An Update on the Cutaneous Manifestations of Darier Disease

BACKGROUND

Knowledge about the clinical features of Darier disease, an orphan autosomal-dominant genetic disorder, is sparse and has been evaluated only in few studies.

OBJECTIVES

To investigate the clinical features of a large group of patients with Darier disease, and to explore for associations between disease characteristics and severity of the disease.

METHODS

Seventy-six individuals with Darier disease were evaluated utilizing a structured questionnaire-based interview, a physical examination, and a retrospective assessment of their medical records.

RESULTS

The most frequent locations of lesions were hands (99%) and fingernails (93%). Wart-like lesions on the hands were more visible after soaking them in water for 5 minutes, we therefore named this phenomenon the "wet hand sign". Oral involvement was found in 43% of patients, while 48% of women and 16% of men showed genital lesions. Patients with severe Darier disease had a tenfold greater risk of developing genital lesions than those with mild disease (P = .01). Most patients (88%) in our study exhibited a combination of the four types of the disease patterns of distribution (flexural, seborrheic, nevoid, and acral).

CONCLUSIONS

Documentation of disease on the hands and fingernails provides a highly sensitive means to aid in the diagnosis of Darier disease. It is important to evaluate mucosal lesions including genital and oral mucosa.

[BULLOUS PEMPHIGOID RESISTANT TO CORTICOSTEROIDS]

Bullous pemphigoid is the most common autoimmune bullous disease, treated with low dosage local or systemic corticosteroids. This is a case report of a 65 years-old female patient with a month long history of a bullous disease before admission to the dermatology department with a generalized bullous rash. Clinical examination and histopathology revealed bullous pemphigoid. She was treated according to the established protocol with systemic corticosteroids. The amount of prednisone was raised to 100mg per day for 8 weeks without any noticeable improvement, instead there was a worsening of her symptoms. In light of the treatment failure we carried out an adrenocorticotropic stimulation hormone test with a normal result. The patient was diagnosed as being resistant to corticosteroids and the treatment with prednisone was immediately terminated. Treatment was initiated with cyclophosphamide with an immediate improvement in her symptoms, and the patient was discharged after complete recovery. Discussion: Resistance to corticosteroids is a rare occurrence that has been reported in the literature on pulmonary and gastric disease. In dermatology, there is a single case report on atopic dermatitis that was treated locally. Awareness of the possibility will allow for a prompt diagnosis and appropriate treatment. Conclusion: We presented the case of a 65 year old female with bullous pemphigoid resistant to corticosteroids that has not been previously reported in the dermatologic literature.

[CUTANEOUS T CELL LYMPHOMA: UNILESIONAL MYCOSIS FUNGOIDES]

Unilesional mycosis fungoides is a rare cutaneous T cell lymphoma that warrants either radiation therapy or surgical excision. Benign characteristics result in misdiagnosis, delayed tissue biopsy and subsequently delayed provision of adequate treatment. A young patient presented with a history of 18 months of eczematous benign - appearing single lesion restricted to her index finger. Local electron-beam radiation following tissue diagnosis resulted in full recovery.

Infantile haemangiomas and quality of life

OBJECTIVE

To determine the quality of life (QOL) and self-esteem of children with infantile haemangiomas using objective measures.

DESIGN

Twenty-one children, 5-8 years old, with a diagnosis of head or neck haemangioma measuring 2 cm or more, were compared with 22 children with no history of haemangioma.

SETTING

A tertiary medical centre in the north of Israel.

INTERVENTIONS

Demographic and clinical details were collected, followed by two questionnaires-Paediatric Quality of Life Inventory (PedsQL) and Harter pictorial scale of Perceived Competence and Social Acceptance for young children-answered by children and parents of the two groups.

MAIN OUTCOME MEASURES

QOL and self-esteem of the children in the two groups.

RESULTS

There were no significant differences in QOL indices or self-perception scores between children with and without haemangioma (86.6±10.3 vs 80.1±15.07, p=0.23 and 3.62±0.2 vs 3.72±0.21, p=0.17, respectively). Interestingly, parents of children with haemangioma reported higher QOL of their children than parents of children without haemangioma (86.4±9.6 vs 77.1±14.9, p<0.03). Likewise, a positive correlation between parents' scored PedsQL and children's scored PedsQL was found (0.56, p=0.008).

CONCLUSIONS

The findings raise a question about aggressive as opposed to more conservative treatment, especially in the era of propranolol.

[Prevalence of thyroid abnormalities among psoriatic patients]

INTRODUCTION

Psoriasis is a chronic papulosquamous cutaneous disease. The etiology is unknown. Several biochemical and immunological processes, which appear in patients with genetic predisposition, lead to enhanced proliferation of epidermal cells, and inflammation of the dermis. Thyroid gland hormones cause an increase of epidermal growth factor level, which has an important role in keratinocyte proliferation, which may be involved in psoriasis disease.

METHODS

In this study, we have prospectively examined the function of thyroid gland hormones--TSH, T3, T4, anti-TPO and antithyroglobulin--in 100 psoriatic patients. This database was compared with a control group of 54 patients, without known thyroid gland abnormalities, who were randomly chosen from the endocrinology clinic's medical records.

RESULTS

In the psoriatic patients, an increase in the anti-TPO levels was demonstrated in 9 psoriatic patients (9%), compared to 3 patients in the control group (5.6%). An increase of anti-TG was demonstrated in 3 psoriatic patients (3%) compared to one patient (1.8%) in the control group. An increase of TSH levels was demonstrated in 5 psoriatic patients (5%) compared to 3 patients (5.6%) in the control group. T3 levels were abnormal in 3 psoriatic patients, and T4 levels were abnormal in 2 psoriatic patients, while the T3 and T4 levels in the control group patients were normal.

CONCLUSIONS

In our study we didn't observe a statistical difference in the thyroid gland functions between the psoriatic and the control patients. We have observed that in patients with severe psoriasis, there were increased TSH levels and positive auto-antibodies titer compared to patients with mild psoriasis.

SUMMARY

The clinical characteristics of the psoriatic patients were connected to the function of the thyroid gland. Nonetheless, the number of patients was low, and more studies are needed to confirm this relationship.

Cutaneous nocardiosis: report of two cases and review of the literature

BACKGROUND

Cutaneous nocardiosis is an uncommon infectious disease that presents as a primary cutaneous infection or as a disseminated disease. It is often misdiagnosed because of its rarity and nonspecific clinical picture.

METHODS

We report a case of each type. The first case is an immunocompetent patient who was infected by Nocardia while gardening and developed a superficial skin infection--one of the three clinical manifestations of primary cutaneous nocardiosis. The second case is an immunocompromised patient with pulmonary nocardiosis that extended to the skin as part of a disseminated disease.

RESULTS

The immunocompetent patient with primary cutaneous nocardiosis had the classical features of a superficial skin infection. He had a nodular–pustular lesion on the right arm, which appeared 7 days after gardening with bare hands. Nocardia was identified in a skin culture taken from a pustule, unfortunately not to the species level. Treatment with minocycline for 3 months resulted in full remission of the lesion. The immunocompromised patient with disseminated nocardiosis had high fever, productive cough, hemoptysis, and erythematous nodules and pustules on the extremities. N. brasiliensis was isolated from bronchial samples and skin. Treatment with a high dose of trimethoprim and sulfamethoxazole for five months resulted in full recovery from cutaneous and pulmonary complaints. No relapse of the infection was found on follow-up in either patient.

CONCLUSION

These cases demonstrate the need for a high degree of suspicion, focused clinical search, and appropriate laboratory procedures in the diagnosis and management of cutaneous nocardiosis.

Pregnancy outcomes in women with moderate-to-severe psoriasis

BACKGROUND

The association between psoriasis and pregnancy outcomes has not been adequately examined, although psoriasis onset is common in the reproductive period.

OBJECTIVE

To evaluate the association between moderate-to-severe psoriasis and pregnancy complications.

METHODS

A retrospective, matched cohort study of 68 deliveries in 35 women with moderate-to-severe psoriasis compared to 237 deliveries in 236 women without psoriasis randomly selected after matching for age, parity and gestational age.

RESULTS

The psoriasis patients had higher mean of past spontaneous (0.42±0.58 vs. 0.26±0.63, P=0.002) and induced (0.32±0.60 vs. 0.06±0.25, P=0.001) abortions than controls. They had a higher percentage of pregnancy-induced hypertensive diseases (7.4% vs. 2.1%, P<0.05) and premature rupture of membranes (16% vs. 5.5%, P<0.008). Newborns to women with psoriasis had higher birth weight (3375±543 g vs. 3247±460 g, P=0.03), increased percentage of large-for-gestational age (24% vs. 12%, P=0.02), and macrosomia (13% vs. 4.2%P=0.02). In multivariate analysis, moderate-to-severe psoriasis was an independent risk factor for previous spontaneous abortions, induced abortions, premature rupture of membranes (PROM), and newborn macrosomia.

CONCLUSION

Moderate-to-severe psoriasis is associated with spontaneous and induced abortions, pregnancy-induced hypertensive diseases, premature rupture of membranes, large-for-gestational age newborns, and macrosomia.

The relationship between sensory hypersensitivity and sleep quality of children with atopic dermatitis

This study aims to investigate the impact of sensory hypersensitivity in children with atopic dermatitis (AD) and to evaluate a possible relationship between sensory hypersensitivity, sleep quality and disease severity in AD. Fifty-seven AD patients and 37 healthy children, aged 3-10 years, participated in this study. Disease severity was assessed using the Severity Scoring of Atopic Dermatitis (SCORAD) Score. The sensory profile was assessed using the Short Sensory Profile (SSP) and sleep characteristics were evaluated using the Children's Sleep Habits Questionnaire (CSHQ). The AD group demonstrated significantly worse sleep quality compared with the controls in the following CSHQ subscales: sleep duration; parasomnias; sleep disordered breathing and daytime sleepiness. Sensory hypersensitivity was correlated with lower sleeping quality. Severity Scoring of Atopic Dermatitis Scores was positively correlated with sleep anxiety and with parasomnias. Sensory hypersensitivity and disturbed sleep patterns were common in the children with AD that participated in this study. A possible common underlying mechanism of hyper-arousability may account for both phenomena. Evaluation of AD children should also refer to their sensory processing abilities and sleep habits to create optimal intervention programs that will be better focused on the child and family needs.

Profile of acute generalized exanthematous pustulosis in Israel during 2002-2005: results of the RegiSCAR Study

BACKGROUND

Acute generalized exanthematous pustulosis is a rare pustular severe cutaneous adverse reaction characterized by a rapid clinical course and unique histological findings. It is usually attributed to drugs, although other factors have also been implicated.

OBJECTIVES

To analyze demographic, clinical and laboratory data of AGEP cases in Israel, based on the RegisCAR study, a multinational European study.

METHODS

Patients included in the present study were actively recruited by the Israeli RegiSCAR network, which comprised 10 dermatology departments and units. The cases were validated by a multinational expert committee of dermatologists based on a standardized scoring system.

RESULTS

Overall, 11 potential cases of AGEP were collected in Israel: 9 (81.8%) definite and 2 (19.2%) possible. The adjusted annual incidence of AGEP in Israel was 0.35/million/year. The nine definite cases that entered the analyses showed a male/female ratio of 0.28 with an age range of 10-60 years. Most cases were reported during the summer months. The clinical course and laboratory findings in most of our patients were in accordance with previous reports. A drug etiology was suspected in the majority of cases and consisted of analgesics (66.7%), antibiotics (22.2%) and non-steroidal anti-inflammatory drugs (11.1%) as the main culprit drugs.

CONCLUSIONS

Whereas the clinical and laboratory findings of AGEP in Israel corresponded to the reported features of AGEP in the literature, some unique findings were noted, namely, marked female predominance, seasonality and a profile of culprit drugs.

The sensory profile of children with atopic dermatitis as determined by the sensory profile questionnaire

BACKGROUND

The increasing prevalence of atopic dermatitis (AD) combined with the limited efficacy of current therapies emphasizes the need to improve care quality for patients with AD. This study aims to characterize the sensory profile of children with AD as expressed in daily living.

METHODS

In all, 53 patients with AD and 61 healthy children, aged 3 to 10 years, participated in this study. Disease severity was assessed using the Severity Scoring of AD (SCORAD) score. The sensory profile was assessed using the Short Sensory Profile.

RESULTS

The study group had significantly higher sensory sensitivity than the control group (t = 2.855; P = .013). These results were seen in all sensory modalities except vestibular sensation.

LIMITATIONS

This study was composed of a relatively small number of participants with a wide spectrum of disease severity.

CONCLUSIONS

Children with AD demonstrated hypersensory sensitivity. Understanding the sensory and behavioral characteristics of children with AD can promote the development of innovative intervention processes better geared to focus on patients' needs.

Nontuberculous mycobacterial infections of the skin: A retrospective study of 25 cases

BACKGROUND

Absence of a pathognomonic clinical picture and variable histologic findings often delay diagnosis of nontuberculous mycobacteria (NTM)-induced cutaneous infections, and antimicrobial therapy varies.

OBJECTIVE

We sought to investigate the clinical, microbiologic, and pathological findings of cutaneous NTM infections and response to different treatments.

METHODS

Records of patients with NTM infections of the skin confirmed by positive cultures or histologic findings were reviewed. Clinical, microbiologic, and epidemiologic data were collected and skin biopsy specimens were reassessed.

RESULTS

The series included 25 cases, one diagnosed by histology and 24 by positive culture: 16 cases with Mycobacterium marinum, 3 of atypical Mycobacterium without species identification, and one each with M chelonae, M xenopi, M abscessus, M gordonae, and M fortuitum. One of 16 patients with M marinum developed tenosynovitis. Mean interval between clinical presentation and diagnosis was 7.1 months (range: 1-27.3 months). All isolates analyzed for antimicrobial susceptibility pattern were sensitive to clarithromycin.

LIMITATIONS

Limitations include methods of case collection, retrospective study, and relatively small number of patients.

CONCLUSIONS

Diagnosis of NTM should be confirmed by histology and bacteriology studies of tissue cultures. Strong clinical suggestion of M marinum infection warrants initial empirical treatment to prevent progression to deep infection. The recommended treatment as indicated by the results of the in vitro susceptibility and clinical response is clarithromycin.

Nail disorders in patients with chronic renal failure and undergoing haemodialysis treatment: a case-control study

BACKGROUND

Few controlled studies have compared nail disorders in patients with chronic renal failure (CRF) and haemodialysis (HD)-dependent individuals with a healthy population.

OBJECTIVE

The aim of this study was to compare the prevalence of nail disorders in patients with CRF and patients undergoing HD treatment with a healthy population, and evaluate the relationship between nail changes and various demographic, medical and laboratory parameters in these groups.

METHODS

In this case-control study we recruited 73 patients affected with CRF, 77 patients undergoing regular HD and 77 healthy individuals. All patients were examined for the presence of nail disorders. Various parameters [age, gender, type of kidney disease, regular medications, duration of renal failure and HD, dialysis efficacy (Kt/v), haemoglobin, neutrophil count, calcium, phosphorus, albumin, creatinine, urea, alkaline phosphatase and parathyroid hormone (PTH) levels] of the patients were determined by multivariate analysis and compared.

RESULTS

Forty-four patients (60.3%) with CRF and 48 patients (62.3%) undergoing HD treatment had at least one type of nail pathology. The most common nail alterations found in patients with CRF and those undergoing HD were absence of lunula (AL) and half-and-half nails (HHN), respectively. Prevalence of nail disorders among patients with CRF was influenced significantly by PTH level (P = 0.03). In the HD group, male sex, age above 65 years and comorbidities (diabetes mellitus, hypertension and heart failure) were significantly associated with nail pathologies.

CONCLUSION

Patients with CRF and those undergoing HD therapy have higher rates of nail disorders when compared to a healthy population. Efficient HD does not improve nail changes.

Epidemiological and clinical manifestations of patients hospitalized with brown recluse spider bite

BACKGROUND

Necrotic arachnidism represents a common health problem and standard treatments are usually safe and effective.

OBJECTIVE

The aim of this study was to review documented Loxosceles species spider envenomations and identify the natural history of affected patients.

METHODS

A retrospective single-centre study included 52 patients with necrotic arachnidism hospitalized in the dermatology department between 1997 and 2004. We examined the relationship between the epidemiological, clinical and laboratory parameters and degree of lesion severity, length of hospitalization and time to complete healing.

RESULTS

The bites occurred predominantly in rural areas, 67% between April and August. Only 35% of the patients sought medical care within 24 h post bite. Most bites were of the extremities (67%). Time to complete healing ranged from 14 days to more than 8 weeks (mean, 4.8 weeks). A marked relationship was found between age, comorbidities, lesion severity and time to complete healing (P < 0.01). Duration of hospitalization was significantly longer in patients with severe thigh lesions (P < 0.02).

CONCLUSIONS

Loxosceles species spider bites frequently induce necrotic, slowly healing ulcers on the fatty areas of the body. Early, appropriate systemic therapy may provide clinical benefit.

Sister Mary Joseph's nodule as a presenting sign of internal malignancy

CASE 1: A 64-year-old, otherwise healthy woman was referred to the surgery clinic for a presumed umbilical hernia. On physical examination, a cutaneous nodule was noted on the umbilical region and the patient was referred to the dermatology clinic. The patient was reexamined and an erythematous nodule was observed in the umbilicus measuring 2.5 cm in diameter. The patient denied pain, change in bowel habits, or weight loss. There were no other abdominal masses, no sign of ascites, and no regional lymphadenopathy. A skin biopsy from the nodule showed mucinous adenocarcinoma. Immunohistochemical staining was positive for carcinoembryonic antigen, and negative for cytokeratin (CK)7 and CK20. These results were consistent with a Sister Mary Joseph's nodule and led to the diagnosis of an occult colon carcinoma. The patient had no risk factors for colorectal carcinoma. The patient underwent surgery in another hospital, and died 3 months after the initial diagnosis of Sister Mary Joseph's nodule. CASE 2: A 73-year-old woman was referred to the dermatology clinic for evaluation of a painful, ulcerated, 3-cm lesion in the umbilicus (Figure 1). She was otherwise asymptomatic. A skin biopsy showed neoplastic glandular cells infiltrating among collagen bundles (Figure 2). Stainings for mucin and for CK7 were positive, while staining for CK20 was negative. An abdominopelvic CT scan demonstrated a 3.5-cm space-occupying lesion in the liver. Results of gastroscopy, colonoscopy, chest computed tomographic (CT) scan, and mammography were normal. Serum levels of the tumor-associated protein CA125 were elevated to 164 units, while those of CA 19-9 and carcinoembryonic antigen were within normal range. A gynecologic examination and a transvaginal ultrasound were normal. The patient had no personal or family history of any malignancy or any risk factors for developing a carcinoma. The patient was scheduled for a palliative resection of the umbilical nodule, combined with a laparoscopic inspection in search of the undetected primary tumor. She refused surgery and was lost to follow-up. She died 4 months after the initial diagnosis of umbilical metastasis. CASE 3: A 51-year-old man was aware of a silent mass in his umbilicus for 2 years without seeking medical advice. Following 2 weeks of increasing pain in this area, he was referred to the emergency room for a suspected incarcerated umbilical hernia. Surgery revealed a mass attached to the fascia and peritoneal fat. The mass was removed and diagnosed as a poorly differentiated adenocarcinoma, staining positively for carcinoembryonic antigen, and negatively for CK20, CK7, prostate-specific antigen, and prostatic acid phosphatase. Both gastroscopy and colonoscopy failed to detect the primary tumor. An abdominopelvic CT scan was normal, but a CT scan of the chest disclosed a nodule measuring 2.5 x 1.5 cm in the lower lobe of the right lung. On bronchoscopy, it was found to be an invasive adenocarcinoma, consistent with a primary tumor of the lung. The patient was a heavy smoker (45 pack-years). The patient received 4 cycles of combined chemotherapy with carboplatine and gemcitabine, with no improvement. A month later, the patient complained of abdominal pain. Following demonstration of intra-abdominal spread of disease by CT scan, a second line chemotherapy was instituted with paclitaxel. A month later the patient's condition deteriorated and he complained of cough, sweating, and pain along the right leg. A bone scan revealed bone metastases in the right femur and left tibia. Two weeks later he was admitted to the hospital with intestinal obstruction and underwent laparotomy. He had massive intra-abdominal spread of cancer and ascites. Only a palliative colostomy was performed. The patient died 3 weeks later, 9 months after the diagnosis of adenocarcinoma of the lung. The clinical data on the three patients are summarized in Table I.

Acute generalized exanthematous pustulosis following a spider bite: Report of 3 cases

Acute generalized exanthematous pustulosis (AGEP) is a rare severe cutaneous adverse reaction caused mostly by drugs. Three of 22 AGEP cases (13.6%), recruited by us as part of two prospective multinational studies, occurred 24 to 48 hours after a spider bite. We suggest that a spider bite is a possible trigger for AGEP.

Unusual skin and testicular lesions in a patient with CMML

Chronic myelomonocytic leukemia (CMML) is a clonal disorder of hematopoetic stem cells with myelodysplastic and myeloproliferative features. Skin infiltration by leukemic cells is rare in CMML. A case is presented with severe dermatological involvement and concomitant testicular infiltration. An unusual feature was the evidence that the skin was the primary site of an acute leukemic transformation.

Hemodialysis-related pruritus and associated cutaneous manifestations

BACKGROUND

Uremic pruritus is one of the most common disabling problems in patients with chronic renal failure. Few studies have evaluated itching and cutaneous manifestations in hemodialysis-dependent patients.

OBJECTIVES

The aim of this prospective study was to identify the prevalence of pruritus and cutaneous changes affecting patients undergoing hemodialysis.

METHODS

The degree of itching in 70 patients treated at the Haemek Medical Center Hemodialysis Unit, in northern Israel, was scored according to presence and severity. We examined the relationship between the quality of dialysis and the frequency of pruritus, and identified concurrent cutaneous disorders.

RESULTS

Pruritus was a common problem in the study cohort and affected 74.3% of hemodialysis patients at some point. The main characteristics of pruritus were a general pattern in 65.7% and mild intensity in 78.3% of observed patients. Duration of hemodialysis varied between 3 months and 13 years. There was no correlation between occurrence of pruritus and demographic or medical parameters (sex, type of kidney disease, regular medications or duration of hemodialysis) of the patients. Higher dialysis efficacy, as expressed by dialyser clearance, volume distribution of area, dialysis duration (Kt/v), may reduce the prevalence of pruritus (P < 0.02). None of the blood and chemical values considered (hemoglobin, creatinine, urea, phosphorus, calcium, albumin, parathormone and alkaline phosphatase) revealed any statistically relevant differences between pruritus groups. The appearance of foot ulcers was different between diabetic and nondiabetic individuals undergoing hemodialysis (P < 0.001).

CONCLUSIONS

Pruritus is still a common problem in hemodialysis-dependent patients. The prevalence of xerosis and excoriations was high in patients undergoing replacement therapy. Efficient replacement hemodialysis may provide a clinical benefit.

Minocycline-induced cutaneous hyperpigmentation: confocal laser scanning microscope analysis

BACKGROUND

Minocycline has a characteristic yellow-green fluorescent emission. This fluorescence has been previously demonstrated only in type 1 minocycline-induced skin hyperpigmentation.

OBJECTIVE

To investigate whether the fluorescence can be detected in other types of minocycline-induced cutaneous hyperpigmentation, and to study the possible mechanisms.

METHODS

Biopsies of pigmented and nonpigmented skin from 3 patients with different types of skin hyperpigmentation induced by minocycline were analysed by light microscopy and Confocal Laser Scanning Microscope (CLSM).

RESULTS

A yellow-green fluorescence was observed in the hyperpigmented skin of two patients with type 2, and one patient with type 4 minocycline-induced cutaneous hyperpigmentation. No fluorescence was detected in the non-pigmented skin.

CONCLUSION

Minocycline can possibly serve as a fluorescent probe in the diagnosis of all types of minocycline-induced cutaneous hyperpigmentation.

Cat scratch disease encephalopathy in an immunocompetent patient

Cat scratch disease (CSD) is typically a self-limited regional lymphadenopathy in children and young adults that is caused by Bartonella henselae. The majority of CSD cases resolve spontaneously; however, many systemic complications have been described. We report an unusual case of CSD presenting as an epitrochlear arm mass and complicated by encephalopathy. Identification of B. henselae DNA in the affected lymph node and cerebrospinal fluid confirmed the diagnosis of CSD. Systemic antibiotic therapy was administered and the patient improved without any neurological deficit.

Leishmania tropica in northern Israel: A clinical overview of an emerging focus

BACKGROUND

In Israel, most cutaneous leishmaniasis (CL) is caused by Leishmania major. Recently a new focus of CL caused by Leishmania tropica has been described in Tiberias and the surrounding area of northern Israel.

OBJECTIVE

The aim of this study was to evaluate clinical (size, number, location, and type of lesion) and laboratory (culture and polymerase chain reaction [PCR] analysis) parameters at diagnosis, response to treatment, and outcome of patients with CL due to L tropica.

METHODS

Between September 2002 and March 2004, patients with direct smear-confirmed CL were evaluated; clinical records were reviewed and a telephone survey was performed.

RESULTS

Forty nine patients, 34 (69%) male and 15 (31%) female, were studied. Mean age was 31.1 years (median 26 years, range 1-70); 76% of patients live in Tiberias and the surrounding area. The mean number of lesions was 2.6 (median 2, range 1-10). Lesions were commonly located on the face (61%) and upper limbs (57%). PCR analysis was performed in 27 patients and was positive for L tropica in 26. Fifty percent of patients studied received multiple therapeutic regimens because of incomplete response or treatment failure. Topical paromomycin was used in 44 patients (90%), with a complete response reported in only 17 (39%); of the 9 patients treated with intralesional sodium stibogluconate, a complete response was reported in 6 (67%); of the 5 patients treated with intravenous sodium stibogluconate, 4 (80%) were cured.

LIMITATIONS

The relatively small number of patients studied combined with the fact that some were assessed retrospectively limit our conclusions. In addition, 50% of the patients studied received multiple therapeutic regimens because of failure of, or incomplete responses to, their initial therapy, thereby making comparisons difficult.

CONCLUSIONS

The cure rate in those completing a course of antimony therapy, either 10 or more days of intravenous therapy or therapy administered intralesionally, was 75% (95% confidence interval [CI], 50.5-99.5%) as compared with 45% (95% CI, 28.9-60.5%) among those completing at least 10 days of topical paromomycin. To date, no standardized, simple, safe, and highly effective regimen for treating L tropica exists. Large, controlled clinical trials to evaluate current treatment regimens as well as new medications for CL, and especially CL attributed to L tropica, are urgently needed.

Infection With Kaposi’s Sarcoma–Associated Herpesvirus Among Families of Patients With Classic Kaposi’s Sarcoma

BACKGROUND

Classic Kaposi's sarcoma (CKS) primarily affects elderly Mediterranean or Eastern European men. Incidence rates of CKS in Israel are among the world's highest. In practically all cases, antibodies against Kaposi's sarcoma-associated herpesvirus (KSHV) can be detected. A relatively high seroprevalence rate of KSHV in Israel generally correlates with the incidence of CKS. A sexual mode of virus transmission is recognized among homosexual men, whereas the precise transmission routes in the heterosexual population and those with CKS are still unclear.

OBJECTIVE

To better assess the transmission routes of KSHV in Israeli patients with CKS and their first-degree relatives as compared with a control group.

DESIGN

Serum was collected from all study participants and tested for KSHV antibodies by means of latent and lytic immunofluorescence assays. An open reading frame 65 (ORF65) Western blot assay was applied as a confirmatory tool.

SETTING

Three dermatological departments in Israel.

PATIENTS

Sixty-four Jewish patients with CKS, 143 of their first-degree relatives, and 186 hospital-based control subjects.

RESULTS

Seropositivity to KSHV was detected in 62 (96.9%) of the patients with CKS, in 56 (39.2%) of their first-degree relatives, and in only 21 (11.3%) of the hospital controls (P<.001). The specific relationship with the index patient (spouse, offspring, or sibling) had no significant effect on the prevalence of serpositivity in the family members.

CONCLUSION

Our serologic evidence of familial clustering of KSHV infection suggests a predominantly nonsexual horizontal transmission route of the virus.

Actinic damage among patients with psoriasis treated by climatotherapy at the Dead Sea

BACKGROUND

Dead Sea climatotherapy is highly effective in the treatment of psoriasis. However, its potential side effects, especially the risk of skin cancer, are unclear.

OBJECTIVE

We sought to determine the prevalence of solar damage and skin cancer among patients with psoriasis who underwent Dead Sea climatotherapy compared with control patients.

METHODS

This multicenter controlled cross-sectional study was carried out at the Dead Sea Solarium Clinic and outpatient clinics of the participating centers. A total of 1198 participants (460 patients with psoriasis and 738 control patients) aged 20 to 70 years were included. A standard questionnaire including demographic parameters and sun exposure habits was administered to all participants. Patients were questioned about previous psoriatic treatments and climatotherapy at the Dead Sea. All participants underwent a structured physical examination of the skin. We compared the prevalence of solar damage for patients with psoriasis and control patients and assessed the extent of photodamage among patients with psoriasis according to exposure time at the Dead Sea in univariate and multivariate analyses.

RESULTS

Elastosis ( P < .001), solar lentigines (P = .03), poikiloderma (P < .001), and facial wrinkles (P < .001) were significantly more common among patients with psoriasis compared with control patients and showed a dose response with increased Dead Sea exposure time. Self-reported previous skin cancers were more common in control patients compared with patients with psoriasis (8.2% vs 3.5%, P = .002), however, the prevalence of nonmelanoma skin cancer on examination did not differ between the two groups. No cases of malignant melanoma were detected in either group.

CONCLUSIONS

Dead Sea climatotherapy is not associated with an increased risk of malignant melanoma or nonmelanoma skin cancer for patients with psoriasis in Israel. However, UV exposure at the Dead Sea may play a role in the development of solar damage.

Mycetoma of the foot caused by Cylindrocarpon lichenicola in an immunocompetent traveler

Cylindrocarpon is a cosmopolitan soil fungus, which rarely causes human disease. It has infrequently been reported as causing keratitis, mycetoma, osteomyelitis and peritonitis in chronic peritoneal ambulatory dialysis patients and disseminated infection in leukemic neutropenic hosts. This report describes a case of invasive infection caused by Cylindrocarpon lichenicola, localized in the right foot of an otherwise immunocompetent traveler.

Electrical impedance scanning: a new approach to skin cancer diagnosis

BACKGROUND/AIMS

Skin cancer diagnosis depends, to a great extent, on visual inspection and histopathological examination of excised tissues. The aim of this study is to evaluate the ability of electrical impedance scanning to differentiate between benign and malignant skin lesions.

METHODS

A preclinical study was conducted on 40 nude mice injected subcutaneously with a human melanoma strain. Impedance measurements were recorded every week to correlate electrical changes with tumor growth and histological findings. A clinical study was also performed on 178 human suspicious skin lesions before excision. The impedance measurements were correlated to the histopathological results.

RESULTS

Normalized conductivity and capacitance, recorded on growing skin tumors in nude mice, were shown to change relative to lesion size. Necrosis, present in most of the larger lesions, was associated with a decrease in the electrical conductivity. Similar electrical parameters were used to classify human melanoma lesions with 92% sensitivity and 67% specificity. In addition, four out of five BCC lesions were correctly diagnosed. Moreover, dysplastic lesions were diagnosed with 91% sensitivity and 59% specificity. For comparison, physicians diagnosed melanoma lesions with 75% sensitivity and 87% specificity and dysplastic lesions with 46% sensitivity and 80% specificity.

CONCLUSIONS

The animal study showed that electrical impedance measurements reflect morphological changes related to the growth of a cancerous skin lesion. These findings are in agreement with a preliminary clinical study. Electrical Impedance Scanning can therefore be considered as an objective and non-invasive tool for differentiation between benign and malignant skin lesions.

[Herpes zoster treated with acyclovir]

During the past 5 years, 99 patients with herpes zoster were hospitalized and followed. Age, sex, localization of rash, complications, duration of hospitalization and treatment were analyzed. Most patients were in their 6th and 7th decades. Cranial nerve involvement was frequent (35%). A generalized rash was more common in those with immunodeficiency. Acyclovir (Zovirax) inhibited to some extent the spreading of the rash and reduced the frequency of herpetic neuralgia. Our findings are in accord with those in the literature.

Skin-isolated, community-acquired Staphylococcus aureus: in vitro resistance to methicillin and erythromycin

During a 10-month period, skin culture specimens were taken from 1680 healthy outpatients with a variety of community-acquired skin infections. Staphylococcus aureus was found in 1035 (61.6%) of these patients. In vitro resistance to methicillin and erythromycin was 1.0% and 42.9%, respectively. Resistance rates to erythromycin in patients with furunculosis and impetigo were 51.5% and 26.2%, respectively (p less than 0.001). The emergence of erythromycin-resistant strains may be the result of widespread use of this drug in our geographic area. There is also the possibility that certain bacteriologic features associated with erythromycin resistance may foster the development of furunculosis.

Isolated necrosis of the tubal fimbriae in a prepubertal girl

A report of haemorrhagic necrosis of the tubal fimbriae in a prepubertal girl is presented. The presumptive aetiology for this is the isolated torsion of the fimbrial end which, to the best of our knowledge, has not been previously described. A high index of suspicion of torsion and early intervention is emphasised. Laparoscopy should usually precede laparotomy in doubtful cases but during laparotomy as little as possible should be done in order to retain future fertility.

Tamoxifen treatment in women with failure of clomiphene citrate therapy

Fourteen pregnancies were achieved with tamoxifen therapy in 12 women who failed to conceive with clomiphene citrate. There were no side-effects and fewer treatment cycles were required than with clomiphene citrate treatment. Ovulation and cervical score with tamoxifen therapy were significantly higher (p less than 0.005).

Ovarian malignancies in pregnancies complicated by colonic perforation

Primary or secondary ovarian carcinoma in pregnancy is very rare. The entity is difficult to diagnose and is not infrequently fatal. Two unusual cases of ovarian carcinoma during pregnancy, complicated by perforation of the colon, are described. Treatment depends upon the time of diagnosis, the stage of growth, and possible complications. More attention should be paid to complaints concerning bowel function during pregnancy, and pelvic sonography and bowel studies may enable earlier diagnosis.

Onchocerciasis in Israel

A 15-year-old boy with onchocerciasis had severe generalized pruritus of five months' duration. He had been born and raised in Ethiopia and had emigrated to Israel one year earlier. A biopsy specimen of an area of depigmentation on the right thigh disclosed microfilaria of Onchocerca volvulus in the dermis. The discovery of an unusual disease in a nonendemic area is an example of the increased complexity of differential diagnosis resulting from the ease of travel from one geographic region to another.