Allergic Dermatitis in Pêga Breed Donkeys (Equus asinus) Caused by Culicoides Bites in the Amazon Biome, Pará, Brazil

An allergy to bites from Culicoides (Diptera: Ceratopogonidae) occurs because of a hypersensitivity reaction caused by the inoculation of insect salivary antigens during the bite, resulting in immune-mediated dermatitis. To the best of our knowledge, no previous studies have focused on allergic dermatitis in donkeys in Brazil. Therefore, this study aimed to describe the epidemiological, clinicopathological, and therapeutic aspects of allergic dermatitis in donkeys and to identify the insects involved in its epidemiology. This study reported the occurrence of dermatitis in 17 animals. The clinical signs were restlessness and severe itching. Skin lesions were found on the head, depigmented areas of the muzzle and cheeks, flanks, pelvic and thoracic limbs, and the scrotal sac. The lesions were characterized by areas of alopecia with crusts accompanied by serosanguineous exudates. Histologically, the lesions were characterized as moderate superficial dermatitis with irregular epidermal acanthosis and pronounced diffuse orthokeratotic hyperkeratosis. In total, 378 Culicoides specimens were collected, with Culicoides ocumarensis Ortiz being the most abundant species. The combined application of copaiba oil and a multivitamin emulsion exhibited potential for topical treatment of allergic dermatitis caused by insect bites in donkeys. Our study revealed an association between allergic dermatitis in donkeys and Culicoides.

Lightweight semantic segmentation network for tumor cell nuclei and skin lesion

In the field of medical image segmentation, achieving fast and accurate semantic segmentation of tumor cell nuclei and skin lesions is of significant importance. However, the considerable variations in skin lesion forms and cell types pose challenges to attaining high network accuracy and robustness. Additionally, as network depth increases, the growing parameter size and computational complexity make practical implementation difficult. To address these issues, this paper proposes MD-UNet, a fast cell nucleus segmentation network that integrates Tokenized Multi-Layer Perceptron modules, attention mechanisms, and Inception structures. Firstly, tokenized MLP modules are employed to label and project convolutional features, reducing computational complexity. Secondly, the paper introduces Depthwise Attention blocks and Multi-layer Feature Extraction modules. The Depthwise Attention blocks eliminate irrelevant and noisy responses from coarse-scale extracted information, serving as alternatives to skip connections in the UNet architecture. The Multi-layer Feature Extraction modules capture a wider range of high-level and low-level semantic features during decoding and facilitate feature fusion. The proposed MD-UNet approach is evaluated on two datasets: the International Skin Imaging Collaboration (ISIC2018) dataset and the PanNuke dataset. The experimental results demonstrate that MD-UNet achieves the best performance on both datasets.

Ameliorative and Disinfection Effects of Ultraviolet-C Radiation on Experimentally Induced and Infected Skin Wounds: A Mice Model Study

Only ultraviolet-C (UV-C) from UV lights, which are emitted by the sun and absorbed by the atmosphere's ozone layer, does not reach the Earth's surface. UV-C is a powerful disinfection method that is commonly used to sterilize fluids, air, and surfaces. There is a little knowledge of the effects of UV-C radiation on living bodies. The purpose of this study is to examine the ameliorative effect of UV-C on skin lesions in mice that have been experimentally created and infected with Staphylococcus aureus, Staphylococcus epidermidis, and Streptococcus sp. In total, 32 mice were used, and 4 mm skin defects were created and lesions infected with bacteria. Half of the mice in each group were treated with 254 nm UV-C twice a day for 4 days before being euthanatized. Blood samples were collected for hematological analysis, while skin samples were collected for microbiological, pathological, and immunohistochemical examinations. In addition, pathological examinations were performed on visceral organ samples. UV-C treatment caused rapid healing and complete or significant disinfection of skin lesions. Moreover, UV-C treatment reduced caspase-3 expressions in lesioned areas, according to immunochemistry. There were no pathological findings in visceral organs as a result of UV-C treatment. This study found that UV-C can be used to treat and disinfect infected skin lesions in short period and repeated doses.

Iatrogenic Kaposi's Sarcoma: A Unique Case Unraveling Gastrointestinal Manifestations and Therapeutic Implications

Kaposi's sarcoma (KS), linked to human herpesvirus 8 (HHV8), manifests in various clinical forms with iatrogenic KS uniquely tied to immune dysregulation induced by medical interventions. This study describes a 58-year-old male of sub-Saharan origin with a medical history of segmental and focal hyalinosis treated with methylprednisolone and mycophenolate mofetil. The patient developed skin lesions on both thighs, accompanied by post-prandial vomiting and abdominal pain. Clinical examination revealed flesh-colored nodules on the thighs and inguinal lymphadenopathy. Biopsy confirmed the diagnosis of KS, exhibiting positive nuclear labeling to anti-HHV8 and negative HIV serology. Additionally, radiological findings from the thoracic-abdominal-pelvic computed tomography (CT) scan significantly contribute to our understanding of the multiorgan involvement associated with KS in this case, providing valuable insights for diagnosis and therapeutic considerations. This case highlights the iatrogenic subtype of KS, linked to immunosuppression from prior medical interventions. Notably, gastrointestinal involvement was evident, with lesions in the stomach and small intestine. Intravenous paclitaxel administration resulted in a positive clinical response. This study underscores the importance of clinical vigilance, endoscopic evaluation, and early intervention in the nuanced diagnosis and management of iatrogenic KS.

Use of an elastic-scattering spectroscopy and artificial intelligence device in the assessment of lesions suggestive of skin cancer: A comparative effectiveness study

Background

Skin cancer is the most common form of cancer worldwide. As artificial intelligence (AI) expands its scope within dermatology, leveraging technology may aid skin cancer detection.

Objective

To assess the safety and effectiveness of an elastic-scattering spectroscopy (ESS) device in evaluating lesions suggestive of skin cancer.

Methods

This prospective, multicenter clinical validation study was conducted at 4 US investigational sites. Patients with skin lesions suggestive of melanoma and nonmelanoma skin cancers were clinically assessed by expert dermatologists and evaluated by a device using AI algorithms comparing current ESS lesion readings with training data sets. Statistical analyses included sensitivity, specificity, AUROC, negative predictive value (NPV), and positive predictive value (PPV).

Results

Overall device sensitivity was 97.04%, with subgroup sensitivity of 96.67% for melanoma, 97.22% for basal cell carcinoma, and 97.01% for squamous cell carcinoma. No statistically significant difference was found between the device and dermatologist performance (P = .8203). Overall specificity of the device was 26.22%. Overall NPV of the device was 89.58% and PPV was 57.54%.

Conclusion

The ESS device demonstrated high sensitivity in detecting skin cancer. Use of this device may assist primary care clinicians in assessing suspicious lesions, potentially reducing skin cancer morbidity and mortality through expedited and enhanced detection and intervention.

Analysis of bioprinting strategies for skin diseases and injuries through structural and temporal dynamics: historical perspectives, research hotspots, and emerging trends

This study endeavors to investigate the progression, research focal points, and budding trends in the realm of skin bioprinting over the past decade from a structural and temporal dynamics standpoint. Scholarly articles on skin bioprinting were obtained from WoSCC. A series of bibliometric tools comprising R software, CiteSpace, HistCite, and an alluvial generator were employed to discern historical characteristics, evolution of active topics, and upcoming tendencies in the area of skin bioprinting. Over the past decade, there has been a consistent rise in research interest in skin bioprinting, accompanied by an extensive array of meaningful scientific collaborations. Concurrently, diverse dynamic topics have emerged during various periods, as substantiated by an aggregate of 22 disciplines, 74 keywords, and 187 references demonstrating citation bursts. Four burgeoning research subfields were discerned through keyword clustering-namely, #3 'in situbioprinting', #6 'vascular', #7 'xanthan gum', and #8 'collagen hydrogels'. The keyword alluvial map reveals that Module 1, including 'transplantation' etc, has primarily dominated the research module over the previous decade, maintaining enduring relevance despite annual shifts in keyword focus. Additionally, we mapped out the top six key modules from 2023 being 'silk fibroin nanofiber', 'system', 'ionic liquid', 'mechanism', and 'foot ulcer'. Three recent research subdivisions were identified via timeline visualization of references, particularly Clusters #0 'wound healing', #4 'situ mineralization', and #5 '3D bioprinter'. Insights derived from bibliometric analyses illustrate present conditions and trends in skin bioprinting research, potentially aiding researchers in pinpointing central themes and pioneering novel investigative approaches in this field.

Cutaneous Metastasis in Colorectal Cancer: A Rare and Overlooked Phenomenon

Cutaneous metastasis from internal malignancies, indicative of poor prognosis, is rare and often involves primary sources like lung, breast, and colorectal cancer (CRC). This case details a 66-year-old male developing a scalp lesion 10 years post colon adenocarcinoma diagnosis. The challenging medical journey included a comprehensive biopsy confirming metastatic CRC in cutaneous tissue through CDX2 and CK20 positivity, emphasizing the importance of advanced diagnostic techniques. Despite medical advancements, the patient's unfavorable prognosis led to succumbing within a year, highlighting challenges in managing such cases and the need for vigilant post-diagnosis care. This report underscores the limited understanding of cutaneous metastasis, emphasizing the role of immunostaining and prompting awareness for early detection and tailored treatment. Further research into atypical metastasis mechanisms is crucial for improved prognostic outcomes and enhanced comprehension of these complex manifestations.

Artificial Intelligence in Dermoscopy: Enhancing Diagnosis to Distinguish Benign and Malignant Skin Lesions

This study presents an innovative application of artificial intelligence (AI) in distinguishing dermoscopy images depicting individuals with benign and malignant skin lesions. Leveraging the collaborative capabilities of Google's platform, the developed model exhibits remarkable efficiency in achieving accurate diagnoses. The model underwent training for a mere one hour and 33 minutes, utilizing Google's servers to render the process both cost-free and carbon-neutral. Utilizing a dataset representative of both benign and malignant cases, the AI model demonstrated commendable performance metrics. Notably, the model achieved an overall accuracy, precision, recall (sensitivity), specificity, and F1 score of 92%. These metrics underscore the model's proficiency in distinguishing between benign and malignant skin lesions. The use of Google's Collaboration platform not only expedited the training process but also exemplified a cost-effective and environmentally sustainable approach. While these findings highlight the potential of AI in dermatopathology, it is crucial to recognize the inherent limitations, including dataset representativity and variations in real-world clinical scenarios. This study contributes to the evolving landscape of AI applications in dermatologic diagnostics, showcasing a promising tool for accurate lesion classification. Further research and validation studies are recommended to enhance the model's robustness and facilitate its integration into clinical practice.

Azathioprine hypersensitivity: A Sweet-like syndrome

INTRODUCTION

Azathioprine hypersensitivity can occasionally present as Sweet-like syndrome, a dose-independent side effect characterized by the unanticipated onset of macules, papules, and pustules.

CASE PRESENTATION

A 35-year-old woman with systemic lupus erythematosus presented with complaints of generalized maculopapular rash, facial swelling, and bilateral lower extremity edema with a duration of 4 days and a 2-day history of constitutional symptoms within 2 weeks of the beginning of azathioprine therapy to treat existing lupus nephritis (class 2/3).

DISCUSSION

Patients who experience azathioprine hypersensitivity syndrome can present with erythema nodosum, small-vessel vasculitis, acute generalized exanthematous pustulosis, Sweet syndrome, and nonspecific dermatosis. The following signs and symptoms are used as criteria to diagnose drug-induced Sweet syndrome: (a) abrupt onset of painful erythematous plaques, (b) histopathological evidence of dense neutrophilic infiltrate without evidence of leukocytoclastic vasculitis, (c) temperature higher than 39.7°C, (d) temporal relationship between drug ingestion and clinical presentation, and (e) temporal resolution of lesions after drug withdrawal. Our patient met three out of five criteria and was diagnosed with Sweet-like syndrome.

CONCLUSION

Our case highlights the uncommonly presented azathioprine-induced Sweet-like syndrome that occurs abruptly after the commencement of the offending drug. This diagnosis can be established through basic laboratory workup and skin biopsy findings.

Bullous Pemphigoid Associated With the Use of Sacubitril/Valsartan: A Case Report and Literature Review

 Bullous pemphigoid (BP) is a complex autoimmune blistering disease with an increased incidence in the comorbid population, particularly among older adults. The occurrence of drug-induced BP is associated with an underlying genetic predisposition, triggering an enhanced immune response, the formation of autoantibodies, and alterations in antigenic properties within the basement membrane zone. With over 90 identified drugs capable of precipitating BP, we present the case of an 87-year-old woman with comorbidities who experienced a medication change from losartan to sacubitril/valsartan. Three months later, erythematous lesions appeared on her lower limbs, progressing to a generalized rash accompanied by itching. Over the following month, these lesions evolved into tense blisters with serous content and intense pain. Suspecting the medication switch to sacubitril/valsartan as the cause, the drug was discontinued, and immunomodulatory treatment was initiated, resulting in a notable improvement in the lesions.

Gut-Skin Axis: Unravelling the Link Between Gut Microbiome and Chronic Kidney Disease-Related Skin Lesions

It is well known that skin lesions are among the most common complications of chronic kidney disease (CKD), which significantly impact the patient's quality of life. Research has demonstrated that gut and skin lesions are closely interconnected and affect each other. This interaction is referred to as the "gut-skin axis" and the intestinal microbiota plays a critical role in this interaction. Changes in gut microbiota composition and function are associated with the development of skin diseases, which are part of the "gut-skin axis". Presently, preliminary results have been demonstrated in basic and clinical research on CKD skin lesions. With further research, the "gut-skin axis" theory can provide new ideas for treating CKD skin lesions and may become a potential treatment target.

Identifying risk factors of anti-TNF induced skin lesions and other adverse events in paediatric patients with inflammatory bowel disease

OBJECTIVES

While higher infliximab (IFX) trough concentrations (TCs) are associated with better outcomes in patients with inflammatory bowel disease (IBD), they could pose a risk for adverse events (AEs), including IFX-induced skin lesions. Therefore, we studied correlations between IFX TCs and occurrence of AEs in paediatric IBD patients.

METHODS

In this single-centre study, all children with Crohn's disease (CD) and ulcerative colitis (UC) receiving IFX maintenance therapy who underwent proactive drug monitoring between March 2015 and August 2022 were included. IFX doses/intervals/TCs and patient characteristics were systematically registered, as well as AEs and skin lesions appearance.

RESULTS

A total of 109 patients (72 CD and 37 UC) contributed 2913 IFX TCs. During a median follow-up of 3.0 [1.5-4.5] years, we observed 684 AEs in 101 patients and 49 skin lesions in 35 patients. There was no significant difference (p = .467) in median TCs between patients with and without skin lesions. However, higher median IFX doses were associated with an increased hazard rate of skin lesions [HR 1.084 (1.024-1.148), p = .005], in addition to female sex [2.210 (1.187-5.310), p = .016] and diagnosis of CD [1.695 (1.241-1.877), p = .011]. Considering IFX therapeutic TC cut-offs of 5.0 and 9.0 µg/mL, there was no significant difference in AE rate (p = .749 and p = .833, respectively). Also, no significant association between IFX doses and AE rate (p = .159).

CONCLUSIONS

Increasing the IFX dose to achieve therapeutic TCs may not increase the overall risk of AEs in paediatric IBD patients. However, concerns arise regarding the risk of skin lesions, especially in female CD patients.

An Outbreak of Paederus Dermatitis in a Suburban Hospital in Southwest China: A Report of 134 Cases and Review of Literature

Reports of paedoptera dermatitis are commonly found in tropical and subtropical regions, while reports in China are rare. In September 2022, an outbreak of paedoptera dermatitis occurred in a minority autonomous county in southwestern China. Here, we report 134 patients with paedoptera dermatitis who were treated at the People's Hospital of Sandu Shui Autonomous County. The skin lesions of these patients were mostly located on the face, neck, trunk, or multiple sites. The skin lesions were mainly distributed in patches and were characterized by vesicular linear or "kissing" lesions. Most patients felt burning pain, and few patients felt pruritus. The treatments with oral antihistamines, calamine lotion, steroids, and antibiotics were effective. For patients with ocular involvement, treatments with oral prednisone and bufexamac cream were effective. All patients recovered within 2 wk. There is a possibility of another outbreak of paedoptera dermatitis in the region. Awareness of the condition and its clinical features will prevent misdiagnosis. Early diagnosis and timely treatment lead to a better prognosis for paederus dermatitis. Simple preventive measures can be undertaken based on the behavioral pattern of this nocturnal beetle.

Zoonotic poxvirus lesions vs mosquito bite lesions: differential diagnosis of the uncommon vs the common

A returning traveller presents with skin lesions resembling an orthopox virus infection and a history of animal contact. Despite the suggestive presentation, polymerase chain reaction (PCR) rules out this rare differential diagnosis. The clinical course and histologic analysis lead to the diagnosis of insect bites; a common traveller’s affliction with an unusual presentation.

Leukemia Cutis-The Current View on Pathogenesis, Diagnosis, and Treatment

Leukemia cutis (LC) is defined as the leukemic infiltration of the epidermis, the dermis, and the subcutaneous tissue. Leukemia cutis may follow or occur simultaneously with the diagnosis of systemic leukemia. However, cutaneous lesions are occasionally diagnosed as the primary manifestation of leukemia. Leukemic skin infiltrations demonstrate considerable variation regarding a number of changes, distribution, and morphology. The highest incidence of LC is observed in chronic lymphocytic leukemia, monocytic and myelomonocytic acute myeloid leukemia, and T-cell lineage leukemia. Although the pathogenic mechanism of the invasion of leukemic cells into the skin is not well understood, chemokine receptors and adhesion molecules as well as the genetic characteristics of leukemia are thought to play a role. Leukemic skin lesions may be localized or disseminated and may occur alone or in combination on any site of the skin, most frequently in the trunk and extremities. The most common clinical presentations of leukemia cutis are papules, nodules, macules, plaques, and ulcers. In most patients, the complete or partial resolution of cutaneous infiltrations occurs simultaneously with hematologic remission. However, in patients with resistant disease or recurrent skin infiltration, local radiotherapy can be used. This review presents recent data on the pathogenesis, diagnosis, and treatment of leukemic skin involvement in different types of leukemia.

Intramammary infections and risk factors in freshly calved heifers in Swedish dairy herds

Subclinical mastitis can be common among freshly calved heifers (FCH), but the prevalence differs between herds, possibly due to variation in risk factors. The aims of this observational study were to identify differences in occurrence of intramammary infection (IMI) in FCH between herds with documented good or poorer first-parity udder health based on cow somatic cell count (CSCC) in early lactation, and to study herd differences in animal factors important for udder health, such as udder and hock skin lesions and animal cleanliness. Three groups of herds were included: those with high proportions of FCH with low CSCC (≤75,000 cells/mL) at the first 2 milk recordings after calving (LL), herds with high proportions of FCH with high CSCC (>100,000 cells/mL) at the first and low CSCC at the second recording (HL), and herds with high proportions of FCH with high CSCC at both recordings (HH). Thirty-nine herds (13 LL, 11 HL, 15 HH) were visited 3 times during a 12-mo period for observation of cleanliness and hock lesions, and sampling of udder and teat skin using swab cloths of milk-fed calves, early-pregnant heifers, and late-pregnant heifers. In 25 (9 LL, 9 HL, 7 HH) udder quarter samples from colostrum and milk on d 3 to 4 after calving were taken by the farmers from FCH during one year. The farmers also provided information on calving (individual or group), use of restraint and oxytocin at milking, and presence of teat and udder skin lesions. Bacterial growth in swab samples and quarter samples was investigated by culturing, and a selection of isolates was genotyped using whole-genome sequencing. Cleanliness, hock and udder skin lesions other than udder-thigh dermatitis, and growth of bacteria in swab samples did not differ between herd groups. It was more common that FCH from LL herds, compared with FCH in HH and HL herds, calved in a group of animals. Use of restraint at milking was more common in LL herds than in HH herds, whereas presence of udder-thigh dermatitis was lowest in LL herds. Specific infection was found in 14% of 5,593 quarter samples from 722 FCH. The most common IMI was Staphylococcus chromogenes. Growth of Staphylococcus simulans was more common in HH than in LL and HL herds. In colostrum samples, Staphylococcus haemolyticus was more common in HL and HH than in LL herds. The proportion of quarters with the same specific infection at both samplings was higher in HH than in LL herds and tended to be higher in HH than in HL herds. The proportion of quarters with Staph. chromogenes IMI at both samplings tended to differ between herd groups and was highest in HH herds. Whole-genome sequencing found the same sequence type of Staph. chromogenes and Staphylococcus aureus in both samples in almost all quarters with the same infection at both samplings. The differences in IMI between herd groups were in line with the higher somatic cell count in HH herds. The reasons for the predominance of Staph. chromogenes IMI in FCH need further studies.

DermAI 1.0: A Robust, Generalized, and Novel Attention-Enabled Ensemble-Based Transfer Learning Paradigm for Multiclass Classification of Skin Lesion Images

Skin lesion classification plays a crucial role in dermatology, aiding in the early detection, diagnosis, and management of life-threatening malignant lesions. However, standalone transfer learning (TL) models failed to deliver optimal performance. In this study, we present an attention-enabled ensemble-based deep learning technique, a powerful, novel, and generalized method for extracting features for the classification of skin lesions. This technique holds significant promise in enhancing diagnostic accuracy by using seven pre-trained TL models for classification. Six ensemble-based DL (EBDL) models were created using stacking, softmax voting, and weighted average techniques. Furthermore, we investigated the attention mechanism as an effective paradigm and created seven attention-enabled transfer learning (aeTL) models before branching out to construct three attention-enabled ensemble-based DL (aeEBDL) models to create a reliable, adaptive, and generalized paradigm. The mean accuracy of the TL models is 95.30%, and the use of an ensemble-based paradigm increased it by 4.22%, to 99.52%. The aeTL models' performance was superior to the TL models in accuracy by 3.01%, and aeEBDL models outperformed aeTL models by 1.29%. Statistical tests show significant p-value and Kappa coefficient along with a 99.6% reliability index for the aeEBDL models. The approach is highly effective and generalized for the classification of skin lesions.

Effectiveness of an image analyzing AI-based Digital Health Technology to identify Non-Melanoma Skin Cancer and other skin lesions: results of the DERM-003 study

Introduction

Identification of skin cancer by an Artificial Intelligence (AI)-based Digital Health Technology could help improve the triage and management of suspicious skin lesions.

Methods

The DERM-003 study (NCT04116983) was a prospective, multi-center, single-arm, masked study that aimed to demonstrate the effectiveness of an AI as a Medical Device (AIaMD) to identify Squamous Cell Carcinoma (SCC), Basal Cell Carcinoma (BCC), pre-malignant and benign lesions from dermoscopic images of suspicious skin lesions. Suspicious skin lesions that were suitable for photography were photographed with 3 smartphone cameras (iPhone 6S, iPhone 11, Samsung 10) with a DL1 dermoscopic lens attachment. Dermatologists provided clinical diagnoses and histopathology results were obtained for biopsied lesions. Each image was assessed by the AIaMD and the output compared to the ground truth diagnosis.

Results

572 patients (49.5% female, mean age 68.5 years, 96.9% Fitzpatrick skin types I-III) were recruited from 4 UK NHS Trusts, providing images of 611 suspicious lesions. 395 (64.6%) lesions were biopsied; 47 (11%) were diagnosed as SCC and 184 (44%) as BCC. The AIaMD AUROC on images taken by iPhone 6S was 0.88 (95% CI: 0.83-0.93) for SCC and 0.87 (95% CI: 0.84-0.91) for BCC. For Samsung 10 the AUROCs were 0.85 (95% CI: 0.79-0.90) and 0.87 (95% CI, 0.83-0.90), and for the iPhone 11 they were 0.88 (95% CI, 0.84-0.93) and 0.89 (95% CI, 0.86-0.92) for SCC and BCC, respectively. Using pre-determined diagnostic thresholds on images taken on the iPhone 6S the AIaMD achieved a sensitivity and specificity of 98% (95% CI, 88-100%) and 38% (95% CI, 33-44%) for SCC; and 94% (95% CI, 90-97%) and 28% (95 CI, 21-35%) for BCC. All 16 lesions diagnosed as melanoma in the study were correctly classified by the AIaMD.

Discussion

The AIaMD has the potential to support the timely diagnosis of malignant and premalignant skin lesions.

The Promise of Semantic Segmentation in Detecting Actinic Keratosis Using Clinical Photography in the Wild

AK is a common precancerous skin condition that requires effective detection and treatment monitoring. To improve the monitoring of the AK burden in clinical settings with enhanced automation and precision, the present study evaluates the application of semantic segmentation based on the U-Net architecture (i.e., AKU-Net). AKU-Net employs transfer learning to compensate for the relatively small dataset of annotated images and integrates a recurrent process based on convLSTM to exploit contextual information and address the challenges related to the low contrast and ambiguous boundaries of AK-affected skin regions. We used an annotated dataset of 569 clinical photographs from 115 patients with actinic keratosis to train and evaluate the model. From each photograph, patches of 512 × 512 pixels were extracted using translation lesion boxes that encompassed lesions in different positions and captured different contexts of perilesional skin. In total, 16,488 translation-augmented crops were used for training the model, and 403 lesion center crops were used for testing. To demonstrate the improvements in AK detection, AKU-Net was compared with plain U-Net and U-Net++ architectures. The experimental results highlighted the effectiveness of AKU-Net, improving upon both automation and precision over existing approaches, paving the way for more effective and reliable evaluation of actinic keratosis in clinical settings.

Infantile Systemic Hyalinosis: A Case Report and Literature Review

Infantile systemic hyalinosis (ISH) is a very rare disorder belonging to the heterozygous group of genetic fibromatosis. There is a diffuse deposition of hyaline material in the skin, gastrointestinal tract, muscle, lymph node, spleen, thyroid, and adrenal gland due to which it presents clinically with multiple subcutaneous skin nodules, gingival hypertrophy, osteopenia, joint contractures, failure to thrive, and diarrhea with protein-losing enteropathy, and is associated with recurrent infections. The disease is caused by mutations in ANTXR2 also known as the CMG2 gene, which encodes the transmembrane-extracellular matrix assembly. In this report, we describe a nine-month-old male diagnosed with ISH based on the clinical presentation of severe skin lesions, painful joint contractures, diarrhea, and failure to thrive. His diagnosis was confirmed by molecular DNA sequencing of the ANTXR2 gene. Consanguinity and molecular diagnosis will be helpful for early diagnosis and accurate management.

Case report: Desquamating dermatitis, bilateral cerebellar lesions in a late-onset methylmalonic acidemia patient

Introduction

Cobalamin C (cblC) deficiency is a rare hereditary disorder affecting intracellular cobalamin metabolism, primarily caused by mutations in MMACHC. This condition is characterized by combined methylmalonic acidemia and hyperhomocysteinemia, displaying a wide range of clinical manifestations involving multiple organs. Owing to its uncommon occurrence and diverse clinical phenotypes, diagnosing cblC deficiency is challenging and often leads to delayed or missed diagnoses.

Case description

In this report, we present a case of late-onset cblC deficiency with brown desquamating dermatitis on the buttocks. Magnetic resonance imaging (MRI) of the brain revealed bilateral cerebellar abnormalities. The suspicion of an inherited metabolic disorder was raised by abnormal serum amino acid and acylcarnitine levels, along with increased urine methylmalonic acid and serum homocysteine levels. Whole-exome sequencing helped identify a homozygous variant (c.482G>A) in MMACHC, confirming the diagnosis of cblC deficiency. However, despite receiving treatment with hydroxocobalamin and betaine, the patient did not experience clinical improvement, which may be attributed to the delayed diagnosis as indicated by the declining homocysteine and methylmalonic acid levels.

Conclusion

Collectively, we emphasize the significance of recognizing the skin lesions and observing serial MRI changes in patients with cblC deficiency. Our case underscores the importance of early diagnosis and timely therapeutic intervention for this severe yet frequently manageable condition.

Effects of Lavender Essential Oil Inhalation on the Welfare and Meat Quality of Fattening Heavy Pigs Intended for Parma Ham Production

We assessed the effects of inhalation administration of lavender essential oil (LEO) either once (L1) or twice (L2) a day on animal welfare indicators, carcass and meat quality of Italian heavy pigs. Pigs (n = 108) were allotted to three experimental groups (control -C-, L1 and L2) and lavender was administered, via a vaporizer device, to the treated groups during the entire fattening-finishing period (79-160 kg BW). Tail lesion severity was reduced in L1 at the end of the trial compared to the other groups (p < 0.05). Body lesion counts, however, were higher in L2 than in C (p < 0.05), resulting in a more severe overall damage classification (p < 0.01). At slaughter, no differences were observed in carcass traits or blood stress indicators, only minor differences were observed in meat quality, and no LEO residual was found in fat or lean tissues, highlighting the preserved suitability of thighs for the dry curing process. While it was not possible to conclude on the ability to improve animal welfare of vaporized LEO in this production phase, the absence of adverse effects on meat quality and the discrepancies observed regarding the body lesions in L1 and L2 make further studies on behavioral aspects and the method of administration (route, frequency) of the product desirable.

Diagnostic Tools for Cutaneous Leishmaniasis Caused by Leishmania donovani: A Narrative Review

Leishmaniasis, a neglected tropical disease, encompasses a spectrum of clinical conditions and poses a significant risk of infection to over one billion people worldwide. Visceral leishmaniasis (VL) in the Indian sub-continent (ISC), where the causative parasite is Leishmania donovani, is targeted for elimination by 2025, with some countries already reaching such targets. Other clinical phenotypes due to the same species could act as a reservoir of parasites and thus pose a challenge to successful control and elimination. Sri Lanka has consistently reported cutaneous leishmaniasis (CL) due to L. donovani as the primary disease presentation over several decades. Similar findings of atypical phenotypes of L. donovani have also been reported from several other countries/regions in the Old World. In this review, we discuss the applicability of different methods in diagnosing CL due to L. donovani and a comprehensive assessment of diagnostic methods spanning clinical, microscopic, molecular, and immunological approaches. By incorporating evidence from Sri Lanka and other regions on L. donovani-related CL, we thoroughly evaluate the accuracy, feasibility, and relevance of these diagnostic tools. We also discuss the challenges and complexities linked to diagnosing CL and review novel approaches and their applicability for detecting CL.

Diagnosing the Dermatologic Blues: Systematic Review of the Rare Conundrum, Psychogenic Purpura

BACKGROUND

Psychogenic purpura is an idiopathic psychodermatologic condition of recurrent, painful purpura precipitated by psychological stress, predominantly affecting young females. Little consensus exists on the diagnostic guidelines for this rare condition, often resulting in costly, unnecessary, and stressful investigations as well as prolonged hospital admissions.

OBJECTIVE

With this first up-to-date systematic review of 134 cases of psychogenic purpura in over a decade, we aim to thoroughly investigate the diagnostic strategy and treatment regimens used in the last decade. With a sooner diagnosis, patient stress and nosocomial ecchymoses can be minimized, and treatment can be expedited.

METHODS

We conducted a literature review of 4 databases (PubMed, Ovid Embase, Ovid MEDLINE, and Web of Science) on October 5, 2022 that yielded 46 full-text articles, which were reviewed and extracted by 2 independent reviewers.

RESULTS

We analyzed a total of 134 cases, consisting largely of females (125/134, 93.3%) with purpura on the upper (103/134, 76.9%) or lower limbs (112/134, 83.6%). Apart from a paresthesia prodrome, patients commonly experienced headaches, malaise, and arthralgia or myalgia. Approximately 70% (95/134) of patients reported a physiological or psychological stressor or psychiatric diagnosis before the development of the purpura. Laboratory testing almost always revealed unremarkable results. The intradermal washed autoerythrocyte sensitization test was positive in 98% (42/43) of cases. Histopathology biopsy findings commonly revealed dermal erythrodiapedesis or hemorrhage (n=34) and perivascular inflammatory infiltrates (n=17). Approximately 42% (56/134) of patients received a novel psychiatric diagnosis, with depression being the most common (40/72, 56%). In both patients with and those without a novel psychiatric diagnosis, observation, counseling, treatment with antidepressants (ie, selective serotonin reuptake inhibitors), and psychotherapy (ie, cognitive behavioral therapy) prevailed in the resolution of the purpura.

CONCLUSIONS

Due to the unclear etiology and infrequent presentation of this condition, it remains a diagnosis of exclusion based on clinical suspicion evaluating the presence of stressors or psychiatric comorbidities and exclusion of systemic conditions. Clinical confirmation can be sought through a positive autoerythrocyte sedimentation test, characteristic histopathology findings, and remission of purpura after psychiatric treatment.

Extra-osseous manifestations in chronic recurrent multifocal osteomyelitis: a retrospective study

OBJECTIVES

Extra-osseous (EO) manifestations are poorly characterized in chronic recurrent multifocal osteomyelitis (CRMO). This study aimed to further define the frequency, characteristics and treatment of EO events in CRMO and whether different phenotypes can be distinguished and benefit from special management.

METHODS

This multicentre retrospective study included CRMO patients followed in several paediatric rheumatology departments in France, between 2015 and 2022. EO manifestations were defined as skin lesions, gastrointestinal manifestations, arthritis, enthesitis, sacroiliitis, uveitis, vasculitis, and fever. At the last visit, the physician defined CRMO as active in the presence of clinical manifestations including both osseous and EO symptoms.

RESULTS

We included 133 patients; 87 (65.4%) were girls; the median age at first symptoms was 9.0 years (interquartile range 7.0-10.0). EO manifestations were described in 90 (67.7%) patients, with a predominance of skin lesions (n = 51/90; 56.7%), followed by sacroiliitis (n = 38/90; 42.2%), enthesitis (n = 21/90; 23.3%), arthritis (n = 14/90, 15.6%) and gastrointestinal manifestations (n = 6/90, 6.7%). The use of non-steroidal anti-inflammatory drugs and bisphosphonates did not differ by presence or not of EO manifestations. Biologics were taken more frequently by patients with than without EO manifestations (p< 0.001); tumour necrosis factor inhibitors were used in 33 (36.7%) EO+ patients. Under this treatment, 18 (54.5%) patients achieved complete remission of osseous and EO manifestations. At the last visit, more EO-positive than EO-negative patients were on treatment (p= 0.009), with active disease in 58 (64.4%) patients.

CONCLUSION

The analysis of EO manifestations in CRMO delineates 2 groups of patients in terms of severity and treatments used. Our study opens up new pathophysiological leads that may underlie the wide range of CRMO phenotypes.

Viral skin diseases in odontocete cetaceans: gross, histopathological, and molecular characterization of selected pathogens

Fifty-five skin lesions from 31 stranded cetaceans along the Canary coasts (2011-2021) were submitted to macroscopic, histological, and molecular analyses to confirm infection by cetacean poxvirus, herpesvirus and cetacean morbillivirus. They were macroscopically categorized into eight categories with respective subcategories according to their color, shape, size, and consistency. Cetacean poxvirus was detected in 54.54% of the skin lesions through real-time and conventional PCRs based on the DNA polymerase gene. Additionally, herpesvirus and morbillivirus were currently detected from 43.63 and 1.82% of the cutaneous lesions, respectively. Coinfection of poxvirus and herpesvirus was detected in nine of them (16.36%), which makes the present study the first to report coinfection by both pathogens in skin lesions in cetaceans. A plausible approach to histopathological characterization of poxvirus-and herpesvirus-positive skin lesions was established. Hyperkeratosis, acanthosis, ballooning degeneration, and intracytoplasmic inclusion bodies in vacuolized keratinocytes through the stratum spinosum were common findings in poxvirus skin lesions. Alphaherpesvirus was associated with a prominent acanthotic epidermis, moderate necrosis, multifocal dyskeratosis, and irregular keratinocytes with both cellular and nuclei pleomorphism. The common histopathological findings of both pathogens were observed in coinfection lesions. However, those associated with herpesvirus were considerably more remarkable. Relationships between molecular and microscopic findings were observed for the lesions that showed tattoo-like and tortuous patterns. Further multidisciplinary diagnostic studies of infected skin lesions are needed to understand the epidemiology of these emerging infectious diseases.

Update on Mpox: a brief narrative review

Mpox (formerly Monkeypox), a neglected tropical disease once confined to Central and West Africa, emerged as a global epidemic outbreak in May, 2022 with 87,529 cases reported as of May, 23, 2023. It predominantly affected men (96.2%) who have sex with men (84-100%), although other transmission routes have been reported, including occupational exposure and vertical transmission. Concomitant HIV infection has been recorded in 21-46.9% and pre-exposure prophylaxis against HIV infection has been reported in 11-57% of published cases. The current outbreak clinical presentation differs from endemic cases with prodromal symptoms that could be absent: the number of lesions is generally low, with skin lesions predominantly localised in the ano-genital areas and frequent lesions present in different stages of progression (i.e., asynchronous). Asymptomatic Mpox infection can occur in 1.8-6.5% of at-risk subjects. People living with HIV with severe immunodeficiency (less than 100 CD4+ lymphocytes per microliter) are at risk of more severe clinical manifestations and death. According to a systematic review and meta-analysis, the hospitalisation rate is around 6% and the observed case-fatality rate is less than 0.1%. Tecovirimat is the drug of choice for treating severe cases although there is no evidence of efficacy from randomised controlled trials. Immunization with a live non-replicating vaccine (JYNNEOS) effectively reduces the disease's incidence.

Improving Skin Cancer Diagnostics Through a Mobile App With a Large Interactive Image Repository: Randomized Controlled Trial

BACKGROUND

Skin cancer diagnostics is challenging, and mastery requires extended periods of dedicated practice.

OBJECTIVE

The aim of the study was to determine if self-paced pattern recognition training in skin cancer diagnostics with clinical and dermoscopic images of skin lesions using a large-scale interactive image repository (LIIR) with patient cases improves primary care physicians' (PCPs') diagnostic skills and confidence.

METHODS

A total of 115 PCPs were randomized (allocation ratio 3:1) to receive or not receive self-paced pattern recognition training in skin cancer diagnostics using an LIIR with patient cases through a quiz-based smartphone app during an 8-day period. The participants' ability to diagnose skin cancer was evaluated using a 12-item multiple-choice questionnaire prior to and 8 days after the educational intervention period. Their thoughts on the use of dermoscopy were assessed using a study-specific questionnaire. A learning curve was calculated through the analysis of data from the mobile app.

RESULTS

On average, participants in the intervention group spent 2 hours 26 minutes quizzing digital patient cases and 41 minutes reading the educational material. They had an average preintervention multiple choice questionnaire score of 52.0% of correct answers, which increased to 66.4% on the postintervention test; a statistically significant improvement of 14.3 percentage points (P<.001; 95% CI 9.8-18.9) with intention-to-treat analysis. Analysis of participants who received the intervention as per protocol (500 patient cases in 8 days) showed an average increase of 16.7 percentage points (P<.001; 95% CI 11.3-22.0) from 53.9% to 70.5%. Their overall ability to correctly recognize malignant lesions in the LIIR patient cases improved over the intervention period by 6.6 percentage points from 67.1% (95% CI 65.2-69.3) to 73.7% (95% CI 72.5-75.0) and their ability to set the correct diagnosis improved by 10.5 percentage points from 42.5% (95% CI 40.2%-44.8%) to 53.0% (95% CI 51.3-54.9). The diagnostic confidence of participants in the intervention group increased on a scale from 1 to 4 by 32.9% from 1.6 to 2.1 (P<.001). Participants in the control group did not increase their postintervention score or their diagnostic confidence during the same period.

CONCLUSIONS

Self-paced pattern recognition training in skin cancer diagnostics through the use of a digital LIIR with patient cases delivered by a quiz-based mobile app improves the diagnostic accuracy of PCPs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05661370; https://classic.clinicaltrials.gov/ct2/show/NCT05661370.

Somatic loss of the Y chromosome is associated with arsenic exposure among Bangladeshi men

BACKGROUND

Arsenic exposure increases the risk of several cancers in humans and contributes to genomic instability. Somatic loss of the Y chromosome (LoY) is a potential biomarker of genomic instability and cancer risk. Smoking is associated with LoY, but few other carcinogens have been investigated. We tested the cross-sectional association between arsenic exposure and LoY in leukocytes among genotyped Bangladeshi men (age 20-70 years) from the Health Effects of Arsenic Longitudinal Study.

METHODS

We extracted the median of logR-ratios from probes on the Y chromosome (mLRR-chrY) from genotyping arrays (n = 1364) and estimated the percentage of cells with LoY (% LoY) from mLRR-chrY. We evaluated the association between arsenic exposure (measured in drinking water and urine) and LoY using multivariable linear and logistic regression models. The association between LoY and incident arsenic-induced skin lesions was also examined.

RESULTS

Ten percent of genotyped men had LoY in at least 5% of cells and % LoY increased with age. Among men randomly selected for genotyping (n = 778), higher arsenic in drinking water, arsenic consumed and urinary arsenic were associated with increased % LoY (P = 0.006, P = 0.06 and P = 0.13, respectively). LoY was associated with increased risk of incident skin lesions (P = 0.008).

CONCLUSION

Arsenic exposure was associated with increased LoY, providing additional evidence that arsenic contributes to genomic instability. LoY was associated with developing skin lesions, a risk factor for cancer, suggesting that LoY may be a biomarker of susceptibility in arsenic-exposed populations. The effect of arsenic on somatic events should be further explored in cancer-prone tissue types.

SBXception: A Shallower and Broader Xception Architecture for Efficient Classification of Skin Lesions

Skin cancer is a major public health concern around the world. Skin cancer identification is critical for effective treatment and improved results. Deep learning models have shown considerable promise in assisting dermatologists in skin cancer diagnosis. This study proposes SBXception: a shallower and broader variant of the Xception network. It uses Xception as the base model for skin cancer classification and increases its performance by reducing the depth and expanding the breadth of the architecture. We used the HAM10000 dataset, which contains 10,015 dermatoscopic images of skin lesions classified into seven categories, for training and testing the proposed model. Using the HAM10000 dataset, we fine-tuned the new model and reached an accuracy of 96.97% on a holdout test set. SBXception also achieved significant performance enhancement with 54.27% fewer training parameters and reduced training time compared to the base model. Our findings show that reducing and expanding the Xception model architecture can greatly improve its performance in skin cancer categorization.

Mycobacterium marinum: A Case-Based Narrative Review of Diagnosis and Management

Skin and soft tissue infections caused by non-tuberculous mycobacteria are occurring more frequently in recent years. However, chronic skin and soft tissue lesions present a challenge for clinicians, as the diagnostic work-up and definitive diagnosis require knowledge and available laboratory resources. We present here the case of a 66-year-old male patient who presented with painful abscess-like nodules on his right hand and forearm, which worsened after treatment with an anti-TNF-a agent. The fluid specimen taken from the lesion was positive for mycobacteria according to the acid-fast stain. Mycobacterium marinum was identified, first by next-generation sequencing and finally grown on culture, after eight weeks. Acknowledging the complexity of diagnosing and managing infections by non-tuberculous mycobacteria, and especially Mycobacterium marinum, we provide a review of the current epidemiology, clinical characteristics, diagnosis and management of Mycobacterium marinum infection.

Phenytoin-Induced Toxic Epidermal Necrolysis

Toxic epidermal necrolysis (TEN) is a rare fatal mucocutaneous blistering disorder that can have varied underlying triggers. The percentage of body surface area (BSA) that is impacted by erosive blistering is what separates it from Steven Johnson syndrome (SJS), both of which have the same underlying pathogenesis and are thought to exist on a continuum of disease with TEN being the more serious of the two. Medications are the most frequent cause of TEN/SJS and typically cause disease in both adults and children within eight weeks; however, the median exposure window is four days to four weeks. Nonsteroidal anti-inflammatory drugs, allopurinol, anticonvulsants including lamotrigine, phenytoin, levetiracetam and carbamazepine, antimicrobial sulfonamides, and the antiviral nevirapine are examples of medications that frequently cause TEN/SJS. Here, we are reporting a case of phenytoin-induced TEN highlighting the patient's excellent response to immunomodulating treatment despite 100% involvement of the BSA.

Prophylactic Use of Mepitel® Film to Prevent Radiation-Induced Moist Desquamation in Cancer Patients

Cancer patients had limited treatment options for decades, such as surgery, chemotherapy, and radiation therapy, alone or combined. However, there have been substantial improvements in recent years with the introduction of stem cell therapy, hormone therapy, anti-angiogenic treatments, immunotherapy, dendritic cell-based targeted therapy, ablation therapy, nanoparticles, natural antioxidants, radionics, chemodynamic therapy, sonodynamic therapy, and ferroptosis-based therapy. Radiation therapy, or radiotherapy, is a cancer treatment that employs high doses of radiation to eliminate cancer cells and shrink tumors. This treatment is effective as a primary, adjuvant, or palliative therapy. It is an essential, efficient, cost-effective intervention crucial for providing proper palliative oncology care. Although cancer treatment modalities such as intensity-modulated radiotherapy have advanced, they still risk harming the skin and surrounding healthy tissue. Radiotherapy may induce clinical toxicity leading to chronic or acute radiation dermatitis, depending on the toxicity caused by the therapy. Radiation dermatitis, whether in its chronic or acute form, can cause skin shedding that may result in the formation of wounds. Such shedding can also lead to non-healing ulcers and radionecrosis. Mepitel® film helps control radiation-induced moist desquamation in cancer patients. Clinical trials on the prophylactic use of Mepitel film on radiation-induced moist desquamation did not show similarities among patients from various countries; however, the film-based method is more beneficial than other methods. This review examines the various types of dressings utilized in managing radiation-induced dermatitis to enhance wound healing effectiveness while avoiding harm to newly developing tissues. Additionally, this review compares the effectiveness of using Mepitel film for treating radiation-induced moist desquamation to other methods.

Gonococcal Infection: Case Report of Bacteremia and Brief Review of a Series of Cases

Neisseria (N) gonorrhoeae is the microorganism responsible for the second-most reported sexually transmitted disease in the world, commonly infecting mucosal surfaces such as the endocervix, urethra, and pharynx. Gonococcal disease is generally non-symptomatic or pauci-symptomatic, but if untreated, it can progress to a more serious disease with joint, cardiac, or nervous system involvement. Disseminated gonococcal infection occurs in 0.5 to 3% of patients with gonorrhea and can present with purulent arthritis or a combination of dermatitis, tenosynovitis, and migratory polyarthralgia. This article presents the case of a 45-year-old woman examined in the emergency room for fever and acute pain in her right shoulder and knee. A few days later, the patient developed petechiae and vesiculopustular lesions on her right hand. Blood analysis showed elevated inflammation markers, and cultures yielded gram-negative diplococcus identified as N. gonorrhoeae. The patient was successfully treated with ceftriaxone, with complete remission of signs and symptoms of infection. The article then examines a series of 42 cases of gonococcal disease diagnosed in a tertiary hospital, their microbiologic susceptibilities, and the antibiotics chosen to treat them.

Skin Manifestations of Neuromyelitis Optica Spectrum Disorder With Secondary Systemic Lupus Erythematosus During Pregnancy: A Three-Year Follow-Up

Neuromyelitis optica spectrum disorder (NMOSD) is a disease of the central nervous system and the optic nerves that disproportionately affects women and occasionally coexists with other autoimmune diseases. NMOSD manifesting as skin lesions is a rare phenomenon. Furthermore, these skin lesions in the setting of NMOSD during pregnancy have not been described. We report the case of a 31-year-old woman from sub-Saharan Africa who presented with initial recurrent skin lesions followed by paraparesis during her second trimester of pregnancy. Her next pregnancy was associated with sudden vision loss. She had positive serology for aquaporin-4 antibodies and subsequently developed a positive dsDNA antibody two years after the initial NMOSD diagnosis. Her skin lesions and symptoms improved following the administration of azathioprine. This case highlights the impact of pregnancy on NMOSD and the significance of a heightened level of suspicion for NMOSD in patients who exhibit recurring skin lesions preceding paraparesis events.

Carcinoma En Cuirasse: A Rare but Striking Cutaneous Manifestation of Metastatic Breast Cancer

Carcinoma en cuirasse is a rare cutaneous metastatic presentation of breast cancer with a poor prognosis. We report a female in her 70s with a prior history of left breast ductal carcinoma in situ status post-radiation and lumpectomy who presented with skin thickening of the left breast and a few solid masses in bilateral breasts. Biopsy showed invasive ductal carcinoma of the left breast (estrogen receptor [ER]/progesterone receptor positive [PR], human epidermal growth factor receptor-2 [HER2] negative) and ductal carcinoma in situ of the right breast (ER/PR positive). She underwent a right breast lumpectomy; however, the left breast mastectomy was aborted due to the worsening of her skin findings on preoperative examination. A skin biopsy revealed poorly differentiated invasive ductal carcinoma. She was diagnosed with stage 4 breast cancer, specifically carcinoma en cuirasse. Systemic treatment was initiated, followed by a left breast mastectomy. A surgical biopsy was HER2-positive, and therefore anti-HER2 therapy was given. She remains on maintenance therapy with an excellent response at present.Any unexplained skin findings in breast cancer patients should prompt consideration of carcinoma en cuirasse. With ongoing treatment advances, many newer therapy options are available for metastatic breast cancer. Based on our case, we think that patients with this disease can have better outcomes.

Invasive fusariosis in acute leukaemia patients-An outbreak in the haematology ward

Fusarium, a common fungus, emerges as a pathogen in severely immunocompromised patients. We present a series of patients who developed invasive fusariosis (IF) during admission to an acute leukaemia ward: an outbreak of 12 cases in June and July 2018, followed by four sporadic cases until 2021. No case was reported earlier. All patients were clustered in the same location with indoor air and water installations found to be contaminated with Fusarium spp. thus a nosocomial outbreak was assumed. Following the water installation replacement, the number of Fusarium cases dramatically dropped to one or two isolated instances per year in the same location. All 16 patients had acute leukaemia and developed IF during severe neutropenia following induction therapy. IF diagnosis was based on positive blood cultures (14 patients) and/or on tissue biopsies (3 patients). The median time from admission to the IF onset was 20 days, and from the first day of severe neutropenia (≤500/mm3) was 11.5 days. All patients were febrile, eight had moderate-to-severe myalgias, eight had respiratory involvements: lung lesions and/or sinusitis and seven had characteristic skin lesions. Follow-up: 12 out of 16 (75%) were alive on Day 90; nine out of 15 (60%) were alive on Month 6. All with intractable neutropenia died. In severely neutropenic febrile patients, the triad of respiratory involvement/skin lesions/severe myalgia may suggest Fusarium aetiology. The ability to recover from neutropenia is critical to surmount IF. The indoor environment in immunocompromised dedicated settings must be constantly controlled.

A Pig Model to Assess Skin Lesions after Apomorphine Application

Owing to their similarities, pigs are often used as experimental models for humans. In particular, the similarity of the skin allows them to be a good dermatological model. The aim of the study was to develop an animal model in conventional domestic pigs to evaluate skin lesions macroscopically and histologically after a continuous subcutaneous apomorphine application. A total of 16 pigs from two different age groups were injected with four different apomorphine formulations for 12 h daily over a period of 28 days into the subcutis, which was then evaluated macroscopically for nodules and erythema, as well as histologically. Differences in skin lesions between the formulations were found, with formulation 1 leading to the fewest nodules, least skin lesions, no lymph follicles, least necrosis, and best skin tolerance. Older pigs were easier to handle and, because of the thicker skin and subcutis of these animals, drug application with the appropriate needle length was safer. The experimental setup worked well and an animal model to assess skin lesions after a continuous subcutaneous application of drugs could be successfully established.

From the Cochrane Library: Optical Coherence Tomography for Diagnosing Skin Cancer in Adults

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The first case of monkeypox virus and acute HIV infection: Should we consider monkeypox a new possible sexually transmitted infection?

Since May 2022, a Monkeypox virus (MPXV) outbreak has been ongoing in several non-endemic countries. MPXV is usually transmitted after intimate contact, through body fluids, close contact from active lesions or through respiratory droplets. The recent outbreak occurrent in people with multiple recent sexual intercourse suggests the sexual route as the main way of transmission. However, there is no sufficient evidence to consider MPXV as a new sexually transmitted infection (STI), even though we believe that a link between MPXV and other STIs may exist with a possible facilitating action on their spreading. Herein, we illustrate the first case described during the current outbreak of a young man with both MPXV and acute HIV infection in a non-endemic country.

Cutaneous Limb Metastasis of Colorectal Cancer Misdiagnosed as Zoster Infection

Cutaneous metastasis is a rare manifestation of internal malignancies. It usually occurs with the later progression of the disease and is associated with a poor prognosis. Common culprits of skin metastasis include lung cancer, melanoma, and colorectal cancer in men and breast cancer, colorectal cancer, and melanoma in women. Given these points, there is a low rate of cutaneous metastasis of colorectal cancer. When present, the most common sites include the abdominal wall and, less frequently, the face and the scalp. Rarely there is cutaneous metastasis to the upper extremity. Herein, we report the case of a female patient in her 50s who presented with a maculopapular rash of the right upper limb four years after her initial diagnosis of colonic adenocarcinoma. However, because of this rare manifestation, she was initially misdiagnosed with more common causes of a maculopapular rash. After a period of no improvement with preliminary treatment, a biopsy with immunohistochemical staining was undertaken, and the specimen stained positive for CK20 and CDX2, confirming metastatic colorectal malignancy. Skin lesions that are not responding to conventional therapy and those which have bizarre presentations can be a harbinger of internal malignancy and should be considered in the differential.

Severe NAD(P)HX Dehydratase (NAXD) Neurometabolic Syndrome May Present in Adulthood after Mild Head Trauma

We have previously reported that pathogenic variants in a key metabolite repair enzyme NAXD cause a lethal neurodegenerative condition triggered by episodes of fever in young children. However, the clinical and genetic spectrum of NAXD deficiency is broadening as our understanding of the disease expands and as more cases are identified. Here, we report the oldest known individual succumbing to NAXD-related neurometabolic crisis, at 32 years of age. The clinical deterioration and demise of this individual were likely triggered by mild head trauma. This patient had a novel homozygous NAXD variant [NM_001242882.1:c.441+3A>G:p.?] that induces the mis-splicing of the majority of NAXD transcripts, leaving only trace levels of canonically spliced NAXD mRNA, and protein levels below the detection threshold by proteomic analysis. Accumulation of damaged NADH, the substrate of NAXD, could be detected in the fibroblasts of the patient. In agreement with prior anecdotal reports in paediatric patients, niacin-based treatment also partly alleviated some clinical symptoms in this adult patient. The present study extends our understanding of NAXD deficiency by uncovering shared mitochondrial proteomic signatures between the adult and our previously reported paediatric NAXD cases, with reduced levels of respiratory complexes I and IV as well as the mitoribosome, and the upregulation of mitochondrial apoptotic pathways. Importantly, we highlight that head trauma in adults, in addition to paediatric fever or illness, may precipitate neurometabolic crises associated with pathogenic NAXD variants.

Engineered NF-κB siRNA-encapsulating exosomes as a modality for therapy of skin lesions

Introduction

Despite the protection and management of skin has been paid more and more attention, effective countermeasures are still lacking for patients suffering from UV or chemotherapy with damaged skin. Recently, gene therapy by small interfering RNA (siRNA) has emerged as a new therapeutic strategy for skin lesions. However, siRNA therapy has not been applied to skin therapy due to lack of effective delivery vector.

Methods

Here, we develop a synthetic biology strategy that integrates the exosomes with artificial genetic circuits to reprogram the adipose mesenchymal stem cell to express and assemble siRNAs into exosomes and facilitate in vivo delivery siRNAs for therapy of mouse models of skin lesions.

Results

Particularly, siRNA enriched exosomes (si-ADMSC-EXOs) could be directly taken up by the skin cells to inhibit the expression of skin injury related genes. When mice with skin lesions were smeared with si-ADMSC-EXOs, the repair of lesioned skin became faster and the expression of inflammatory cytokines were decreased.

Discussion

Overall, this study establishes a feasible therapeutic strategy for skin injury, which may offer an alternative to conventional biological therapies requiring two or more independent compounds.

Immunomodulatory Effects of Cinnamaldehyde in Staphylococcus aureus-Infected Wounds

Cinnamaldehyde (CNM) is an essential-oil component with reported anti-infective, anti-inflammatory, and healing effects, making it an interesting compound for the treatment of wound infection. Herein, we evaluated the effects of topical administration of CNM in experimental wounds infected by Staphylococcus aureus. Swiss mice (n = 12/group) were randomly allocated into three groups (CON: animals with uninfected lesions; Sa: animals with untreated infected lesions; Sa + CNM: animals with infected wounds and treated with CNM). Excisional lesions (64 mm²) were induced at the dorsal area followed by the addition of S. aureus (80 μL of a 1.5 × 10⁸ CFU/mL bacterial suspension). The wounds were treated with CNM (200 μg/wound/day) or vehicle (2% DMSO) for 10 days. Skin samples were taken on the 3^rd or 10^th treatment day for quantification of inflammatory mediators, bacterial load, immunophenotyping, and histological analysis. The treatment with CNM improved the healing process and attenuated the severity of skin lesions infected by S. aureus. These effects were associated with significant decreases in bacterial loads in CNM-treated wounds. The levels of neutrophils, TNF-α, IL-6, NO, and VEGF were decreased in the lesions treated with CNM. Taken together, these data provide further evidence of the effectiveness of CNM for the treatment of skin infections.

Protective effects of dietary grape against atopic dermatitis-like skin lesions in NC/NgaTndCrlj mice

Atopic dermatitis (AD) is a chronic inflammatory skin disease with significant health/economic burdens. Existing therapies are not fully effective, necessitating development of new approaches for AD management. Here, we report that dietary grape powder (GP) mitigates AD-like symptoms in 2,4-dinitrofluorobenzene (DNFB)-induced AD in NC/NgaTndCrlj mice. Using prevention and intervention protocols, we tested the efficacy of 3% and 5% GP-fortified diet in a 13-weeks study. We found that GP feeding markedly inhibited development and progression of AD-like skin lesions, and caused reduction in i) epidermal thickness, mast cell infiltration, ulceration, excoriation and acanthosis in dorsal skin, ii) spleen weight, extramedullary hematopoiesis and lymph nodes sizes, and iii) ear weight and IgE levels. We also found significant modulations in 15 AD-associated serum cytokines/chemokines. Next, using quantitative global proteomics, we identified 714 proteins. Of these, 68 (normal control) and 21 (5% GP-prevention) were significantly modulated (≥2-fold) vs AD control (DNFB-treated) group, with many GP-modulated proteins reverting to normal levels. Ingenuity pathway analysis of GP-modulated proteins followed by validation using ProteinSimple identified changes in acute phase response signaling (FGA, FGB, FGG, HP, HPX, LRG1). Overall, GP supplementation inhibited DNFB-induced AD in NC/NgaTndCrlj mice in both prevention and intervention trials, and should be explored further.

Pathology and pathogenesis of cutaneous lesions in beef cattle associated with buffalo fly infestation

Haematobia irritans exigua, commonly known as buffalo fly, is the major hematophagous ectoparasite of north Australian cattle herds. Lesions associated with buffalo fly infestation are generally alopecic, hyperkeratotic, or scab encrusted wounds with variable hemorrhagic ulceration. Buffalo flies can transmit a filarial nematode, Stephanofilaria sp., which has been implicated in the pathogenesis of buffalo fly lesions, but Stephanofilaria infection has not been detected in all lesions suggesting that other causal factors may be involved. This study characterized the pathology of buffalo fly lesions to identify the role of Stephanofilaria in lesion development, as well as to identify other potential agents. Lesion biopsies were collected from north and south Queensland and tested for the presence of Stephanofilaria by qPCR. Each lesion was scored grossly (0-4) for hemorrhage, ulceration, exudation, and alopecia. Lesions were also scored microscopically (0-4) for epidermal and dermal damage and inflammatory characters. Stephanofilaria infection was detected in 31% of lesion biopsies. Grossly, Stephanofilaria-infected lesions had significantly larger lesion area and higher scores for alopecia and hyperkeratosis than lesions where no nematodes were found (P < 0.05). Histologically, epidermal, dermal, and adnexal damage was significantly higher in Stephanofilaria infected lesions than lesions without nematodes. Eosinophils, macrophages, and lymphocytes were significantly more abundant in Stephanofilaria positive lesions as compared to negative lesions. This study also noted bacterial infection with colonies of coccoid bacteria, observed in skin sections from 19 lesions. Grossly, lesions with bacterial infection had significantly higher ulceration scores compared to Stephanofilaria positive lesions, and histologically epidermal disruption was significantly greater in bacteria-infected lesions. We found no evidence of bacteria or Stephanofilaria infection in 49% of the lesions assessed and tissue damage patterns and eosinophilic inflammation suggested hypersensitivity to buffalo fly feeding as a possible cause of these lesions. These findings suggest that although the presence of Stephanofilaria infection may increase the severity of lesion pathology, it is not essential for lesion development. These outcomes also suggest a potential role of bacteria and hypersensitivity in pathogenesis of some lesion. A better understanding of buffalo fly lesion etiology will contribute to the optimal treatment and control programmes.

Malignant Syphilis: A Rare Case of Early Secondary Syphilis in an Immunocompetent Patient

Early malignant syphilis is an uncommon form of secondary syphilis and characterized by pleomorphic multiple round-to-oval papules, some with necrosis, and associated with systemic signs and symptoms. Usually seen in immunosuppressed patients, mainly those infected with HIV, it can also be observed in immunocompetent patients. We report a case in a young healthy woman with the characteristic features of the disease and with favourable skin lesion evolution after appropriate treatment with penicillin.

LEARNING POINTS

Skin lesions can be caused by numerous systemic diseases.Syphilis is the 'great mimicker' and should always be considered as a diagnosis in those with skin lesions.

A dermatologic assessment of 101 mpox (monkeypox) cases from 13 countries during the 2022 outbreak: Skin lesion morphology, clinical course, and scarring

BACKGROUND

In the 2022 mpox (monkeypox) outbreak, 79,000 global cases have been reported. Yet, limited dermatologic data have been published regarding lesion morphology and progression.

OBJECTIVE

The objective of this study was to characterize skin lesion morphology, symptomatology, and outcomes of mpox infection over time.

METHODS

The American Academy of Dermatology/International League of Dermatological Societies Dermatology COVID-19, Mpox, and Emerging Infections Registry captured deidentified patient cases of mpox entered by health care professionals.

RESULTS

From August 4 to November 13, 2022, 101 cases from 13 countries were entered, primarily by dermatologists (92%). Thirty-nine percent had fewer than 5 lesions. In 54% of cases, skin lesions were the first sign of infection. In the first 1-5 days of infection, papules (36%), vesicles (17%), and pustules (20%) predominated. By days 6-10, pustules (36%) were most common, followed by erosions/ulcers (27%) and crusts/scabs (24%). Crusts/scabs were the predominant morphology after day 11. Ten cases of morbilliform rash were reported. Scarring occurred in 13% of the cases.

LIMITATIONS

Registry-reported data cannot address incidence. There is a potential reporting bias from the predilection to report cases with greater clinical severity.

DISCUSSION

These findings highlight differences in skin findings compared to historical outbreaks, notably the presence of skin lesions prior to systemic symptoms and low overall lesion counts. Scarring emerged as a major possible sequela.

Toxoplasma gondii and Alternaria sp.: An Original Association in an Immunosuppressed Dog with Persistent Skin Lesions

Dogs and cats may suffer from a variety of diseases, mainly immune mediated, that require the administration of immunosuppressive drugs. Such therapies can cause adverse effects either by the toxicity of the drugs or as a consequence of immune suppression and associated opportunistic infections. Here we present an, yet unknown, association of Toxoplasma gondii and Alternaria fungus, within cutaneous lesions in a dog under long-term immunosuppressive therapy. The diagnosis of such infections is laborious and not obvious at first glance, since the clinical signs of cutaneous toxoplasmosis, neosporosis or alternariosis are not specific. A further laboratory confirmation is needed. Therefore, we currently recommend that dogs and cats should undergo serologic testing for toxoplasmosis or neosporosis prior to immunosuppressive therapy and a regular dermatological evaluation during the immunosuppressive therapy.