Nicotinamide for Skin-Cancer Chemoprevention in Transplant Recipients

BACKGROUND

Immunosuppressed organ-transplant recipients have an increased incidence of, and mortality from, skin cancer. Nicotinamide (vitamin B3) enhances the repair of ultraviolet (UV) radiation-induced DNA damage, reduces the cutaneous immunosuppressive effects of UV radiation, and reduces the incidence of keratinocyte cancers (including squamous-cell and basal-cell carcinomas) and actinic keratoses among high-risk immunocompetent patients. Whether oral nicotinamide is useful for skin-cancer chemoprevention in organ-transplant recipients is unclear.

METHODS

In this phase 3 trial, we randomly assigned, in a 1:1 ratio, organ-transplant recipients who had had at least two keratinocyte cancers in the past 5 years to receive 500 mg of nicotinamide or placebo twice daily for 12 months. Participants were examined for skin lesions by dermatologists at 3-month intervals for 12 months. The primary end point was the number of new keratinocyte cancers during the 12-month intervention period. Secondary end points included the numbers of squamous-cell and basal-cell carcinomas during the 12-month intervention period, the number of actinic keratoses until 6 months after randomization, safety, and quality of life.

RESULTS

A total of 158 participants were enrolled, with 79 assigned to the nicotinamide group and 79 to the placebo group. The trial was stopped early owing to poor recruitment. At 12 months, there were 207 new keratinocyte cancers in the nicotinamide group and 210 in the placebo group (rate ratio, 1.0; 95% confidence interval, 0.8 to 1.3; P = 0.96). No significant between-group differences in squamous-cell and basal-cell carcinoma counts, actinic keratosis counts, or quality-of-life scores were observed. Adverse events and changes in blood or urine laboratory variables were similar in the two groups.

CONCLUSIONS

In this 12-month, placebo-controlled trial, oral nicotinamide therapy did not lead to lower numbers of keratinocyte cancers or actinic keratoses in immunosuppressed solid-organ transplant recipients. (Funded by the National Health and Medical Research Council; ONTRANS Australian New Zealand Clinical Trials Registry number, ACTRN12617000599370.).

Study protocol: Australasian Registry of Severe Cutaneous Adverse Reactions (AUS-SCAR)

INTRODUCTION

Severe cutaneous adverse reactions (SCAR) are a group of T cell-mediated hypersensitivities associated with significant morbidity, mortality and hospital costs. Clinical phenotypes include Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS) and acute generalised exanthematous pustulosis (AGEP). In this Australasian, multicentre, prospective registry, we plan to examine the clinical presentation, drug causality, genomic predictors, potential diagnostic approaches, treatments and long-term outcomes of SCAR in Australia and New Zealand.

METHODS AND ANALYSIS

Adult and adolescent patients with SCAR including SJS, TEN, DRESS, AGEP and another T cell-mediated hypersensitivity, generalised bullous fixed drug eruption, will be prospectively recruited. A waiver of consent has been granted for some sites to retrospectively include cases which result in early mortality. DNA will be collected for all prospective cases. Blood, blister fluid and skin biopsy sampling is optional and subject to patient consent and site capacity. To develop culprit drug identification and prevention, genomic testing will be performed to confirm human leukocyte antigen (HLA) type and ex vivo testing will be performed via interferon-γ release enzyme linked immunospot assay using collected peripheral blood mononuclear cells. The long-term outcomes of SCAR will be investigated with a 12-month quality of life survey and examination of prescribing and mortality data.

ETHICS AND DISSEMINATION

This study was reviewed and approved by the Austin Health Human Research Ethics Committee (HREC/50791/Austin-19). Results will be published in peer-reviewed journals and presented at relevant conferences.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12619000241134).

Upper airway involvement in Stevens-Johnson syndrome and toxic epidermal necrolysis

BACKGROUND

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare life-threatening hypersensitivity conditions associated with epidermal detachment and mucositis. The indication for flexible nasoendoscopy (FNE) and overall predictive factors for early intubation are unclear.

OBJECTIVES

To describe the incidence of airway involvement and the key indicators for intubation in our SJS or TEN patient cohort. To determine the association between FNE findings and early intubation.

METHODS

A retrospective review of 45 patients with biopsy proven SJS or TEN admitted to an Australian tertiary burns centre from 2010 to 2017.

RESULTS

Thirty-five patients were diagnosed with TEN (77.8%), followed by overlap syndrome (SJS-TEN) (n = 6, 13.3%) and SJS (n = 4, 8.9%). Twenty (44.4%) patients were intubated; and all 20 had a diagnosis of TEN (100.0%) (p < 0.05). Intubated patients had a higher increase in total body surface area percentage(%) from day 1-3 [10.0% (IQR 0.0-23.8%)] and a longer length of stay [26.0 days (IQR 12.5-34.0)], compared to non-intubated patients [0.0% (IQR 0.0-4.0%)], [10.0 days (IQR 6.0-14.0)] (p < 0.05) respectively. The main indications for intubation were to facilitate operative and dressing management (47.4%) followed by airway involvement (26.3%). FNE was performed on 32 patients (71.1%), however FNE findings did not significantly influence intubation rates.

CONCLUSION

More than half (n = 20, 57.1%) of the 35 patients diagnosed with TEN underwent intubation, mainly to facilitate operative and dressing management. FNE was performed on most patients, however there was no clear association between FNE findings and early intubation.

Disseminated cutaneous-only histoplasmosis in a patient with AIDS

Histoplasmosis is an opportunistic fungal infection that occurs predominantly in immunocompromised patients. Cutaneous lesions in histoplasmosis are rare and typically occur in the absence of extra-cutaneous manifestations. We present a rare case of disseminated cutaneous-only histoplasmosis in a patient with recently diagnosed AIDS.

High resolution gamma-ray spectrometer with MHz capabilities for runaway electron studies at ASDEX Upgrade

A new gamma-ray spectrometer with MHz capabilities has been developed to measure the bremsstrahlung emission spectrum in the gamma-ray energy band generated by MeV range runaway electrons in disruption experiments at ASDEX Upgrade. Properties of the runaway electrons are inferred from the measured bremsstrahlung spectrum by a deconvolution technique, particularly with regard to their maximum energy. Changes induced to the runaway electron velocity space are unambiguously observed both in massive gas injection and resonant magnetic perturbation experiments with the detector.

A systematic review of the management and outcome of toxic epidermal necrolysis treated in burns centres

INTRODUCTION

Toxic epidermal necrolysis (TEN) is a rare condition characterised by mucocutaneous exfoliation of greater than 30% total body surface area (%TBSA), increasingly being treated in burns centres. The rate of mortality varies significantly in the literature, with recent prospective studies in non-burns centres reporting percentage mortality of approximately 45%. We undertook a systematic review of published studies that included TEN patients treated specifically in burns centres to determine a cumulative mortality rate.

METHODS

Electronic searches of MEDLINE, EMBASE and The Cochrane Library (Issue 4, 2010) databases from 1966 onwards were used to identify English articles related to the treatment of TEN in burns centres.

RESULTS

The systematic literature search identified 20 studies which specifically described patients with TEN grater than 30% %TBSA. Treatment regimens varied amongst studies, as did mortality. The overall percentage mortality of the combined populations was 30%. Risk factors commonly described as associated with mortality included age, %TBSA and delay to definitive treatment.

CONCLUSION

The review highlights the variation between principles of treatment and mortality amongst burns centres. It offers a standard that burns centre can use to internationally compare their mortality rates. The review supports the ongoing reporting of outcomes in TEN patients with epidermal detachment greater than 30%.

Spontaneous cutaneous endometriosis of the umbilicus

Cutaneous endometriosis that arises de novo, without a prior history of surgery, is a rare phenomenon. The clinical diagnosis of cutaneous endometriosis remains challenging due to the variable clinical appearance and symptoms of the condition, and therefore must be considered in the differential diagnosis of any umbilical lesion. We report a 31-year-old woman who presented with spontaneous cutaneous endometriosis of the umbilicus.

Mortality and use of the auxiliary score in extensive toxic epidermal necrolysis patients admitted to an adult burns referral centre

BACKGROUND

Toxic epidermal necrolysis (TEN) is a rare but fatal condition characterised by cutaneous exfoliation of the dermoepidermal layer and mucosal surfaces. Extensive TEN with epidermal detachment >30% of the total body surface area has been associated with a high mortality.

OBJECTIVE

This study aims to evaluate factors associated with mortality in extensive TEN. In the absence of data to qualify scoring systems such as SCORTEN, this study also aims to evaluate the use of the auxiliary score as a tool for calculating expected mortality.

METHODS

A retrospective chart review of all patients presenting to our burns service with extensive TEN was undertaken. Application and evaluation of the auxiliary score was also undertaken for this patient population.

RESULTS

In extensive TEN, age and delay in admission to a burns centre were factors associated with mortality. Applying the auxiliary score to our patient population, there were no significant differences between expected mortality and observed mortality.

CONCLUSION

Mortality was associated with age and delay in definitive treatment in extensive TEN. Whilst SCORTEN is the gold standard prognostic tool for patients with TEN, in the absence of SCORTEN values, the auxiliary score provides an alternative scoring system to evaluate expected mortality.

Leukaemia cutis in chronic lymphocytic leukaemia following varicella zoster virus reactivation

We report a case of a 75-year-old male with indolent chronic lymphocytic leukaemia (CLL) for 8 years, who presented with a 6-month history of a painful, zosteriform eruption in a T3-4 distribution that evolved into an unusual crop of papular nodules. Upon biopsy and immunostaining of these lesions CLL was proven consistent with leukaemia cutis related to varicella-zoster virus reactivation. In the absence of other treatment indices, he was commenced on chlorambucil with successful resolution of both his pain and the lesions.

Metoprolol-induced psoriatic nail disease

We describe the development of psoriatic nail disease due to metoprolol in a 58-year-old woman who was being treated for cardiac arrhythmias. The nail condition was unresponsive to topical and systemic treatments but resolved completely with the withdrawal of metoprolol. The reaction recurred with drug rechallenge and resolved when the drug was ceased.

Balamuthia mandrillaris brain abscess successfully treated with complete surgical excision and prolonged combination antimicrobial therapy

Amoebic encephalitis is an uncommon and usually fatal condition. This case describes successful treatment of a Balamuthia mandrillaris brain abscess using prolonged antimicrobial agents with complete excision. It illustrates the risk of dissemination from cutaneous to cerebral amoebic lesions, potential progression with corticosteroid therapy, and the prospect for curative excision.

Energy resolution of gamma-ray spectroscopy of JET plasmas with a LaBr3 scintillator detector and digital data acquisition

A new high efficiency, high resolution, fast γ-ray spectrometer was recently installed at the JET tokamak. The spectrometer is based on a LaBr3(Ce) scintillator coupled to a photomultiplier tube. A digital data acquisition system is used to allow spectrometry with event rates in excess of 1 MHz expected in future JET DT plasmas. However, at the lower rates typical of present day experiments, digitization can degrade the energy resolution of the system, depending on the algorithms used for extracting pulse height information from the digitized pulses. In this paper, the digital and analog spectrometry methods were compared for different experimental conditions. An algorithm based on pulse shape fitting was developed, providing energy resolution equivalent to the traditional analog spectrometry method.

Palifermin-induced acral erythrodysaesthesia variant in the treatment of acute myeloid leukaemia

The recombinant human keratinocyte growth factor, palifermin, offers a potential means of reducing or preventing mucositis in patient undergoing intensive cancer treatments. This case report details the development of acral erythrodysaesthesia in one patient who underwent palifermin treatment prior to high-intensity re-induction chemotherapy for acute myeloid leukaemia.

Sweet's syndrome associated with cellulitis

A 38-year-old woman developed an acute, painful cutaneous eruption on her lower legs, neck, chest and fingers while receiving a number of oral and intravenous antibiotics for left leg cellulitis caused by trauma. Clinically and histopathologically, she was diagnosed with Sweet's syndrome with typical pseudovesicular skin changes in conjunction with erythema nodosum-like lesions on her lower legs. She responded quickly to oral prednisolone. We propose Staphylococcal cellulitis as a cause of Sweet's syndrome.

Severe toxic epidermal necrolysis precipitated by amphetamine use

A 48-year-old man presented with a maculopapular truncal rash 9 days following intravenous amphetamine use. He subsequently developed widespread bullae over his trunk and upper limbs. Treatment was initially commenced with intravenous hydrocortisone. A diagnosis of toxic epidermal necrolysis was made and the treatment was changed to intravenous immunoglobulin at a lower dose than requested. At the height of the reaction, there was 90% body surface area involvement with tri-mucosal involvement. His response to the intravenous immunoglobulin was poor and was complicated by infection with methicillin-resistant Staphylococcus aureus, Candida albicans and Pseudomonas aeruginosa. Gradual re-epithelialization took place over the next 6 weeks.

Multiple periungual pyogenic granulomas following systemic 5-fluorouracil

A 65-year-old man presented with a 7-month history of eight bleeding periungual lesions on both feet. The clinical diagnosis of multiple pyogenic granulomas was confirmed by histological examination. Historically, the pyogenic granulomas appeared 3 months after commencing 5-fluorouracil chemotherapy for rectal carcinoma, suggesting a possible causative relationship. Chemotherapy was ceased by the supervising oncologist. Resolution occurred after two lesions had been treated with curettage and diathermy, and the remaining lesions with occlusive dressings over Kenacomb ointment (triamcinolone acetonide 0.1%, neomycin sulphate 0.25%, gramicidin 0.025%, nystatin 100,000 U/g) topically twice daily for a period of 3 months.

Bowel-associated dermatosis-arthritis syndrome

A 48-year-old woman, who had undergone reversal of a jejunal loop, presented with skin eruptions, myalgia and arthralgia. Delayed gastric emptying was associated with a gastric phytobezoar. The clinicopathological features and response to therapy were typical of the dermatosis-arthritis syndrome, and probably were related to bacterial overgrowth.