Cutaneous Metastases: Clinicopathologic Study of 30 Patients

Cutaneous metastases (CMs) of internal malignancies are uncommon. The breast in women and the lung in men represent the two elective sites of internal malignancies metastasizing to the skin. The aim of this study was to determine the epidemiologic, clinical, and pathologic features of CMs. A retrospective study of the patients diagnosed with CMs over 30 years was conducted. Thirty cases of CMs were enrolled in our study. In 16 cases (53%), the skin metastasis revealed the internal malignancy. The mean age was 66.4 years with sex ratio men/women of 2. CMs were solitary in 18 cases and multiple in 14 cases. The most frequent location was the chest (12 cases), followed by the abdomen (eight cases), the scalp (seven cases), and the arms (six cases). The common sites of primary malignancy were the lungs in men (nine cases) and the breast in women (three cases). Nine out of 30 patients died with an average of 33 months after diagnosis. In our study, the most frequent primary malignancy in men was lung cancer and in women breast cancer. The onset of CMs during the course of internal malignancy worsens the prognosis of the disease.

Nail involvement in connective tissue diseases: an epidemiological, clinical, and dermoscopic study

BACKGROUND

The assessment of nail changes in connective tissue diseases (CTD) has been rarely explored in previous studies. The use of dermoscopy to study vascular changes in nailfolds is an interesting diagnostic technique. The aim of the study was to describe the epidemiological, clinical, and dermoscopic features of nail lesions in CTD.

METHODS

A prospective study was performed at the Dermatology Department of Habib Thameur Hospital (Tunis, Tunisia) in collaboration with the Internal Medicine Department over a period of 15 months, from July 2020 to September 2021, including patients diagnosed with systemic sclerosis (SS), systemic lupus erythematosus (SLE) and dermatomyositis (DM).

RESULTS

Our study included 48 patients. Nail involvement was found in 44 cases. Dermoscopic nailfold abnormalities were identified in 37 cases. The most common clinical features were ragged cuticle, nailfold erythema, and onycholysis. Additionally, splinter hemorrhage, longitudinal ridging, lunula abnormalities, melanonychia, trachyonychia, leukonychia, increase in transverse curvature, parrot beak nail, half and half nails, and onychorrhexis were described. Nailfold dermoscopy showed a normal pattern in 10 cases, a nonspecific pattern in nine cases (SLE), and a scleroderma pattern in 29 cases (SS and DM). The scleroderma pattern was further categorized into an early pattern (6), an active pattern (14), and a late pattern (9). Normal pattern was observed solely in patients in remission. The late scleroderma pattern was associated with disease duration and systemic involvement. In SLE, disease activity correlated with onycholysis, nailfold erythema, and pathologic pattern in dermoscopy. However, patients with DM displayed a positive correlation between pulmonary involvement and scleroderma pattern.

CONCLUSION

Nail involvement in CTD includes a diverse range of abnormalities. Despite being nonspecific, it can provide crucial clues for establishing a diagnosis. Nailfold dermoscopy serves as a mirror for microangiopathy, enabling the detection of changes at an initial stage, and thus, it becomes a diagnostic and prognostic tool.

Idiopathic Granulomatous Mastitis Associated with Erythema Nodosum in a Pregnant Woman

A 32-year-old woman at 17 weeks' gestation presented with fever and a 1-week history of an acute nodular eruption involving her legs, along with bilateral ankle and knee pain. She also had had a recurrent right breast abscess for 2 months for which she had been treated with oral antibiotics and surgical drainage, but with slight improvement. Cultures of the abscess showed no bacteria or fungi. She had no history of tuberculosis, sarcoidosis, trauma to the breast, or a family history of breast pathology. Cutaneous examination revealed multiple, tender, erythematous, subcutaneous nodules on her legs (Figure 1) and an ill-defined tender mass involving the inferior quadrant of the right breast without nipple discharge or retraction. There was a scar with drainage on her right breast (Figure 2). There were no regional lymphadenopathies. Left breast and left axilla examination was unremarkable. Significant laboratory findings included an erythrocyte sedimentation rate of 54 mm/hour (normal levels [NL] < 20 mm/hour), an elevated C reactive protein at 148 mg/L (NL < 5 mg/L), and a high level of white blood cells averaging 15,000 elements/mm3 (NL < 10,000/mm3).

Exceptional outcome in cutaneous myeloid sarcoma

Recognition of cutaneous myeloid sarcoma is important for all dermatologists to avoid further progression to acute myeloid leukemia. Nevertheless, we highlight the presence of a favorable clinical outcome in some patients with spontaneous regression.

Familial homozygous hypercholesterolemia with arcus cornea and xanthomas: A rare but serious entity

Familial hypercholesterolemia (FH) is a rare but life-threatening disorder. Skin manifestations can be its only manifestation. We present a case of a fifteen-year-old female child, with multiple eruptive xanthomas, xanthomas anarcus, and a deranged lipid profile consistent with FH. The presence of this manifestation especially in the younger age group should draw attention to hypercholesterolemia. A timely diagnosis is fundamental to prevent serious complications and for early treatment.

Impact de la crise sanitaire « COVID-19 » sur l’activité d’un service de médecine nucléaire

Les médicaments radiopharmaceutiques « chauds » sont importés en Tunisie, par le biais de la pharmacie centrale. Durant la pandémie, le trafic aérien a été réduit à minima et par moment complètement arrêté, affectant directement l’importation du générateur 99Mo/99mTc. Nous avons évalué les conséquences de la crise sanitaire « COVID-19 » sur l’activité d’un service de médecine nucléaire muni de gamma-caméra.

Matériels et méthode

C’est une étude rétrospective descriptive sur une période de trois années et 10 mois (2019, 2020, 2021 et de janvier à octobre 2022). L’étude a été réalisée dans un service de médecine nucléaire ayant une seule gamma-caméra. Nous avons comparé le nombre d’actes réalisés en prenant comme référence l’activité de l’année 2019. Concernant l’année 2022, qui n’a couvert que dix mois, nous avons normalisé l’activité sur 12 mois.

Résultats

En Tunisie, la fermeture des frontières a commencé en mars 2020, causant des troubles de l’importation des médicaments radiopharmaceutiques « chauds » pendant environ 3 mois. Pour l’année 2020, nous avons trouvé une baisse de l’activité globale de 26,66 %. Cette baisse était plus marquée en nombre pour la scintigraphie osseuse (nombre de patients 614 vs 820) et la scintigraphie myocardique (nombre de patients 381 vs 521). Cependant, l’exploration de l’arbre urinaire était quasiment stable. En 2021, l’activité globale s’est améliorée de 17,89 %, mais reste inférieure à l’année référence 2019 (baisse de 13,55 %). En revanche, on n’a noté une augmentation de 9,58 % pour l’exploration isotopique des reins et une augmentation de 48,8 % pour le traitement à l’iode 131 des cancers de la thyroïde. Concernant l’année 2022, sur les 10 mois passés, nous avons déjà quasiment atteint les chiffres de 2019 (2125 vs 2163). Nos prévisions sont une augmentation de l’activité d’un tiers environ par rapport à l’année de référence et ceci est dû à l’augmentation du nombre de scintigraphie myocardique (en 2019 un jour par semaine, en 2022 deux jours par semaine).

Conclusion

La pandémie a réduit l’activité en médecine nucléaire d’un quart environ en 2020. Ceci est essentiellement dû à l’arrêt quasi-total du trafic aérien. Le retour à la normale a mis environ deux ans en Tunisie.

Deep-learning approach to automate the segmentation of aorta in non-contrast CTs

Purpose

Segmentation of vascular structures in preoperative computed tomography (CT) is a preliminary step for computer-assisted endovascular navigation. It is a challenging issue when contrast medium enhancement is reduced or impossible, as in the case of endovascular abdominal aneurysm repair for patients with severe renal impairment. In non-contrast-enhanced CTs, the segmentation tasks are currently hampered by the problems of low contrast, similar topological form, and size imbalance. To tackle these problems, we propose a novel fully automatic approach based on convolutional neural network.

Approach

The proposed method is implemented by fusing the features from different dimensions by three kinds of mechanisms, i.e., channel concatenation, dense connection, and spatial interpolation. The fusion mechanisms are regarded as the enhancement of features in non-contrast CTs where the boundary of aorta is ambiguous.

Results

All of the networks are validated by three-fold cross-validation on our dataset of non-contrast CTs, which contains 5749 slices in total from 30 individual patients. Our methods achieve a Dice score of 88.7% as the overall performance, which is better than the results reported in the related works.

Conclusions

The analysis indicates that our methods yield a competitive performance by overcoming the above-mentioned problems in most general cases. Further, experiments on our non-contrast CTs demonstrate the superiority of the proposed methods, especially in low-contrast, similar-shaped, and extreme-sized cases.

Verrucous Carcinoma Arising in an Extended Giant Condyloma Acuminatum

A 43-year-old heterosexual Tunisian man presented to the dermatology department with complaints of a genital friable mass. He had a past medical history of chronic hepatitis B. He was married and had a history of multiple sexual partners. The lesion had been present for over 10 years and gradually increased in size, disfiguring his genitalia. It had a major impact on his quality of life, preventing sexual intercourse and resulting in poor personal hygiene. On physical examination, the vegetative lesion presented as a giant cauliflower-like tumor (Figure 1) with a foul smell. The tumor involved the left inguinal region, the suprapubic genitalia, and was encircling the entire penile shaft. He also had inguinal lymphadenopathies. Under local anesthesia, a skin biopsy of the vegetative tumor was performed and sent for histopathologic examination. It revealed an exophytic epithelial tumor with papillomatosis, marked acanthosis, and many koilocytes, especially in the superficial layers of the epidermis. These signs along with the preservation of regular cytology were consistent with the diagnosis of condyloma acuminatum (Figure 2a). The histologic examination also showed clusters of atypical keratinocytes with high mitotic activity and keratinization, suggesting nests of squamous cell carcinoma (SCC) (Figure 2b and 2c). DNA-polymerase chain reaction (PCR) marker for Human papilloma virus (HPV) stains 11 was positive. Serology for hepatitis C, HIV, and syphilis non-reactive. Computed tomography scan of the abdomen and pelvis showed inguinal lymphadenopathies. The patient was referred to the oncologist for radiotherapy to reduce the size of the tumor followed by surgery. (SKINmed. 2023;21:53-54).

An unusual presentation of celiac disease in adult patient

Pyoderma gangrenosum is among the exceptional extra‐intestinal manifestations of celiac disease. We report a case of a 52‐year‐old patient who presented with pyoderma gangrenosum that turned out to be the initial presentation of celiac disease.

We report a case of a 52‐year‐old patient who presented with pyoderma gangrenosum as initial presentation of celiac disease. We highlighted the importance of considering cutaneous manifestations in celiac disease patients presenting in adulthood.

Extensive keloid scarring in a patient with pemphigus vulgaris

Since pemphigus blisters are intraepidermal, scarring should induce at most a post‐inflammatory hyperpigmentation. We describe a very atypical and unusual course of pemphigus vulgaris with extensive keloid formation despite high systemic steroids. This could be promoted by the severe flare of the disease, the delay of scarring, and the superinfection.

When to Recommend a Peripheral Blood Smear to Patients with Congenital Ichthyosiform Erythroderma

A 4-year-old boy born from a consanguineous marriage was referred to our department for congenital ichthyosis. He was a collodion baby at birth and progressively developed a generalized erythroderma with fine whitish scales covering his body. Initially, he was diagnosed as having congenital ichthyosiform erythroderma. Physical examination revealed fine white grayish scales with an erythematous background involving the scalp and flexural areas (Figure 1a). His palms and soles depicted hyperlinearity (Figure 1b). His hair, teeth, nails, and mucosa were normal. Abdominal examination revealed hepatomegaly, and the liver was enlarged by 4 cm below the right costal margin. He had a normal motor and mental development, and his neurologic examination was normal. There was no muscular weakness. (SKINmed. 2022;20:305-306).

Solitary pigmented nodule on the trunk: What is your diagnosis?

The aim of my clinical image is to recall this rare and benign tumor and to emphasize the role of dermoscopy in the diagnosis.

Nail Involvement in Autosomal Recessive Congenital Ichthyosis

Autosomal recessive congenital ichthyosis (ARCI) is a clinically and genetically heterogeneous category of non-syndromic ichthyosis (2). Nail changes in ARCI are generally frequent but have been rarely reported and studied in the literature. This stimulated us to conduct a study to describe nail changes in ARCI using a combined literature review and prospective examination from March 2019 to August 2019 (6 months) in the Dermatology Department of Habib Thameur Hospital, Tunis, Tunisia. A total of twenty-five patients with ARCI had a clinical and dermatoscopic review. Mean age was 19.8 years old [range 1-43], with a female predominance- 17 women (68%) and 8 men (32%). Seventy-two percent had nail unit changes involving more than one nail, none with single nail disease, involvement of fingernails (64%) and toenails (68%) cases including periungual hyperkeratosis (64%), xanthonychia (40%), pachyonychia (40%), macrolunula (36%), digital clubbing (32%) and onychomycosis (24%). Rarer findings included pseudoainhum, transverse leukonychia, longitudinal melanonychia, and subungual hemorrhages each in one patient (4%). There was a statistically significant increased frequency of nail changes in adults over children (p = 0.001). Nail abnormalities statistically associated with ARCI were macrolunula, periungual hyperkeratosis, xanthonychia, and pachyonychia. A comprehensive review of the literature was performed, creating the first comprehensive review addressing nail disease in ARCI.

Acquired Digital Fibrokeratoma of the Toe

Acquired digital fibrokeratoma is a rare and benign fibrous tumor; it is usually asymptomatic, and frequently arises from the fingers. The diagnosis is easily confirmed by pathologic evaluation. However, in some cases, it may be misdiagnosed as other benign conditions, mainly adnexal tumors and common warts, especially when located on the foot and toes. In this article, we report the case of a 45-year-old man who presented to our clinic for an acquired growth over the plantar surface of the second right toe. The tumor had evolved for 1 year and affected the patient's activities and mobility. On examination, the lesion was a dome-shaped, firm tumor with keratotic distal changes and a broad base attached to the overlying skin. Pathologic assessment was consistent with the diagnosis of acquired digital fibrokeratoma, ruling out other causes of abnormal growth. The tumor was completely excised with surgery, with excellent outcomes and no recurrence at follow-up. Although acquired digital fibrokeratoma is a rare condition, mostly located on the distal upper extremities and fingers, it should be considered in the differential diagnosis of plantar soft-tissue tumors. Surgical management remains the mainstay of treatment.

Efficacy and Safety of Contact Cryosurgery in the Treatment of Earlobe Keloids

Earlobe keloids, although not a life-threatening disease, can severely impair a patient's quality of life. Contact cryosurgery is a safe technique for the management of earlobe keloids with tolerable side effects. The aim of this study was to assess the safety and efficacy of contact cryosurgery in the treatment of earlobe keloids through a 1-year prospective study. We treated 15 Caucasian women ranging in age from 8 to 54 years with a total of 18 earlobe keloids. Excellent improvement was noted in 11 earlobe keloids, with a 75%-100% reduction in the volume of the keloids. An improvement ranging from 50% to 75% was observed in the seven other earlobe keloids. During the 18-month follow-up period, there was no evidence of bleeding, infection, recurrence, or permanent hypopigmentation. Two patients had a transient hypopigmentation which disappeared 2 months after the final session of contact cryosurgery. The results of our study highly encourage the use of contact cryosurgery which has tolerable side effects and high safety.

Genetic analysis of milk urea concentration and its genetic relationship with selected traits of interest in dairy cows

The aim of this study was to estimate genetic parameters of milk urea concentration (MU) and its genetic correlations with milk production traits, longevity, and functional traits in the first 3 parities in dairy cows. The edited data set consisted in 9,107,349 MU test-day records from the first 3 parities of 560,739 cows in 2,356 herds collected during the years 1994 to 2020. To estimate the genetic parameters of MU, data of 109 randomly selected herds, with a total of 770,016 MU test-day records, were used. Genetic parameters and estimated breeding values were estimated using a multiple-trait (parity) random regression model. Herd-test-day, age-year-season of calving, and days in milk classes (every 5 d as a class) were used as fixed effects, whereas effects of herd-year of calving, permanent environment, and animal were modeled using random regressions and Legendre polynomials of order 2. The average daily heritability and repeatability of MU during days in milk 5 to 365 in the first 3 parities were 0.19, 0.22, 0.20, and 0.48, 0.48, 0.47, respectively. The mean genetic correlation estimated among MU in the first 3 parities ranged from 0.96 to 0.97. The average daily estimated breeding values for MU of the selected bulls (n = 1,900) ranged from -9.09 to 7.37 mg/dL. In the last 10 yr, the genetic trend of MU has gradually increased. The genetic correlation between MU and 11 traits of interest ranged from -0.28 (milk yield) to 0.28 (somatic cell score). The findings of this study can be used as the first step for development of a routine genetic evaluation for MU and its inclusion into the genetic selection program in the Walloon Region of Belgium.

Epidemiological, clinical, and therapeutic characteristics of Behçet's disease: a monocentric study in Tunisia

INTRODUCTION

to describe the epidemiological, clinical, therapeutic and evolving characteristics of Behçet´s disease and identify prognostic factors.

METHODS

we have realized a retrospective, single-center study, conducted over a period of 26 years and including 130 patients presenting Behçet´s disease and hospitalized in an Internal Medicine Department.

RESULTS

the mean age of the Behçet´s disease at onset was 30.3 ±8.8 years and that at diagnosis was 34.6 ±9.4 years. The sex ratio (male/female) was 2.5. The mean delay of diagnosis was 53.5 months. Oral aphthosis was constant. The frequency of the manifestations was: genital aphtosis 71.5%, pseudofolliculitis 84.6%, erythema nodosum 11.5%, positive pathergy test 50%, ocular disease 36.9%, venous thrombosis 30%, arterial disease 4.6%, joint damage 30.8%, neurological disease 19.2% and digestive disease 0.8%. The male gender was significantly associated with ocular involvement (p =0.02), venous disease (p =0.01) and occurrence of relapses (p =0.01). The mean follow up was 68.5 ± 77.3 months. The poor survival prognostic factors were male gender, ocular involvement, venous disease, cardiovascular disease, a duration of follow up ≤12 months and a diagnostic delay ≤ 24 months. Conclusion: improving the prognosis of Behçet´s disease requires a shortening of the time to diagnosis, multidisciplinary collaboration, intensive treatment of functional threats, regular monitoring, and patient adherence.

Dermoscopic features of mucosal lichen planus

BACKGROUND

Lichen planus (LP) is a chronic inflammatory dermatosis that affects the skin and the mucous membranes. The literature on the dermoscopic aspects of mucosal LP is still scarce. This study aimed to describe the dermoscopic aspects of mucosal LP and to provide a comprehensive updated summary of the literature.

METHODS

This was a cross-sectional, multicenter study conducted in Charles Nicolle, La Rabta, and Habib Thameur hospitals from December 2019 to October 2020. We included patients with histologically confirmed mucosal LP for whom a dermoscopic examination was performed.

RESULTS

Twenty-seven patients were enrolled. The main dermoscopic structures observed were as follows: Wickham's striae (WS) (91%), vessels (88%), pigmentated structures (41%), erosions (63%), scales (34%), and blunting of lingual papillae (3.1%). WS patterns were as follows: reticular (67%), radial (48%), annular (30%), globular (15%), dotted/starry sky (15%), and veil-like blue or grey-white homogenous pattern (19%). Vascular structures were as follows: linear (85%), dotted (70%), looped (22%), and peripheral sea anemone-like vessels (37%). These vessels were distributed in a radial arrangement at the periphery of the lesions in 67% of the cases. Pigmented structures included brown/blue globules (33%), grey-blue dots (30%), and brown dots (26%).

CONCLUSION

Dermoscopic features of mucosal LP are varied. WS is the hallmark of LP. The distribution and aspects of WS in mucosal LP were slightly different from those described in cutaneous LP. Physicians should be aware of these dermoscopic features that could help differentiate LP from other mucosal inflammatory diseases.