Ocular manifestations and complications of Stevens-Johnson syndrome and toxic epidermal necrolysis: an Asian series

BACKGROUND

To describe the acute and late ocular manifestations and complications in toxic epidermal necrosis (TEN) and Stevens-Johnson syndrome (SJS), and identify predictors for development of late complications.

METHODS

Cases of TEN and SJS during a 9-year period were included. Patients with ocular involvement were reviewed for acute ocular complications. Patients with a minimum 6 months follow-up were reviewed for late complications. Records were reviewed for their demographics, etiology, and severity of ocular involvement.

RESULTS

There were 117 patients with a mean age of 52.2 +/- 18.6 years. Eighty-one of these (69%) had acute ocular involvement. This was mild in 40%, moderate in 25% and severe in 4%. Adverse drug reactions were the predominant cause. Patients with thrombocytopenia had more severe acute ocular involvement. Forty-four patients had a minimum 6 months of follow-up and half developed late complications. Severe dry eyes and trichiatic lashes were the commonest late complications. Patients treated with topical antibiotic were more likely to have late complications, particularly dry eyes. There was no difference in the severity of acute eye involvement or late complications when SJS and TEN patients were compared. The severity of the acute ocular disease and abnormal laboratory tests were not found to be the significant risk factors of late complications.

CONCLUSIONS

Ocular involvement is common in SJS and TEN and can be severe and blinding. The severity of acute ocular complications does not predict late complications. The diagnosis of TEN does not imply a more severe ocular involvement or increased frequency of late ocular complications compared with SJS. Care should be taken even in mild cases. Appropriate intervention during acute ocular disease may prevent late complications.

A simple method for evaluation of tongue position

Neck extension because of contraction of cervical extensor muscles often brings about a lower-positioned tongue secondary to jaw opening in patients with congenital myopathy (CM). We hypothesized that neck extension in control subjects would reproduce the lower position of the tongue similar to that found in a CM patient. A simple method was formulated to evaluate the tongue position in terms of tongue pressure on the maxillary molar. A pair of pressure sensors was attached to the buccal and lingual surfaces of the upper molar for both the CM patient and four control subjects. Changes in the buccal and tongue pressures were recorded at the neck extension position for the CM patient and during both the natural head position and neck extension for the control subjects. There was a remarkable difference between buccal and tongue pressures in the neck extension position in the CM patient: tongue pressure was not detected at all, indicating there was no contact between tongue and upper molar. The buccal and tongue pressures were approximately equal in the natural head position in the control subjects. However, both buccal and tongue pressures were reduced during neck extension in the control subjects, with a greater decrease in the tongue pressure than the buccal pressure. These findings suggest that neck extension in a control subject reproduces the lower position of the tongue observed in CM patients. We propose that the pressure sensor enables evaluation of the tongue position, but further investigation is required.

Comparative efficacy of Hanifin and Rajka's criteria and the UK working party's diagnostic criteria in diagnosis of atopic dermatitis in a hospital setting in North India

BACKGROUND

Diagnosis of atopic dermatitis (AD) depends on clinical features because no definitive diagnostic test exists. Criteria proposed by Hanifin and Rajka (Acta Derm Venereol (Stockh) 1980; Suppl 92: 44-47) were acceptable for hospital-based studies but were found not to be suitable for field studies. A UK working party formulated clinical diagnostic criteria that could be used in both hospital and epidemiological settings. Validation studies of the criteria showed widely variable results, probably due to different clinical settings and ethnicity.

AIM AND OBJECTIVE

This study was undertaken to validate Hanifin and Rajka's criteria and to assess the comparative efficacy of their criteria and the UK working party's diagnostic criteria in the diagnosis of AD in a hospital setting in North India.

SUBJECTS AND METHODS

This study serially included 101 patients with AD and 48 controls of paediatric age group. The study period was from July 2003 to December 2004.

RESULTS

Hanifin and Rajka's criteria (sensitivity 96%, specificity 93.75%, positive predictive value 97% (PPV) and negative predictive value (NPV) 91.84%) had a statistical advantage over the UK working party's diagnostic criteria (sensitivity 86%, specificity 95.83%, PPV 97.75% and NPV 76.67%), with a P-value < 0.005.

Detection of high-risk human papillomavirus type 16/18 in cutaneous warts in immunocompetent patients, using polymerase chain reaction

Cutaneous warts are caused by human papillomavirus (HPV). Prevalence studies of the types of HPV present in cutaneous warts have been carried out more frequently in immunosuppressed patients. The present study was designed to study the association of high-risk HPV in cutaneous warts of immunocompetent patients. A total of 45 cases of cutaneous warts from various sites in immunocompetent subjects were analyzed for HPV. Samples included both archival material i.e., paraffin embedded and fresh tissue. Highly sensitive and comprehensive polymerase chain reaction (PCR) methodology for detection of HPV of high oncogenic potential, HPV 16/18, was employed. Human papillomavirus 16 was detected in 3 (6.6%) patients. None of the lesions demonstrated HPV 18. None of the cutaneous warts demonstrated histopathological features associated with dysplasia or neoplasia. The identification of HPV 16 in cutaneous warts, which are benign proliferations of the skin, further expands the spectrum of HPV-linked lesions. It remains of critical interest to determine whether these types are specifically associated with the development of malignant lesions analogous to those seen in anogenital cancer.

Accelerated tubular cell senescence in SMP30 knockout mice

An experimental model with accelerated but not drastic renal senescence seemed useful to recognize the mechanisms of how kidney function deteriorates with age. Senescence marker protein-30 (SMP30), whose expression decreased with age and was sex-independent, is mainly expressed in hepatocytes and proximal tubular cells. Therefore, we established a SMP30 deficient strain of mice with a C57BL/6 background by gene targeting to investigate whether this molecule is involved in renal tubular cell senescence. Male SMP30 knockout (SMP30Y/-) mice and male wild-type (SMPY/+) mice (n=5) aged 12 months were examined histologically. Their tubular epithelia showed the deposition of lipofuscin and the presence of senescence-associated beta-galactosidase (SA-beta-GAL). However, no tubular cells were atrophic. In electron microscopy, SMP30-KO mice showed markedly enlarged lysosomes containing an electron dense substance. These are convincing hallmarks of senescence. We recognized the early manifestation of senescence hallmarks in SMP30-KO mice at 12 months old. Thus, this model represents the first report of a mouse strain that manifests accelerated ordinal senescence in a kidney after gene manipulation.

Linear hypopigmentation after triamcinolone injection: a rare complication of a common procedure

The development of linear hypopigmentation after intralesional or intraarticular injection of triamcinolone acetonide has been reported in the literature as a very rare side effect. This case report describes a patient with linear hypopigmentation and discusses the possible pathophysiology. Clinicians involved in the care of hypertrophic scars and keloids need to be aware of this rare side effect so that they can guide their patients appropriately. They need to understand the pathogenesis of this complication better so that it may become avoidable.

Comparative efficacy of cetirizine and fexofenadine in the treatment of chronic idiopathic urticaria

OBJECTIVES

Antihistamines are the first line of therapy for chronic idiopathic urticaria (CIU). The present study was designed considering the lack of reports comparing the efficacy and safety of commonly prescribed cetirizine and fexofenadine in the treatment of CIU.

METHODS

A total of 116 patients, aged 17 to 65 years, with CIU (urticarial wheals for at least two days per week for six consecutive weeks before entry) were enrolled in this randomised double-blind study. Study period was 28 days with patient visits on days 14 and 28 for investigator evaluation of the clinical response. Patient evaluation was on the basis of an analogue scale. Final response to treatment was judged as symptom free, partial improvement, and no improvement.

RESULTS

Ninety-seven patients (52 cetirizine, 45 fexofenadine) completed the study. The response to treatment in both the groups at the end of treatment period was as follows; symptom free [cetirizine 27(51.9%), fexofenadine 2(4.4%)], partial improvement [cetirizine 19(36.5%), fexofenadine 19(42.2%)], no improvement [cetirizine 6(11.5%), fexofenadine 24(53.3%)]. Side effects noted were mild with no significant difference between the two.

CONCLUSION

Cetirizine seems to have therapeutic advantage over fexofenadine in the treatment of CIU.

Biochemical markers of vasospastic coronary artery disease

OBJECTIVE

The risk factors for vasospastic angina pectoris (VSA) have not yet been well defined. We compared the plasma levels of lipids, apo(lipo)proteins, remnants of triglyceride (TG)-rich lipoproteins, oxidized low density lipoprotein (Ox-LDL), cholesteryl ester transfer protein (CETP) [which transfers esterified cholesterol (EC) from HDL to TG-rich lipoproteins and reduces plasma HDL levels], high-sensitivity C-reactive protein (hs-CRP), homocysteine and plasminogen-activator inhibitor (PAI)-1 in background-matched groups of controls, and patients with VSA or coronary atherosclerotic disease (CAD) (n=50 subjects each).

METHODS AND RESULTS

The cholesterol levels of remnant-like particles (RLP), which are equivalent to the remnants of TG-rich lipoproteins, were measured using a precipitation method. Ox-LDL, CETP and PAI-1 were measured by means of sandwich ELISA; hs-CRP by means of nephelometry; and homocysteine by means of HPLC. Plasma LDL-C levels were high only in the CAD group, and plasma apo E and PAI-1 levels were high only in the VSA group. The plasma levels of TG, apo CII and RLP-C were highest in the VSA group, followed by the CAD group. The plasma levels of apoB, apo CIII, Ox-LDL, CETP, hs-CRP and homocysteine were equally increased in both the VSA and CAD groups. The increases in plasma RLP-C, CETP, hs-CRP and homocysteine were not significantly different between stable and unstable states of angina pectoris in either the VSA or CAD group.

CONCLUSION

The increases in plasma TG-rich lipoproteins and their remnants were more significant markers of VSA than of CAD. The increases in plasma CETP, Ox-LDL, hs-CRP and homocysteine were equally important markers of VAS and CAD.

A study of 124 Indian patients with lichen planus pigmentosus

Lichen planus pigmentosus is a fairly common disorder of pigmentation in Indians, but reports comprising a sizeable number of patients are lacking in the literature. We now describe the clinical and epidemiological features and histopathological findings for 124 lichen planus pigmentosus patients. A retrospective analysis of medical records of patients attending our centre during the past 12 years was undertaken. Of the 124 patients (56 male, 68 female), the majority (48.4%) had the disease for 6 months to 3 years. The face and neck were the commonest sites affected with pigmentation varying from slate grey to brownish-black. The pattern of pigmentation was mostly diffuse (77.4%), followed by reticular (9.7%), blotchy (7.3%) and perifollicular (5.6%). Lichen planus was noted in 19 patients with typical histopathological changes of the disorder. Lichen planus pigmentosus, a distinct clinical entity commonly encountered in the Indian population, should be considered in the spectrum of lichenoid disorders as a variant of lichen planus.

Different effects of various anti-GPIIb-IIIa agents on shear-induced platelet activation and expression of procoagulant activity

Inhibitors of the platelet glycoprotein (GP)IIb-IIIa receptor (integrin alphaIIbbeta3) reduce acute thrombotic events in patients with coronary artery disease. To characterize the mechanism of action of these drugs, we evaluated the effects of different GPIIb-IIIa antagonists on shear-induced platelet aggregation, activation, and the expression of procoagulant activity. Samples of platelet-rich plasma from 16 volunteers were exposed to the shear rate of 10 800 s-1 for 6 min in an optically modified cone-plate viscometer. Abciximab, tirofiban and eptifibatide inhibited aggregation to a similar extent (mean +/- SD: 74.1 +/- 8.5%, 69.5 +/- 13.6%, 65.6 +/- 17.0%, respectively), but only abciximab inhibited significantly microparticle release associated with shear-induced platelet activation (64.4 +/- 13.6%, P = 2.2 x 10-7; tirofiban = 20.0 +/- 23.4%; eptifibatide = 23.9 +/- 17.4%). P-selectin platelet surface translocation was also strongly inhibited by abciximab, weakly by eptifibatide, but not by tirofiban. The addition of anti-alphavbeta3 to tirofiban enhanced the inhibiting effects on shear-induced P-selectin translocation and microparticle release. Shearing of platelet-rich plasma shortened the re-calcification clotting time after addition of kaolin from 106.9 +/- 14.3 to 94.2 +/- 10.7 s (mean +/- SD; P = 0.0013). This effect, which is mediated by the appearance of procoagulant phospholipids on the surface of sheared platelets and microparticles, was prevented by abciximab and by the combination of tirofiban and anti-alphavbeta3, but not by tirofiban alone or eptifibatide. The ability to inhibit shear-induced platelet activation, as evidenced by microparticle release and P-selectin surface translocation as well as the expression of procoagulant activity, differentiates the effects of anti-GPIIb-IIIa agents, which may explain the distinct antithrombotic efficacy of the agents.

Chronic macrocheilia: a clinico-pathological study of 28 patients

Chronic macrocheilia has a multifactorial aetiology and is often a diagnostic and therapeutic challenge. Epidemiological information on this condition is scarce, most of the data reported relating only to granulomatous cheilitis. We have performed a detailed clinico-pathological analysis of all patients with chronic macrocheilia presenting to us during the last 6.5 years. Of the 28 patients identified, 13 (46.4%) had granulomatous cheilitis (GC), six (21.4%) had tuberculosis of the lip, three (10.7%) had leprous macrocheilia, two (7.1%) had multiple endocrine neoplasia type IIb, and one each had Ascher's syndrome and non-Hodgkin's lymphoma. Two patients were diagnosed as 'nonspecific cheilitis'. Histopathological differentiation between tuberculosis and GC was often not possible; but PCR for Mycobacterium tuberculosis was positive in all patients with tuberculosis and negative in four patients with GC in whom M. tuberculosis was sought. In spite of detailed clinical examination and investigations, a therapeutic trial was required to confirm the diagnosis in five (17.9%) patients. We have reviewed the available literature on this subject, and to our knowledge this study is the first of its kind. More such studies from other centres will help physicians to make an accurate aetiological diagnosis and treat this uncommon but disfiguring condition with confidence.

Psychiatric morbidity in vitiligo: prevalence and correlates in India

BACKGROUND

Vitiligo, a common pigmentary disorder, is recognized to be associated with a high psychiatric morbidity, yet compared to other dermatological disorders like leprosy, psoriasis, etc., it has not been subjected to detailed evaluation of its psychological consequences. The data from the developing countries on this aspect in particular is meager.

METHODS

One hundred and thirteen cases with vitiligo were evaluated along with 55 healthy controls comparable for sociodemographic profile and matched on attitude to appearance scale. Clinical details, impact of illness, associated dysfunction and psychological morbidity were additionally assessed.

RESULTS

Twenty-eight patients with vitiligo were found to have psychiatric morbidity, a clinic prevalence rate of 25% (95% confidence interval 20.3-29.3%). The majority of the cases had a diagnosis of adjustment disorder. Psychiatric morbidity was significantly correlated with dysfunction arising out of illness.

CONCLUSIONS

Vitiligo is associated with high psychiatric morbidity. There is a need to develop cross-cultural database on psychosocial aspects and psychiatric morbidity associated with vitiligo.

Estimation of left ventricular systolic pressure by the left ventricular volume-time curve obtained from electrocardiograph gated 99m Tc-tetrofosmin single photon emission tomography using quantitative gated SPECT

We report the estimation of left ventricular systolic pressure (LVSP) by a left ventricular (LV) volume-time curve obtained from electrocardiogram (ECG) gated 99mTc-tetrofosmin single photon emission computed tomography (SPECT) using quantitative gated SPECT (QGS). LVSP was calculated based on the following parameters: LV volumes, velocity and acceleration of LV contraction, aortic valve area and density of blood. The first three parameters can be derived from ECG gated SPECT. In 16 patients, the LV volume-time curve was obtained from ECG gated SPECT by using QGS. LVSP was estimated by the above-mentioned theory. The values of estimated peak LVSP were compared with those measured from a pressure transducer. There was a correlation between the values of peak LVSP estimated by the LV volume-time curve and those measured by pressure transducer (r=0.69, P<0.01). Using QGS, LVSP and the systolic LV pressure-volume relationship could be estimated by the LV volume-time curve.

Effects of ticlopidine on von Willebrand factor-mediated shear-induced platelet activation and aggregation

Ticlopidine, recently classified as a P2Y(12) ADP receptor blockade, is known to be an effective antiplatelet agent preventing arterial thrombosis, e.g., myocardial infarction or cerebral infarction, but the mechanism of the in vivo antithrombotic effects of ticlopidine is not fully understood. Blood was drawn from seven normal volunteers before and 7 days after consecutive intake of ticlopidine, and 1 day after oral intake of aspirin after 7 days of ticlopidine wash-out period. Effects of drug intake on shear-induced von Willebrand factor (vWF) binding to platelets, platelet activation evidenced by P-selectin surface expression and translocation of GP Ibalpha, and vWF-mediated platelet aggregation, were investigated by using an optically modified cone-plate viscometer and quantitative flow cytometry. The maximum extent of platelet aggregation occurring under a high shear rate of 10800 s(-1), presumably mediated by vWF, was not significantly influenced by either ticlopidine or aspirin. However, significant dissociation of once aggregated platelets occurred in samples obtained after ticlopidine intake (25.4 +/- 9.3%, P = 0.00030) and less significantly after aspirin intake (15.9 +/- 5.7%, P = 0.0013), while only insignificant and modest dissociation occurred in controls (6.3 +/- 4.4%, n.s.). Binding experiments also revealed that the shear-induced vWF binding to platelets was significantly inhibited by ticlopidine, and less significantly by aspirin, although other indicators of platelet activation, such as shear-induced P-selectin expression and GP Ibalpha translocation were not influenced by either ticlopidine or aspirin. We demonstrate here that platelet aggregation mediated by von Willebrand factor (vWF) under a high shear rate of 10800 s(-1) cannot be stabilized and that dissociation occurs readily when ADP receptor stimulation is blocked by continuous intake of ticlopidine, indicating that these effects on platelet thrombus formation may contribute to the in vivo antithrombotic effects of ticlopidine.