritis was the commonest urethritis seen followed by Chlamydia infection in the studied group of adult males.

Different faces of gastroparesis

AIM: To test the hypothesis that pain and affect rather than impaired emptying determine symptom severity in patients with gastroparesis.

METHODS: Adult patients with documented gastroparesis were enrolled prospectively in a single center and asked to complete the Gastroparesis Cardinal Symptom Index (GCSI), Hospital Anxiety and Depression Scale (HADS), the Short Form 12 (SF-12) as quality of life index, rate pain severity and answer 10 open-ended questions.

RESULTS: A total of 55 patients (44 women) participated. Idiopathic (n = 29) or diabetic (n = 11) gastroparesis and connective tissue disease (n = 8) were the most common underlying causes. Antiemetics (n = 30) and prokinetics (n = 32) were most often prescribed. Seventeen patients used opioids on a daily basis. Nausea and/or vomiting (n = 28), pain (n = 24) and bloating (n = 14) were most commonly listed as dominant symptoms. Patients subjectively attributed symptom improvement to nutritional and dietary therapy (n = 11), prokinetics (n = 11), antiemetics (n = 10) or analgesic agents (n = 3). In univariate analyses, the physical subscore of the SF-12 and HADS, but not gastric emptying delay or symptom duration significantly correlated with disease severity as measured by the GCSI. In multivariate analyses, the combination of vomiting, bloating and depression best predicted the overall impact on quality of life.

CONCLUSION: The study confirms the importance of pain and affect in gastroparesis, which requires novel approaches to improve more effectively the quality of life in patients with this disorder.

Discriminative value of anorectal manometry in clinical practice

Guidelines recommend anorectal manometry in patients with fecal incontinence and chronic constipation. However, limited evidence supports the utility of manometric testing. We retrospectively reviewed tracings obtained between November 2005 and May 2008. A total of 298 patients (86% women; average age 52 years) were included. The main indications were incontinence (51%) and constipation (42%). Patients suffering from incontinence were older and had lower resting and squeeze pressure compared to continent patients. However, the discriminative power of manometric pressure data was poor, with low sensitivity and specificity. An abnormal straining pattern suggesting dyssynergic defecation was seen in 43% of constipated patients compared to 13% of patients with fecal incontinence. A concordance between manometric patterns and the balloon expulsion test was seen in 72%. The low sensitivity and specificity of manometric parameters does not support the routine use of anorectal manometry in patients with defecation disorders.

Risk factors for scabies among male soldiers in Pakistan: case-control study

Being a preventable disease, good control of scabies can be achieved by identification of risk factors. During the 3-month period February 2006-April 2006 we carried out a case-control study on 200 patients with scabies and 200 controls to identify risk factors for scabies among male soldiers in Pakistan. We identified risk factors for the infestation using logisitic regression analysis. Itching in family/dormitory mates, infrequent bathing, infrequent changing of clothes, low education, sharing beds and being away from the barracks were identified as significant risk factors for scabies, while overcrowding, large family size and sharing of towels and hospitalisation were not.

Why dermatology patients are hospitalized? A study from Pakistan

In most countries, there are no specified protocols or guidelines for admitting dermatology patients and admission criteria depend on assessment and sometimes the whim of the dermatologist. Although the severity and extent of the disease are the commonest reasons for hospitalizing dermatology patients, sometimes other factors also operate to provide comfort to the patient. This study was carried out to determine the reasons for hospitalizing patients on dermatology beds in secondary care hospitals of Pakistan. A questionnaire comprising patients' demographic data, diagnosis, specific reasons for hospitalization and length of hospital stay was sent to dermatologists of 10 secondary care hospitals in the country. The data received in response were processed and analyzed using the SPSS-10 computer program. A total of 310 patients were included in the study. Patient age ranged from 1 to 87, mean 28.87+/-12.32 years. The severity and extent of the disease (n=122; 39.3%), outpatient treatment failure (n=57; 18.4%) and need for further observation and/or investigations (n=51; 16.5%) were the most common reasons for hospitalizing these patients. Hospital stay of the patients ranged from 2 to 30, mean 9.82+/- 6.43 days. Scabies (n=56; 18.1%), chickenpox (n=52; 16.8%) and eczema (n=41; 13.2%) were the most common diagnoses.

Dermatosis neglecta in a case of multiple fractures, shoulder dislocation and radial nerve palsy in a 35-year-old man: a case report

INTRODUCTION

Dermatosis neglecta is an often misdiagnosed and under-diagnosed condition. In dermatosis neglecta, a progressive accumulation of sebum, sweat, keratin and other dirt and debris, occurs due to inadequate local hygiene resulting in a localized hyperpigmented patch or a verrucous plaque. Vigorous rubbing with alcohol-soaked gauze or soap and water results in a complete resolution of the lesion. This is the first case of dermatosis neglecta reported in a patient with multiple traumatic injuries.

CASE PRESENTATION

We report a case of a 35-year-old male Caucasian of Pakistani origin, with multiple fractures, neurological deficit and immobility sustained in a fall, leading to the development of dermatosis neglecta of the left hand.

CONCLUSION

Early and prompt clinical recognition of this condition eliminates the need for aggressive diagnostic and therapeutic procedures.

Comparison of 30% salicylic acid with Jessner's solution for superficial chemical peeling in epidermal melasma

OBJECTIVE

To compare the efficacy and safety of Jessner's solution with 30% salicylic acid as superficial chemical peeling agents in treating epidermal melasma in Asian skin.

STUDY DESIGN

Double blind, randomized, interventional comparative study.

PLACE AND DURATION OF STUDY

Department of Dermatology, Combined Military Hospital, Malir Cantt, Karachi, from January to December 2004.

PATIENTS AND METHODS

Sixty consenting patients with epidermal melasma were randomly divided into two groups. Group A was treated with Jessner's solution and Group B with 30% salicylic acid. Baseline Melasma Area Severity Index (MASI) score was noted and peeling started at 2-weekly intervals. Sunscreen in morning and moisturizer at night were prescribed in all patients. MASI score and adverse effects were recorded biweekly. Treatment was stopped at 12 weeks and patients were followed-up at 4 weekly intervals for further 12 weeks. Final MASI score and adverse effects were noted at the end of follow-up period. Mean MASI scores were compared using paired sample t-test and one-way ANOVA.

RESULTS

Difference in baseline, treatment end and follow-up end MASI scores was not statistically significant between the two groups (p 0.54, 0.26, and 0.55 respectively). On the other hand, within group analysis of difference between pre and posttreatment MASI score was highly significant in both groups (p<0.0001). Adverse effects were mild and comparable in both groups.

CONCLUSION

Jessner's solution and 30% salicylic acid are equally effective and safe peeling agents for use in epidermal melasma in Asian skin.

Papulonecrotic tuberculids associated with uveitis

Papulonecrotic tuberculids represent an immunological expression of an internal focus of tuberculosis in an individual with a moderate or high degree of immunity. It responds to anti-tuberculosis treatment and is characterized by an eruption of necrotizing papules occurring in symmetrical crops, particularly affecting the elbows, knees, buttocks and face. A case of papulonecrotic tuberculids associated with immune mediated unilateral uveitis is reported in which all investigations were negative for tuberculosis except a strongly positive tuberculin test. There was an excellent response to anti-tuberculosis treatment. The association of immune mediated uveitis with papulonecrotic tuberculids has not been described before.

Localized lesions in secondary syphilis

The clinical manifestations of secondary syphilis are variable and can mimic many skin diseases, mostly being generalized and symmetrical in distribution. Localized lesions of secondary syphilis are rarely seen in dermatology clinics. We report an unusual presentation wherein a patient had localized lesions over face and soles only. There is a need for increased awareness on the part of physicians to recognize new patterns of syphilitic infection, together with a willingness to consider the diagnosis of syphilis in patients with unusual clinical features.

Onset of chilblains in relation with weather conditions

BACKGROUND

Chilblains or perniosis is a moderately severe form of cold injury, localized to peripheral parts of the body, which occurs after exposure to non-freezing temperatures and damp conditions. Although inter-individual variations exist with respect to susceptibility to develop chilblains, no study has been carried out in this region to determine the role of different weather conditions either alone or in combination, in predisposing the susceptible individuals to chilblains. The objective of this study was to determine the relationship between weather conditions and onset of chilblains at a moderately cold weather station.

METHODS

This study was conducted at the Department of Dermatology, Combined Military Hospital, Abbottabad, from Dec 2004 to Mar 2005. All patients fulfilling the clinical criteria for diagnosis of chilblains were included in the study. These patients were interviewed and examined thoroughly. A specially designed proforma was filled for each patient separately. Meteorological department was contacted for record of weather conditions. Onset of chilblains in each patient was related with weather conditions of that particular month. Computer programme SPSS 10 was used for statistical analysis.

RESULTS

Out of 111 patients, 67 (60.4%) were males and 44 (39.6%) were females. Eighty nine (80.2%), 90 (81.1%) and 90 (81.1%) patients had onset in relation with lower temperature (< 10 degrees C), relatively low atmospheric pressure (< 1500 kpa) and higher relative humidity (> 60%) respectively. There was statistically significant relationship of weather conditions with onset of chilblains when different groups, i.e., elderly and young, males and females, locals and non locals, outdoor workers and those remaining inside most of the time and those having disease of longer or shorter duration were compared.

CONCLUSION

The cold weather conditions that can be endured by humans depend on combination of the duration and the extent of the exposure, in addition to physiological adaptive changes. However, susceptibility to chilblains increases when ambient temperature is less than 10 degrees C and relative humidity is more than 60%. Elderly, females, outdoor workers and those having chronic or recurrent episodes of chilblains are less tolerant to cold weather and develop the disease under lesser ambient cold.

Onset of adult varicella in relation to rural or urban origin and its complications

OBJECTIVES

To determine area of origin of adult varicella patients, whether rural or urban, to compare the mean interval between leaving the area of origin and onset of varicella in adults of rural origin in comparison with those of urban origin and to observe its complications.

STUDY DESIGN

A cross-sectional study.

PLACE AND DURATION OF STUDY

Combined Military Hospital, Abbottabad, from January to December 2006.

PATIENTS AND METHODS

All patients over the age of 18 years, presenting with acute illness clinically, suggestive of varicella were included in the study. A specially designed proforma was filled for each patient separately, which included demographic features as well as area of origin, whether rural or urban, and the age at which they left the area of origin. These patients were examined, treated and assessed clinically on regular basis for the progress of the disease as well as for its possible local or systemic complications. Data analysis was done by using statistical programme SPSS-10.

RESULTS

Out of 9155 adult patients, 156 (1.70%) had varicella, including 128 (82.1%) males and 28 (17.9%) females. Origin was rural in 125 (80.1%) and urban in 31 (19.9%) patients. Mean interval between leaving area of origin and developing varicella in those of rural origin was 01.79+/-01.78 years and that in patients of urban origin was 03.37+/-05.72 years (p+/-0.009). None of the patients developed any complication of the disease.

CONCLUSION

Varicella in adults is generally a benign illness. It is more common among adult males of rural origin and the interval between leaving the area of origin and onset of varicella in these patients is significantly less as compared to that in adults of urban origin.

Drug induced linear IgA disease with unusual features: Koebner phenomenon, local insulin sensitivity and annular blister of the nipples

Linear IgA disease is an autoimmune subepidermal bullous disease in which linear IgA deposits are found at the basement membrane zone. It is classically idiopathic but may be drug induced. We report on a patient with drug induced linear IgA disease who exhibited certain unusual and interesting clinical features including isomorphic Koebner response, annular blister of the nipples and local insulin sensitivity. To the best of our knowledge, these clinical features have not yet been reported in linear IgA disease.

Granulomatous cheilitis: sustained response to combination of intralesional steroids, metronidazole and minocycline

Various conservative methods for treatment of labial swelling in patients with granulomatous cheilitis have been attempted, often with only moderate success. We report a case of granulomatous cheilitis who showed excellent sustained response to combination of intralesional steroids, metronidazole and minocycline for initial one month followed by prolonged maintenance treatment with minocycline alone.

Juvenile onset classical pityriasis rubra pilaris: every patient may not require systemic therapy

Juvenile onset classical Pityriasis Rubra Pilaris (PRP), although rare, is the most common presentation of PRP in children. It has good prognosis and resolution over a few months. Use of potentially hazardous systemic drugs in a disease, that is likely to resolve spontaneously, needs to be assessed carefully. We report a 09 years old boy suffering from this rare disorder, whose disease is well under control with emollients and a combination of diluted topical steroids and keratolytics, for over 06 months.

Hydroa vacciniforme in an adolescent girl

Hydroa vacciniforme (HV) is a rare photosensitivity disorder with onset in childhood. Recurrent vesicles, bullae and crusting occur on sun-exposed skin that heals with vacciniform scarring. This rare disorder is hereby reported in an adolescent girl who developed a severe episode of hydroa vacciniforme on a hot sunny day during harvesting season. She had repeated episodes afterwards in succession until she was appropriately sun-screened. Her lesions healed without scarring because of early reporting, short-lived episodes, early diagnosis and response to appropriate therapy.