Bullous drug eruption after second dose of mRNA-1273 (Moderna) COVID-19 vaccine: Case report

Background

In December 2020, Moderna released the mRNA-1273 vaccine. The most common side effects are headache, muscle pain, redness, swelling, and tenderness at the injection site. In addition, there have been dermatological adverse events, such as hypersensitivity reactions. Although rare, various bullous eruptions have been described following vaccination. Bullous pemphigoid has been reported to occur most often after receipt of influenza and the diphtheria-tetanus-pertussis vaccine. To the best of our knowledge, there have been no reports of bullous drug eruptions resulting from mRNA vaccines.

Case summary

A 66-years-old obese Guyanese male presented with a bullous rash following receipt of a commercial COVID-19 mRNA vaccine. He received the first dose uneventfully. However, within 24 h of receiving the second dose, he developed fever, myalgias, and malaise accompanied by a painful blistering rash of his torso, arms, and legs. His fever and myalgias improved after 24 h, but his painful rash did not, and five days after the initial symptoms, he presented to the hospital. There were many violaceous, poorly demarcated patches on his trunk, arms, and thighs on examination, many of which had large flaccid bullae within, and a few areas on his buttocks, posterior shoulder, and scrotum were eroded. The exam was also significant for lower extremity muscle tenderness, stiffness with preserved strength. A skin biopsy showed epidermal necrosis and sparse perivascular dermatitis concerning Stevens-Johnson syndrome or erythema multiforme. However, in the absence of mucous membrane involvement or targetoid lesions, the diagnosis of an extensive bullous fixed drug eruption was made.

Conclusion

This case illustrates that the bullae eruption occurred as a result of receiving the Moderna vaccination.

68 A Full Audit Cycle: Documentation of Discharge Summaries and Functional Status in Electronic Discharge Letters

Introduction

Electronic discharge letter is the most effective way to handover to General Practitioners for the continuity of care by providing the information about what happened during hospitalisation and what needs to happen after discharge. Well written discharge letters prevent miscommunication, missing information and medications errors as well as reduction of hospital workload. It also provides timely follow up to decrease the risk of re-hospitalisation.

The aim of this project is to analyse the documentation of discharge summaries and functional status after hospital admission in discharge letters. Discharge summary template was introduced and made compulsory in all Geriatric wards following first cycle of audit. We then compared data after introduction of discharge summary template.

Methods

Electronic discharge letters were reviewed for all patients discharged from Geriatric Department in July 2019 and results were compared with data from January 2019.

Results

162 patients were discharged in the second cycle of audit. Among these, 18 patients were deceased, and 4 patients had no discharge letters available. Therefore, total number of discharge letters analysed was 140. Please see Table 1 for comparative results on documentation of discharge summaries in discharge letters.

Conclusions

Introduction of the discharge summary template improved the documentation of summaries in discharge letters. Well-written discharge letter ensures the smooth transition for when patients leave the hospital. Therefore, it should be accurate, precise and relevant.

Assessing comfort level with pediatric skin specimens among dermatopathologists and pediatric pathologists: A national cross-sectional survey

BACKGROUND

Cutaneous histopathologic diagnoses in children often differ from those in adults. Depending on practice setting, these specimens may be evaluated by dermatopathologists or pediatric pathologists. We sought to determine whether comfort level with pediatric dermatopathology is associated with prior training, pediatric dermatopathology exposure during fellowship, career duration, or specimen subtype.

METHODS

We surveyed dermatopathologists and pediatric pathologists practicing in the United States. Training and practice variables were evaluated by multivariable regression for association with comfort level.

RESULTS

Of the 156 respondents, 72% were dermatopathologists (response rate 11.6%) and 28% were pediatric pathologists (response rate 9.3%). Dermatopathologists reported higher comfort overall (P < .001); this was also true for inflammatory dermatoses and melanocytic neoplasms (P < .001). Thirty-four percent and 75% of dermatopathologists and pediatric pathologists, respectively, reported lower comfort with pediatric skin specimens than their usual cases. Pediatric pathologists were 28% more likely to refer these cases to colleagues. Among dermatopathologists, dermatology-trained were more comfortable than pathology-trained colleagues interpreting inflammatory dermatoses (P < .001).

CONCLUSIONS

Pathologists' comfort with pediatric dermatopathology varied significantly based upon prior training, career duration, and specimen subtype. These results suggest opportunities for improving education in this domain.

Healthcare workers' knowledge and attitudes towards COVID-19 in Saudi Arabia

OBJECTIVE

The world is facing a devastating challenge in the COVID-19 (coronavirus disease 19) outbreak.  Healthcare workers (HCWs) provide the first line of defense against any disease outbreak. Thus, the present study is designed to assess HCWs' attitudes towards, knowledge of, and awareness of COVID-19.

MATERIALS AND METHODS

A cross-sectional observational study was conducted using an online survey on social media; the participants were 597 adults. The study was conducted from March to April 2020. The questionnaire was randomly administered on Arabic-language social media applications; the 26-item survey assessed knowledge levels, attitudes, and practices.

RESULTS

The analysis includes 597 complete responses from HCWs; participants included physicians, nurses, medical students, and pharmacists. Most participants were females aged 18 to 25 years. Most participants agreed that the virus can spread via direct and indirect contact. Most participants indicated that they wash their hands; avoid touching their eyes, nose, or mouth; and avoid crowded places to protect themselves against infection. Most indicated that a bat was the original source of the virus. Most participating HCWs indicated that the symptoms of COVID-19 include fever, cough, and shortness of breath. Most of the participants also indicated that there is no specific treatment for patients infected with COVID-19.

CONCLUSIONS

The findings of this work can support the design of effective measures to prevent and control COVID-19 infections during the pandemic. The results also highlight where improvement is needed to HCWs' knowledge of and attitudes towards COVID-19; the findings also highlight the best healthcare practices regarding this illness.

A novel fusion based on the evolutionary features for protein fold recognition using support vector machines

Protein fold recognition plays a crucial role in discovering three-dimensional structure of proteins and protein functions. Several approaches have been employed for the prediction of protein folds. Some of these approaches are based on extracting features from protein sequences and using a strong classifier. Feature extraction techniques generally utilize syntactical-based information, evolutionary-based information and physicochemical-based information to extract features. In recent years, finding an efficient technique for integrating discriminate features have been received advancing attention. In this study, we integrate Auto-Cross-Covariance and Separated dimer evolutionary feature extraction methods. The results’ features are scored by Information gain to define and select several discriminated features. According to three benchmark datasets, DD, RDD ,and EDD, the results of the support vector machine show more than 6\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\%$$\end{document}% improvement in accuracy on these benchmark datasets.

Verrucous pilar cysts infected with beta human papillomavirus

Epidermoid cysts with histopathologic features of human papillomavirus (HPV) infection have been previously reported and are commonly termed verrucous cysts. We report a series of eight histopathologically distinct verrucous pilar cysts, distinguished from traditional verrucous epidermoid cysts by trichilemmal keratinization, as well as two verrucous hybrid pilar-epidermoid cysts. These lesions contain characteristic stratified epithelial linings with abrupt transitions to compact eosinophilic keratin, as well as areas of papillomatosis, coarse intracytoplasmic keratohyalin granules, and vacuolar structures suggestive of HPV-induced cytopathic change. HPV-24, a β genus HPV species, was identified by degenerate polymerase chain reaction in DNA extracted from two of the lesions, and the presence of β-HPV E4 protein was confirmed by immunohistochemistry. HPV-60, the HPV species most commonly reported in verrucous epidermoid cysts, was not detected. Verrucous pilar cysts represent histopathologically and potentially etiologically distinct lesions which may be underrecognized.

Skin disease profile of Syrian refugees in Jordan: a field-mission assessment

BACKGROUND

Since the beginning of the Syrian war in 2011, the world has faced the most severe refugee crisis in history and 5.6 million Syrians have sought asylum in neighbouring countries or in Europe. According to recent estimates, more than 650 000 Syrian refugees are displaced in Jordan.

OBJECTIVES

This article aims to assess the demographic characteristics and skin disease profile of Syrian displaced people residing in Al Za'atari camp and in communities in Jordan. Furthermore, the authors discuss the barriers to healthcare provision experienced during field missions.

METHODS

This is a retrospective analysis of medical records collected during three medical missions in Jordan by an international dermatological team. Data on patient age, gender, country of origin and skin disease diagnoses were recorded both in Al Za'atari camp and Jordanian towns near the Syrian border.

RESULTS

A total of 1197 patients were assessed during the field missions, with 67.7% female and 37.1% under the age of 14 years. Dermatitis was the leading dermatological condition in both refugee camp and community healthcare clinics. Infectious diseases were the second most common; however, fungal presentations were more common in the community as opposed to viral in Al Za'atari.

CONCLUSIONS

High dermatitis presentations were likely secondary to the environment, living conditions and lack of access to emollients. Infectious diseases were postulated secondary to poor hygiene and sharing of overcrowded spaces. Barriers to health care included limited pharmacological formulary, difficulty in continuity of care and case referrals due to lack of specialized services. Better access to health care, improvement of living conditions and hygiene, and increased availability of medications including emollients and sunscreens are all interventions that should be carried out to reduce skin disease burden. Our findings should further urge the international community to uphold their commitments and uptake engagement in improving health care for Syrian displaced people.

Therapy for anogenital verrucae in preadolescent children with topical and systemic treatment

BACKGROUND/OBJECTIVES

Anogenital verrucae (AV) are benign, human papillomavirus (HPV)-induced tumors of the anogenital skin and mucosa. Medical therapy for AV in preadolescents has not been well studied. We explore the efficacy and safety profile of sinecatechins 15% ointment and imiquimod 5% cream in the treatment of AV, alone and in combination therapy with other commonly used medications.

METHODS

A single-institution, retrospective review of children under 12 years of age with AV treated with imiquimod 5% cream and sinecatechins 15% ointment was performed. Demographic data, side effects, and outcomes of therapy were recorded for each patient, and overall efficacy was determined.

RESULTS

A total of 37 patients met inclusion criteria. Responses were seen in 8 out of 9 patients treated with sinecatechins 15% ointment (5 full, 3 partial, and 1 no response) and 9 out of 17 patients treated with imiquimod 5% cream (4 full, 5 partial, and 8 no response). Combination therapy with one or more of the following treatments (podophyllin, cimetidine, candida antigen injection, and HPV vaccine) were evaluated, but no combination was objectively superior to the others. No significant difference was found in overall efficacy between sinecatechins and imiquimod. Side effects were mild and limited to irritation and erythema.

CONCLUSIONS

Both imiquimod 5% cream and sinecatechins 15% ointment are moderately effective in the treatment of AV in preadolescent children, with a trend toward greater effectiveness of sinecatechins. Combination therapy with other treatments did not significantly increase the effectiveness of topical therapies. Each modality has a tolerable side effect profile with a low risk of serious complications.

Giant Congenital Melanocytic Nevus Treated With Trametinib

Giant congenital nevi are melanocytic proliferations of the skin that may be complicated by melanoma, neurocutaneous melanocytosis, pain, pruritus, and disfigurement. Current treatment options include surgical resection and medical management of associated symptoms. There is limited efficacy in these modalities. No effective pharmacologic treatments are available for the treatment of these lesions. We present the case of a 7-year-old girl with a giant congenital melanocytic nevus that had an AKAP9-BRAF fusion and was treated with trametinib, which resulted in rapid resolution of the patient's lifelong, intractable pain and pruritus as well as dramatic improvement in the extent of her nevus.

High-risk human papillomavirus in a child with digital pigmented Bowen's disease: Case report and dermoscopic findings

Squamous cell carcinoma in situ, also known as Bowen's disease (BD), is a skin malignancy most commonly seen in middle-aged and elderly adults. Pediatric BD is rare and can be a diagnostic challenge for physicians. Digital BD has largely been associated with human papilloma virus. We report an immunocompetent 11-year-old girl with periungual pigmented BD induced by high-risk human papilloma virus.

Vulvar Nodules: A Rare Presentation of Mastocytosis

BACKGROUND

Mastocytosis is a rare benign disorder characterized by the finding of mast cells in the skin and other organs, occurring in adult as well as pediatric age groups. The cutaneous form is the most common presentation in childhood and is rarely located on the vulva.

CASE

A 9-year-old prepubertal girl presented with bilateral vulvar nodules found incidentally by her pediatrician. Biopsy and histopathologic review confirmed mastocytosis. Her lesions significantly diminished over the following year.

SUMMARY AND CONCLUSION

Mastocytosis should be on the differential for lesions on the vulva in children, in addition to the more common disorders such as condyloma acuminata and molluscum contagiosum. It is a benign condition in children, and conservative, symptomatic management is recommended.

Pernio as the presenting sign of blast crisis in acute lymphoblastic leukemia

A previously healthy 5-year-old girl presented with acute onset of blue toes and red spots on the nose and fingers. The striking nature of these lesions, along with the finding of submandibular lymphadenopathy, prompted further evaluation. Laboratory findings were remarkable for anemia, high transaminase levels, and high blast count. Histopathologic findings were consistent with early pernio. Further examination revealed acute B-cell lymphoblastic leukemia. Treatment of the leukemia led to resolution of the pernio.

Nodal signalling in Xenopus: the role of Xnr5 in left/right asymmetry and heart development

Nodal class TGF-β signalling molecules play essential roles in establishing the vertebrate body plan. In all vertebrates, nodal family members have specific waves of expression required for tissue specification and axis formation. In Xenopus laevis, six nodal genes are expressed before gastrulation, raising the question of whether they have specific roles or act redundantly with each other. Here, we examine the role of Xnr5. We find it acts at the late blastula stage as a mesoderm inducer and repressor of ectodermal gene expression, a role it shares with Vg1. However, unlike Vg1, Xnr5 depletion reduces the expression of the nodal family member xnr1 at the gastrula stage. It is also required for left/right laterality by controlling the expression of the laterality genes xnr1, antivin (lefty) and pitx2 at the tailbud stage. In Xnr5-depleted embryos, the heart field is established normally, but symmetrical reduction in Xnr5 levels causes a severely stunted midline heart, first evidenced by a reduction in cardiac troponin mRNA levels, while left-sided reduction leads to randomization of the left/right axis. This work identifies Xnr5 as the earliest step in the signalling pathway establishing normal heart laterality in Xenopus.

Acral Plexiform Palisaded Encapsulated Neuromas as the Initial Cutaneous Manifestation of Cowden Syndrome

Cowden syndrome (CS) is an autosomal dominant genodermatosis associated with characteristic mucocutaneous findings of facial trichilemmomas, palmoplantar keratoses, sclerotic fibromas, and oral papillomas. Mucocutaneous neuromas have also been reported in association with CS. We describe a patient with CS whose sole cutaneous finding was palisaded encapsulated neuromas (PENs) with a plexiform growth pattern in an acral location. Along with previous reports, this case suggests that acral plexiform PENs may be an early, highly specific finding in CS and highlights the importance of screening these patients for PTEN mutation.

Topical drug-induced subacute cutaneous lupus erythematosus isolated to the hands

Subacute cutaneous lupus erythematosus (SCLE) is a well-defined subtype of lupus erythematosus, characterised by photosensitivity, annular and/or psoriasiform lesions, variable systemic involvement and presence of circulating SSA/anti-Ro antibodies. SCLE may be idiopathic or drug-induced. Both the idiopathic and drug-induced forms of SCLE are analogous in their clinical, serological and histological features. Drug-induced SCLE has been reported with various oral agents, but to our knowledge this is the first reported case due to a topical medication. A 34-year-old female foot masseuse presented with a 2-month history of scaly, erythematous lesions isolated to the dorsal hands and interdigital spaces. She had used topical terbinafine, a topical antifungal cream, to her clients’ feet for a number of years. ANA and anti-SSA/Ro antibodies were positive. Physical examination, serology and histopathology were consistent with SCLE. We propose that our patient's unique presentation of SCLE may be explained by a prolonged occupational exposure to topical terbinafine as a foot masseuse. While oral terbinafine is a drug known to cause drug-induced SCLE, to our knowledge, this is the first topically induced form of the disease.

Generalized granuloma annulare in a folliculocentric distribution

We present a 69-year-old man with type 2 diabetes mellitus and a five-year history of an eruption of follicular pustules, papules, and nodules, which was identified histopathologically as folliculocentric granuloma annulare (GA). Folliculocentric generalized GA is a rarely reported variant of GA, in which the the palisading histiocytes form focal granulomas in a follicular pattern. In this case, the GA may represent an isotopic phenomenon, with lesions developing in hair follicles that were previously affected by a suppurative folliculitis.

Paraneoplastic erythema annulare centrifugum eruption (PEACE)

Erythema annulare centrifugum (EAC) is a reactive erythema with distinct, annular, erythematous plaques with trailing scale. This condition has been associated with various etiologies, which include an associated malignant condition. EAC with cancers or paraneoplastic erythema annulare centrifugum eruptions (PEACE), is more likely to be associated with lymphoproliferative malignancies such as lymphomas and leukemias. Histopathologic features include a superficial and deep, lymphohistiocytic perivascular infiltrate. We present a patient with a history of diffuse large B cell lymphoma in remission for two years, who presented with a one-year history of EAC.

Photodistributed granuloma annulare

Annular elastolytic giant cell granuloma (AEGCG) is a controversial entity that is considered by many to be a variant of granuloma annulare (GA). The majority of cases of AEGCG occur in Caucasian women (3:2) between the ages of 40 and 70, with the distribution of the mostly annular lesions favoring exposed areas of skin and rarely involving covered skin. The most common systemic association has been with diabetes mellitus. We present a 52-year-old woman with an asymptomatic, annular, erythematous, photodistributed eruption of two-years duration. As part of her evaluation, it was detected that she had a hemoglobin A1C of 10.3% and a diagnosis of diabetes mellitus was made. We review the literature on the clinical and histopathologic features of GA and AEGCG and the overlap between these entities.

Acrokeratoelastoidosis

Acrokeratoelastoidosis is a rare palmoplantar keratoderma. We report the case of a 32-year old man with multiple keratotic papules and plaques on the peripheral margins of his hands and feet. Histopathologic evaluation showed compact orthokeratosis; Verhoeff van Gieson stain showed thin and fragmented elastic fibers. The differential diagnosis includes focal acral hyperkeratosis, which has a similar presentation but with normal elastic fibers. Treatment of acrokeratoelastoidosis is often disappointing, with minimal response to topical glucocorticoids, keratolytics, retinoids, cryotherapy, and lasers.

Squamous-cell carcinoma in situ

We present a 30-year-old woman with atopic dermatitis and ichthyosis vulgaris and a one-year history of an erythematous, scaly plaque on the dorsal surface of her right hand, which developed three years after an accidental exposure to prolonged ultraviolet C (UVC) radiation in a laboratory accident. The plaque, which was initially treated as eczematous dermatitis, was eventually identified histopathologically as squamous-cell carcinoma in situ. Although causation is not definitive, this case is the first to describe development of non-melanoma skin cancer (NMSC) in an area of skin known to be acutely exposed to UVC radiation. As UVC radiation becomes a more frequently used anti-microbial technology, UVC radiation may become a more commonly identified risk factor in the development of NMSC.

Eosinophilic dermatitis of hematologic malignancy

Eosinophilic dermatosis of hematologic malignancy is a rare, paraneoplastic phenomenon that presents as a pruritic papular or vesicular eruption that is clinically and histopathologically similar to insect bites. We present a 56-year-old man with multiple relapses of diffuse large B cell lymphoma with a typical presentation of pruritic papules and vesicles on the extremities that correlate with a recent relapse of his lymphoma.

Vesicular erythema migrans: an atypical and easily misdiagnosed form of Lyme disease

Erythema migrans is the initial sign in the majority of patients infected with Borrelia, the genus of spirochetes that causes Lyme disease. Early identification and treatment decrease the risk of progression to later stages of disease. Although a "bull's eye" appearance owing to lesional clearing is considered classic for erythema migrans, this feature is surprisingly often lacking among patients in the United States. Furthermore, cutaneous Lyme disease can exhibit a wide range of morphologic variability in a minority of patients. Herein, we describe the case of a patient with Lyme disease in which the presence of atypical vesicular features, in conjunction with the initial absence of clearing, resulted in multiple misdiagnoses and delayed treatment. We also review the literature on the epidemiology and management of erythema migrans for cases in which the diagnosis may pose a challenge.

Rubisco catalytic properties optimized for present and future climatic conditions

Because of its catalytic inefficiencies, Rubisco is the most obvious target for improvement to enhance the photosynthetic capacity of plants. Two hypotheses are tested in the present work: (1) existing Rubiscos have optimal kinetic properties to maximize photosynthetic carbon assimilation in existing higher plants; (2) current knowledge allows proposal of changes to kinetic properties to make Rubiscos more suited to changed conditions in chloroplasts that are likely to occur with climate change. The catalytic mechanism of Rubisco results in higher catalytic rates of carboxylation being associated with decreased affinity for CO2, so that selection for different environments involves a trade-off between these two properties. The simulations performed in this study confirm that the optimality of Rubisco kinetics depends on the species and the environmental conditions. In particular, environmental drivers affecting the CO2 availability for carboxylation (Cc) or directly shifting the photosynthetic limitations between Rubisco and RuBP regeneration determine to what extend Rubisco kinetics are optimally suited to maximize CO2 assimilation rate. In general, modeled values for optimal kinetic reflect the predominant environmental conditions currently encountered by the species in the field. Under future climatic conditions, photosynthetic CO2 assimilation will be limited by RuBP-regeneration, especially in the absence of water stress, the largest rise in [CO2] and the lowest increases in temperature. Under these conditions, the model predicts that optimal Rubisco should have high Sc/o and low kcat(c).

A 1-year-old boy with persistent, generalized eruption. Urticaria pigmentosa

A healthy 1-year-old boy born at full term after an uncomplicated pregnancy presented to the dermatology clinic for a widespread eruption with gradual onset since 3 months of age. He was otherwise well, afebrile, feeding well, and gaining weight appropriately. The child was overall asymptomatic, though some of his lesions occasionally became red and pruritic. His mother noticed that after mild illnesses, he was more prone to these flares. She denied flushing, vomiting, diarrhea, respiratory distress, and irritability. He was meeting all developmental milestones and started walking at 11 months of age. The remainder of his review of systems was unremarkable, and family history was noncontributory. Physical exam revealed a well-appearing, well-nourished, playful, and interactive toddler. There were innumerable discrete and coalescing pink-brown macules and papules concentrated on the trunk and extending onto the proximal upper and lower extremities bilaterally, as well as the neck and lower face. Stroking the lesions quickly led to development of erythematous edematous wheals. There was no hepatosplenomegaly, and the lymph node exam was unremarkable.

Hydroxycholoroquine-induced hyperpigmentation

A 57-year-old woman with systemic lupus erythematosus and Sjögren syndrome presented with blue-grey hyperpigmentation of the face, upper back, and dorsal aspects of the feet after seven years of therapy with hydroxychloroquine. We present an unusual case of drug-induced hyperpigmentation.