Spontaneous eruptive disseminated lobular capillary haemangioma

Lobular capillary haemangioma (LCH), previously known as pyogenic granuloma, is a benign vascular tumour of the skin or mucosa. We report a patient with spontaneous eruption of LCH, a rare occurrence, which resolved probably due to reverse koebnerisation.

Segmental neurofibromatosis with Lisch nodules

Neurofibromatosis (NF) is an inherited neuroectodermal abnormality that primarily affects the growth of neural tissues, and Riccardi classified it into eight types. Segmental neurofibromatosis, which is a rare form of neurofibromatosis, is classified as type 5. We report a case for very unusual presentation of segmental NF with unilateral lisch nodules and uncommon sites involving the scalp. Moreover, we could find only one case report of segmental NF with lisch nodules in the literature and could not find any case report involving the scalp.

Regulation of human cortical interneuron development by the chromatin remodeling protein CHD2

Mutations in the chromodomain helicase DNA binding protein 2 (CHD2) gene are associated with neurodevelopmental disorders. However, mechanisms by which CHD2 regulates human brain development remain largely uncharacterized. Here, we used a human embryonic stem cell model of cortical interneuron (hcIN) development to elucidate its roles in this process. We identified genome-wide CHD2 binding profiles during hcIN differentiation, defining direct CHD2 targets related to neurogenesis in hcIN progenitors and to neuronal function in hcINs. CHD2 bound sites were frequently coenriched with histone H3 lysine 27 acetylation (H3K27ac) and associated with high gene expression, indicating roles for CHD2 in promoting gene expression during hcIN development. Binding sites for different classes of transcription factors were enriched at CHD2 bound regions during differentiation, suggesting transcription factors that may cooperatively regulate stage-specific gene expression with CHD2. We also demonstrated that CHD2 haploinsufficiency altered CHD2 and H3K27ac coenrichment on chromatin and expression of associated genes, decreasing acetylation and expression of cell cycle genes while increasing acetylation and expression of neuronal genes, to cause precocious differentiation. Together, these data describe CHD2 direct targets and mechanisms by which CHD2 prevents precocious hcIN differentiation, which are likely to be disrupted by pathogenic CHD2 mutation to cause neurodevelopmental disorders.

A descriptive study of onychoscopic features in various subtypes of onychomycosis

Background

The diagnosis of onychomycosis is usually clinical and is confirmed by 40% KOH examination. A diagnostic dilemma occurs when KOH examination is negative despite strong clinical suspicion. Dermoscopic evaluation of the nail is referred to as onychoscopy. We attempted to assess the dermoscopic findings in Onychomycosis positive with KOH examination.

Methods

A cross sectional study was conducted in a tertiary care center including 122 patients with clinical suspicion of onychomycosis with KOH positivity. After assessment of risk factors and gross nail examination, onychoscopic examination was done to identify the presence of the specific features.

Results

Primary findings of onychoscopic examination were 'spiked pattern' in 80.3% subjects, of which 95 were distal lateral subungual onychomycosis (DLSO), 8 of total dystrophic onychomycosis (TDO). True leukonychia was seen in the single patient of proximal subungual onychomycosis (PSO) and pseudoleukonychia in the single patient of white superficial onychomycosis (WSO). Distal irregular termination was observed in 23% of subjects - 8 from DLSO and in all 20 patients of TDO. 'Ruin appearance' was observed in all 20 patients of TDO, 56 patients with DLSO and not seen in other types of onychomycosis (OM). Presence of spiked pattern, Longitudinal striae, Distal irregular termination and Ruin appearance were found to be statistically significant (p < 0.001).

Conclusion

In suspected onychomycosis, specific onychoscopic findings such as Spiked pattern, Longitudinal striae, Ruin appearance and Distal irregular termination can be used as supporting evidence for diagnosing onychomycosis clinically and initiating antifungal therapy if mycological testing is unavailable or negative.

Syphilis D' Emblée: A case series of the great masquerader

Syphilis, a chronic infectious disease caused by Treponema pallidum subspecies pallidum, progresses through three arbitrary stages resulting in varied clinical manifestations. The aberrant presentation of syphilis in the secondary stage without any clinical evidence of the primary stage is referred to as syphilis d’ emblée. Here we report a series of six cases in male patients. Five out of six patients presented with multiple, non-pruritic, macular palmar, and/or plantar lesions. One patient had typical facial and perianal lesions of condyloma lata. The diagnosis was confirmed by a reactive VDRL with titers ranging from 1:16 to 1:64 and a positive Treponema pallidum hemagglutination assay (TPHA). Syphilis being a great imitator can present in different ways without a typical history of primary chancre following sexual exposure, and can mimic many dermatological disorders in its secondary stage. Unless physicians have a high index of suspicion, the diagnosis may be missed. Early identification aids in prompt initiation of therapy and prevention of disease progression to chronic stages and systemic manifestations.

A rare case of disseminated superficial porokeratosis-Case report

Porokeratosis is a keratinization disorder characterized by hyperkeratotic sharply demarcated plaques with central atrophy and histopathologically, by cornoid lamella. A 30-year-old male presented with multiple pruritic dark raised skin lesions over the trunk, face, and upper limbs for past 3 years. Cutaneous examination revealed hyperkeratotic annular plaques with raised margins over face, trunk, and arms. Histopathology revealed marked hyperkeratosis with irregular acanthosis and papillomatosis. Vertical parakeratotic foci and focal hypergranulosis were seen. Hence, a diagnosis of disseminated superficial porokeratosis was made. We present this rare case which may have association with systemic disease, immunosuppression, and malignant transformation.

Lax skin and blurring of vision- A case report of pseudoxanthoma elasticum

Increased laxity of the skin can be caused by aging, significant weight loss, or defects in the elastic tissue. A 38-year-old female presented with increased laxity of the skin over the neck, thighs, and abdomen for 6 years, associated with headache and blurring of vision for a week. On cutaneous examination, prominent skin folds, laxity, and wrinkles were noted over the neck, abdomen, thighs, and groin, with yellowish papules along the neck creases. Ocular examination revealed features suggestive of angioid streaks. Skin biopsy showed fragmented elastic fibers and intervening calcium deposits on Verhoeff Van Gieson and Von Kossa stains. Based on these findings, a diagnosis of pseudoxanthoma elasticum (PXE) was made. The patient was started on oral and topical sunscreens and eye protection and advised regular follow-up. Diagnosing the condition early based on skin findings can help prevent further multi-system manifestations by taking appropriate preventive measures as this condition is progressive and has no cure.

Tuberous xanthoma with cardiac failure in a child

A 14-year-old girl presented with gradually progressive breathlessness for 3 weeks. On evaluation, it was found that she had left ventricular hypertrophy and nonprogressive R wave in ECG. An echocardiogram revealed aortic stenosis and severe left ventricular dysfunction.Computed Tomography (CT) imaging showed aortic annulus calcifications causing aortic stenosis. Over three years she had gradually developed asymptomatic cutaneous swellings over the small and large joints of the extremities suggestive of tuberous xanthomas. Skin biopsy revealed scattered foamy macrophages in the upper dermis and cholesterol clefts. Her lipid profile showed raised total cholesterol and low-density lipoprotein levels. With the above clinical, histological, and laboratory findings she was diagnosed as a case of familial homozygous hypercholesterolemia with tuberous xanthomas and cardiac failure. She was started on statins, ezetimibe, and other anti-failure measures. We present this case for its rarity. Early diagnosis of this condition based on skin findings, could have prevented cardiac failure by initiating early appropriate treatment.

An interesting case of nevus flammeus with loss of vision and hemiparesis

Nevus flammeus is the most common benign congenital capillary malformation, often known as a port-wine stain. Sturge–Weber syndrome (SWS) is a congenital, sporadic, nonfamilial disease characterized by intracranial and ophthalmic vascular anomalies and nevus flammeus. It usually manifests as developmental delay, learning problems, paralysis, seizures, glaucoma and attention deficit, and hyperactivity disorder. A 29-year-old male patient presented with a reddish patch over the face since birth. He was found to have hemihypertrophy of face, hemiparesis of right limbs, and low intelligence quotient. On ophthalmic examination, the patient was found to have glaucoma and only perception of light in the left eye. Computed tomography brain showed atrophy of the left cerebral hemisphere and calcifications in the left frontal, parietal and occipital regions. With these findings, he was diagnosed as SWS type I. A multidisciplinary approach was followed for patient evaluation and management. This case also highlights the irreversible sequelae of this rare phacomatosis.

A descriptive study of the clinical and etiological profile of balanoposthitis

Background:

Balanoposthitis is defined as an inflammatory condition of glans penis and prepuce. There are wide variety of etiologies including both infectious and noninfectious conditions. This study attempts to throw light on information regarding clinical and microbiological aspects of balanoposthitis.

Objectives:

To study various clinical patterns, etiologies, and predisposing factors of balanoposthitis.

Methodology:

A descriptive study was undertaken on 106 cases who presented to sexually transmitted disease (STD) clinic with balanoposthitis between November 2017 and April 2019. A detailed history, physical examination, and investigations like KOH mount, leishman staining, gram staining, dark field microscopy, cultures, and other investigations were done wherever indicated. The data collected was tabulated and analyzed.

Results:

In our study, infectious etiology was the most common and was found in 77.36% cases. About 13.41% of cases with infectious balanoposthitis had multiple etiological agents. Noninfectious etiology was found in 22.64% cases. The most common infectious cause of balanoposthitis was candida, noted in 59.76% cases, followed by herpes simplex virus (19.51%), human papilloma virus (13.41%), and scabies (8.54%). Among noninfectious etiologies, adverse drug reaction (4.72% of total cases) was the most common, followed by lichen planus (3.77%) and psoriasis (3.77%). There was significantly higher incidence of phimosis in diabetic patients with candidal balanoposthitis.

Conclusion:

Identifying the etiology facilitates early treatment and hence reduces the infectivity and transmission of disease and also the disease complications like phimosis. In addition, multiple infectious etiologies should always be kept in mind while evaluating STDs.

Decrease in "Hamilton Rating Scale for Depression" Following Isotretinoin Therapy in Acne: An Open-Label Prospective Study

Background:

Acne is a common disorder among adolescents and young adults causing a considerable psychological impact including anxiety and depression. Isotretinoin, a synthetic oral retinoid is very effective in the treatment of moderate to severe acne. But there have been many reports linking isotretinoin to depression and suicide though no clear proof of association has been established so far.

Objective:

To determine whether oral isotretinoin increases the risk of depression in patients with moderate to severe acne.

Materials and Methods:

One hundred and fifty patients with moderate to severe acne were treated with oral isotretinoin 0.5 mg/kg/day for a period of 3 months. Their acne and depression scoring was done at baseline and then every month for the first 3 months and then at 6 months.

Results:

We found that the acne scoring reduced from 3.11 ± 0.49 to 0.65 ± 0.62 (P = < 0.001) at the end of 3 months. Also, the depression scoring decreased significantly from 3.89 ± 4.9 at the beginning of study to 0.45 ± 1.12 (P < 0.001) at the end of 3 months. Both the acne and depression scores continued to remain low at the end of 6 months at 0.5 ± 0.52 (P = < 0.001) and 0.18 ± 0.51 (P = < 0.001), respectively.

Conclusions:

Our study proves that oral isotretinoin causes significant clearance of acne lesions. It causes significant reduction in depression scores and is not associated with an increased incidence of depression or suicidal tendencies.

Autosomal dominant hearing loss resulting from p.R75Q mutation in the GJB2 gene: nonsyndromic presentation in a South Indian family

Mutations in the GJB2 gene encoding the gap junction protein Connexin 26 have been associated with autosomal recessive as well as dominant nonsyndromic hearing loss. Owing to the involvement of connexins in skin homeostasis, GJB2 mutations have also been associated with syndromic forms of hearing loss showing various skin manifestations. We report an assortatively mating hearing impaired family of south Indian origin with three affected members spread over two generations, having p.R75Q mutation in the GJB2 gene in the heterozygous condition. The inheritance pattern was autosomal dominant with mother and son being affected. Dermatological and histopathologic examinations showed absence of palmoplantar keratoderma. To the best of our knowledge, this is the first report from India on p.R75Q mutation in the GJB2 gene with nonsyndromic hearing loss.

Squamous cell carcinoma of penis with bullous pemphigoid masquerading as lymphogranuloma venereum

We report a case of a 60-year old unmarried male who presented with multiple ulcers and foul smelling discharge from the groin since 4 months and multiple tense bullae over the trunk of 1 month duration. Groove sign was present. Investigations for lymphogranuloma venereum (LGV) and other sexually transmitted diseases were negative. Histopathology from the ulcer in the groin and growth in the penis revealed squamous cell carcinoma (SCC). Skin biopsy of bulla was diagnostic of bullous pemphigoid (BP). We report a rare case of SCC masquerading as LGV with BP occurring as a paraneoplastic phenomenon.

Woolly hair nevus: a rare entity

Woolly hair nevus is a rare non-hereditary focal condition characterized by unruly and tightly coiled hair. It can appear in childhood or adolescence and may be associated with epidermal or melanocytic nevus. Patients presenting with woolly hair must be examined completely to rule out cardiofaciocutaneous and Noonan syndrome.

Venlafaxine induces P-glycoprotein in human Caco-2 cells

PURPOSE

The objective of this study was to evaluate the effect of a treatment with venlafaxine on the expression of multidrug resistance-associated protein (MRP) gene and multidrug resistance-related proteins (MDR) in human colon carcinoma cells (Caco-2) compared to a known P-glycoprotein (PGY1) inducer, rifampine.

METHODS

Caco-2 cells were treated with venlafaxine (50 microM, 100 microM, 250 microM, and 500 microM) and rifampin (25 microM and 50 microM) to test the possible induction of MRP and MDR expression. The treatment times used were 1.5, 3, 6, 12, 24, 48, and 72 h. RNA was isolated from the cells, and MDR and MRP genes were amplified using PCR.

RESULTS

Both venlafaxine and rifampine had the most dramatic effect at the 50 microM concentration. There was an increase in MDR and MRP expression in Caco-2 cells after the acute treatment (1.5, 3, and 6 h) with venlafaxine. These results were similar to those with rifampine.

CONCLUSIONS

PGY1 contributes to renal and biliary elimination of drugs by transporting the drug out of the cell and back into the intestinal lumen, where drugs may be further metabolized by intestinal enzymes such as Cytochrome P (CYP)-450 3A4. Its function is to limit the bioavailability of orally administered compounds. Due to the increase in MDR and MRP gene expression seen after the acute treatment with venlafaxine, there could be a potential drug-drug interaction with other medications that are metabolized via CYP450-3A4 when coadministered with venlafaxine.

Treatment-refractory depression: definitions and characteristics

Forty to 50% of depressed patients who are initially prescribed antidepressant medications or administered electroconvulsive therapy do not experience a timely remission. This group typifies treatment-refractory depression (TRD), defined as a failure to demonstrate an "adequate" response to an "adequate" treatment trial (i.e., sufficient intensity of treatment for sufficient duration). The approach to the patient with TRD must be methodical. The clinician should examine potential factors contributing to apparent non-response: trial adequacy, compliance, differential diagnosis, and treatable comorbid conditions. After addressing these variables, a patient who does not demonstrate a remission may be considered treatment resistant (relative or absolute). Although many of these patients will respond to a subsequent treatment regimen, there are no (or only nominally useful) predictors for the initial selection of that "subsequent" antidepressant treatment. Hence, the initial treatment is typically chosen on the basis of safety and convenience, not differential efficacy. The search for the clinical and biological correlates of long-term or acute outcome presents a major nosologic conundrum: Who will respond to treatment? Which treatment? In this manner, TRD challenges the prognostic utility of our current phenomenologic-based diagnostic system.

A randomized clinical trial of repetitive transcranial magnetic stimulation in the treatment of major depression

BACKGROUND

Multiple groups have reported on the use of repetitive transcranial magnetic stimulation (rTMS) in treatment-resistant major depression. The purpose of this study is to assess the efficacy of rTMS in unmedicated, treatment-resistant patients who meet criteria for major depression.

METHODS

Depressed subjects, who had failed to respond to a median of four treatment trials, were assigned in a randomized double-blind manner to receive either active (n = 10; 20 2-sec trains of 20 Hz stimulation with 58-sec intervals; delivered at 80% motor threshold with the figure-of-eight coil positioned over the left dorsolateral prefrontal cortex) or sham (n = 10; similar conditions with the coil elevated and angled 45 degrees tangentially to the scalp) rTMS. These sequences were applied during 10 consecutive weekdays. Continuous electroencephalogram sampling and daily motor threshold determinations were also obtained.

RESULTS

The group mean 25-item Hamilton Depression Rating Scale (HDRS) score was 37.2 (+/- 2.0 SEM) points. Adjusted mean decreases in HDRS scores were 14.0 (+/- 3.7) and 0.2 (+/- 4.1) points for the active and control groups, respectively (p <.05). One of 10 subjects receiving active treatment demonstrated a robust response (i.e., HDRS decreased from 47 to 7 points); three other patients demonstrated 40-45% decreases in HDRS scores. No patients receiving sham treatment demonstrated partial or full responses.

CONCLUSIONS

A 2-week course of active rTMS resulted in statistically significant but clinically modest reductions of depressive symptoms, as compared to sham rTMS in a population characterized by treatment resistance.

Transient depressive relapse induced by catecholamine depletion: potential phenotypic vulnerability marker?

BACKGROUND

Although state-related alterations in catecholamine function have been well-described in depressed subjects, enduring abnormalities have been less reliably identified. In our study, medication-free subjects with fully remitted major depression underwent a paradigm of catecholamine depletion, via use of the tyrosine hydroxylase inhibitor alpha-methylparatyrosine.

METHOD

Subjects underwent 2 sets of testing conditions in a double-blind, random-ordered, crossover design, approximately 1 week apart. They underwent active catecholamine depletion (via oral administration of 5 g alpha-methylparatyrosine) or sedation-controlled, sham catecholamine depletion (via oral administration of 250 mg diphenhydramine hydrochloride), during a 2-day observation. Serial mood ratings and blood samples were obtained.

RESULTS

Fourteen subjects completed the active testing condition; 13 completed sham testing. Subjects experienced marked, transient increases in core depressive and anxiety symptoms, as demonstrated by a mean 21-point increase on Hamilton Depression Rating Scale scores. Furthermore, 10 (71%) of 14 subjects fulfilled relapse criteria during active testing, whereas 1 (8%) of 13 subjects did so during sham testing. The severity of the depressive reaction correlated with baseline plasma cortisol levels (r = 0.59; P =.04).

CONCLUSIONS

Euthymic, medication-free subjects with a history of major depression demonstrate significant depressive symptoms when undergoing testing with alpha-methylparatyrosine. This depressive reaction may represent a reliable marker for a history of depression. Further work is needed to clarify the significance of this finding.

Carbohydrate binding and resistance to proteolysis control insecticidal activity of Griffonia simplicifolia lectin II

Griffonia simplicifolia leaf lectin II (GSII), a plant defense protein against certain insects, consists of an N-acetylglucosamine (GlcNAc)-binding large subunit with a small subunit having sequence homology to class III chitinases. Much of the insecticidal activity of GSII is attributable to the large lectin subunit, because bacterially expressed recombinant large subunit (rGSII) inhibited growth and development of the cowpea bruchid, Callosobruchus maculatus (F). Site-specific mutations were introduced into rGSII to generate proteins with altered GlcNAc binding, and the different rGSII proteins were evaluated for insecticidal activity when added to the diet of the cowpea bruchid. At pH 5.5, close to the physiological pH of the cowpea bruchid midgut lumen, rGSII recombinant proteins were categorized as having high (rGSII, rGSII-Y134F, and rGSII-N196D mutant proteins), low (rGSII-N136D), or no (rGSII-D88N, rGSII-Y134G, rGSII-Y134D, and rGSII-N136Q) GlcNAc-binding activity. Insecticidal activity of the recombinant proteins correlated with their GlcNAc-binding activity. Furthermore, insecticidal activity correlated with the resistance to proteolytic degradation by cowpea bruchid midgut extracts and with GlcNAc-specific binding to the insect digestive tract. Together, these results establish that insecticidal activity of GSII is functionally linked to carbohydrate binding, presumably to the midgut epithelium or the peritrophic matrix, and to biochemical stability of the protein to digestive proteolysis.

Adhesion molecules (E-selectin and ICAM-1) in pulmonary allograft rejection

Vascular endothelial cells act as antigen-presenting cells in the lung allograft and stimulate alloreactive host lymphocytes. Activated lymphocytes and cytokines can induce expression of leukocyte-endothelial adhesion molecules that facilitate invasion of the allograft by circulating leukocytes. To define the role of endothelial HLA class II antigen and adhesion molecule expression in lung allograft rejection, we prospectively analyzed endothelial expression of HLA class II, E-selectin, and intercellular adhesion molecule-1 (ICAM-1) antigens in 52 transbronchial biopsy specimens from 24 lung allograft recipients as compared to normal control subjects. Thirty-one of 52 specimens showed histologic rejection and 8 of 24 patients developed histologic obliterative bronchiolitis (OB) by the end of the study period. Increased expression of HLA class II antigen was seen in 32 of 52 (62%) lung allograft specimens, but increased expression did not correlate with acute rejection or OB. In contrast, E-selectin expression was seen in 30 of 52 (58%) biopsy specimens and was associated with acute rejection (p < 0.005) and with the development of OB (p < 0.05). Increased expression of ICAM-1 was seen in only 18 of 52 (35%) biopsy specimens and did not correlate with acute rejection or OB. These data suggest that E-selectin expression may be a tissue marker of acute and chronic lung rejection possibly by promoting leukocyte adhesion to the allograft endothelium. The high levels of endothelial HLA class II expression may reflect long-term antigenic stimulation of the allograft even in the absence of rejection.

A NaCl-regulated plant gene encoding a brain protein homology that activates ADP ribosyltransferase and inhibits protein kinase C

A cDNA clone pCZ1, with a 1.1 kb insert, was isolated from a NaCl-adapted tobacco cell cDNA library that encodes an apparently full-length 29 kDa protein (251 amino acids) with a calculated pI of 5.7. The encoded peptide had a high amino acid sequence identity with bovine 14-3-3 protein which was originally found as an abundant protein in the animal central nervous system. Recently, proteins with sequence identity to 14-3-3 protein have also been found in plants, insects and yeast, and appear to have diverse physiological functions. Similar to the bovine brain 14-3-3 protein, the recombinant pCZ1 protein stimulated ADP-ribosylation of protein substrate by ADP-ribosyltransferase from the plant and animal pathogenic bacterium Pseudomonas aeruginosa. This recombinant protein also inhibited protein kinase C activity in vitro. Southern blot analyses indicated that most likely five genes encoding 14-3-3-like proteins are present in tobacco. The pCZ1 cDNA insert hybridized to a single mRNA of 1.1 kb from cultured tobacco cells. The level of this mRNA transcript in tobacco cells was downregulated upon adaptation to NaCl but was unaffected by short-term treatment with NaCl, ABA or ethylene. In tobacco plants, expression of transcript that hybridized to pCZ1 was tissue specific, and was most abundant in roots and flower parts. Monoclonal antibody raised against GF14 protein, a maize protein with substantial sequence identity with 14-3-3 protein detected two bands on SDS-PAGE of total proteins from unadapted tobacco cells and only a single band from cells adapted to NaCl. The GF14 antibody was also used to illustrate that the G-box element of a salt-induced gene is associated with a 14-3-3-type protein.

Derived amino acid sequence and identification of active site residues of Escherichia coli beta-hydroxydecanoyl thioester dehydrase

The nucleotide sequence of the fabA gene encoding beta-hydroxydecanoyl thioester dehydrase, a key enzyme of the unsaturated fatty acid synthesis pathway of Escherichia coli, has been determined by the dideoxynucleotide sequencing technique. Most of the sequence was obtained by sequencing intragenic insertions of the transposon, Tn1000, isolated in vivo. A synthetic primer complementary to a portion of the inverted repeat sequences at the ends of the transposon was used to prime DNA synthesis into the flanking fabA sequences. The gene is composed of 516 nucleotides (171 amino acid residues) encoding a protein with a molecular weight of 18,800. Approximately half of the derived amino acid sequence was confirmed by automated Edman sequencing of peptides obtained by cyanogen bromide cleavage. The active site histidine residue (His-70) has been identified by analysis of the peptides labeled by reaction with 14C-labeled 3-decynoyl-N-acetylcysteamine, a specific mechanism-activated inhibitor. A cysteine residue (Cys-69) adjacent to the active site histidine may play the role in catalysis previously assigned to a tyrosine residue. We also report a simplified purification process for the dehydrase beginning with extracts of a brain which greatly overproduces the enzyme.