Comparative Efficacy of Intralesional Chloroquine With Intralesional Meglumine Antimoniate in the Treatment of Cutaneous Leishmaniasis

BACKGROUND AND AIM

This comparative prospective study was conducted at the Department of Dermatology, Pak Emirates Military Hospital, Rawalpindi, from August 1, 2018, to January 31, 2019 (six months). This study aimed to compare the efficacy of intralesional chloroquine with intralesional meglumine antimoniate in the treatment of cutaneous leishmaniasis.

MATERIALS AND METHODS

A total of 64 patients fulfilling the inclusion criteria reporting to the Department of Dermatology, Pak Emirates Military Hospital were included in this study. Informed consent was taken and demographic data including patients' hospital registration number, age, gender, and number of lesions were noted. The subjects were randomly assigned into two groups. In group A, intralesional chloroquine was injected two times per week, and in group B, intralesional meglumine antimoniate was injected two times per week. The efficacy of both treatments was noted after eight weeks of treatment. Frequency and percentages were computed for qualitative variables like gender and number of lesions. Mean±standard deviation was presented for quantitative variables like age. Analysis was done to compare the proportion of both groups. Chi-square test was applied to compare the efficacy of both groups, p≤0.05 was taken as significant.

RESULTS

In this study, the mean age of patients was 29.69±08.95 years. There were 63 (98.44%) males and one (1.56%) female. In this study, efficacy was achieved in six (18.8%) patients in group A, while in 17 (53.1%) patients in group B. This difference was statistically significant, i.e., p=0.004.

CONCLUSION

This study concluded that intralesional meglumine antimoniate is more effective in treating cutaneous leishmaniasis than intralesional chloroquine.

Comparative analysis of the severity and progression of cutaneous leishmaniasis caused by Leishmania tropica in untreated and glucantime-treated patients

Millions of people worldwide are affected by cutaneous leishmaniasis (CL), a disease that has a significant impact on morbidity and mortality. Understanding the immune responses responsible for tissue damage or the process of lesion healing plays a pivotal role in shaping optimal treatment strategies. In this study, we investigated immunological phenotypes for three groups: glucantime treated (n = 30) and untreated (n = 30) CL patients infected with Leishmania tropica (L. tropica), and healthy controls (n = 20). T-lymphocytes (CD4+ and CD8+), and B lymphocytes (CD14+ and CD19+) were isolated using antibody-conjugated microbeads and magnetic field isolation to achieve high purity. A higher significant difference was observed between T-lymphocytes (CD4+ and CD8+), and B-lymphocytes (CD14+ and CD19+) cells in CL-infected groups before and after treatment (p < 0.0001). When compared, there was also a significant difference among T-lymphocytes (CD4+ and CD8+), B lymphocytes (CD14+ and CD19+) p < 0.0001, p < 0.0005, and p < 0.0007, respectively between CL-infected individuals (before and after treatment) to controls. Our findings suggest that an increased proportion of these cells seen in treated patients may mediate healing, while it is also possible that they may contribute to tissue injury. Understanding the immune system and lesion size of CL can help develop immunotherapies and comprehend the evolution of this parasitic disease.

Multiparametric approach to assess the disease severity and progression of cutaneous leishmaniasis infection

The pathophysiology of Cutaneous Leishmaniasis (CL), an infection caused by Leishmania tropica (L. tropica) and Leishmania major (L. major) is primarily determined by inflammation-mediated immune cells. The immune response mainly depends on cells and molecules related to T-cells that influence susceptibility and disease development. Understanding the immunological mechanisms that cause tissue injury or lesion healing is critical for developing appropriate treatment strategies. In the present study, T-cells profile and cell-free mitochondrial DNA (CF mt-DNA) were investigated in CL patients infected with L. tropica (n = 34) and L. major (n = 2) and compared with non-infected healthy controls (n = 20). There was a significant (p<0.0001) difference between CD4+ T-cells among L. tropica and L. major CL-infected groups as compared to control while no significant difference (p = 0.8597) was found in the percentages of CD8+ T-cells. When L. tropica and L. major CL-infected individuals were compared to controls, the levels of IL-4 and expression of CF mt-DNA were significantly higher (p<0.0001). Higher levels of CF mt-DNA were detected in CL patients, irrespective of the infective Leishmania species. We proposed that the levels of CF mt-DNA and IL-4 in CL-infected individuals can be used to determine the disease progression. A better understanding of these biomarkers and evaluation of the immune responses in CL patients might benefit the development of vaccines and immunotherapies.

Search for Subsolar-Mass Binaries in the First Half of Advanced LIGO's and Advanced Virgo's Third Observing Run

We report on a search for compact binary coalescences where at least one binary component has a mass between 0.2  M_{⊙} and 1.0  M_{⊙} in Advanced LIGO and Advanced Virgo data collected between 1 April 2019 1500 UTC and 1 October 2019 1500 UTC. We extend our previous analyses in two main ways: we include data from the Virgo detector and we allow for more unequal mass systems, with mass ratio q≥0.1. We do not report any gravitational-wave candidates. The most significant trigger has a false alarm rate of 0.14  yr^{-1}. This implies an upper limit on the merger rate of subsolar binaries in the range [220-24200]  Gpc^{-3} yr^{-1}, depending on the chirp mass of the binary. We use this upper limit to derive astrophysical constraints on two phenomenological models that could produce subsolar-mass compact objects. One is an isotropic distribution of equal-mass primordial black holes. Using this model, we find that the fraction of dark matter in primordial black holes in the mass range 0.2  M_{⊙}<m_{PBH}<1.0  M_{⊙} is f_{PBH}≡Ω_{PBH}/Ω_{DM}≲6%. This improves existing constraints on primordial black hole abundance by a factor of ∼3. The other is a dissipative dark matter model, in which fermionic dark matter can collapse and form black holes. The upper limit on the fraction of dark matter black holes depends on the minimum mass of the black holes that can be formed: the most constraining result is obtained at M_{min}=1  M_{⊙}, where f_{DBH}≡Ω_{DBH}/Ω_{DM}≲0.003%. These are the first constraints placed on dissipative dark models by subsolar-mass analyses.

COMPARISON OF LOCAL METHYLCOBALAMINE INJECTION VERSUS LOCAL BUPIVACAINE INJECTION FOR THE TREATMENT OF ACUTE HERPETIC NEURALGIA

Objective: To compare the reduction in mean pain score with local Methylcobalamin injection versus local Bupivacaine injection in patients with acute herpetic neuralgia. Study Design: Quasi experimental study. Place and Duration of Study: Dermatology Outpatient Department, Pak Emirates Military Hospital, Rawalpindi, from Jun to Dec 2019. Methodology: Total 100 patients, having pain score more than 3, fulfilling the selection criteria were divided into two groups. Group A was treated with daily subcutaneous injection Bupivacaine, whereas Group B was treated with daily subcutaneous injection Methycobalamin at the site of neuralgia. Patients were followed up for 4 weeks. The pain score was noted. All the data was entered and analyzed on SPSS version 21. Results: In this study mean age of patients in group A was 43.82 ± 15.76 years and in group B was 44.76 ± 16.92 years. The mean visual analogue pain score at 4th week in the group A patients was 1.14 ± 0.32 and in group B was 1.90 ± 0.97. Statistically significant difference was found in group A (local Bupivacaine) with visual analogue score (VAS) at 4th week (pvalue=0.002). Conclusion: The local Bupivacaine injection showed significant reduction in mean pain score than local Methylcobalamin injection in patients with acute herpetic neuralgia.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

COMPARATIVE EFFICACY OF A AND B IN PITYRIASIS VERSICOLOR

Objective: To compare the efficacy of oral fluconazole and oral itraconazole in the treatment of Pityriasisversicolor. Study Design: Comparative prospective study. Methodology: Total 72 patients of both genders with Pityriasis versicolor were included. Patients were randomly allocated into two treatment groups with 36 patients in each group: group A and group B by lottery method. Patients in group A received Cap Fluconazole 150 mg bi- weekly for two consecutive weeks while those in group B received two doses of 400 mg of itraconazole once weekly for two weeks. Patients were asked to follow-up after 4 weeks skin scrapings for microscopy using 10% KOH mount was done at follow-up. Efficacy was assessed in terms of negative fungal hyphae on microscopy. Results: In this study, age ranged from 18 to 40 years with mean age of 33.52 ± 4.12 years in group A, whereas35.055 ± 4.18 years in group B. Mean duration of disease was 4.66 ± 1.51 months in group A and 5.27 ± 1.70months in group B. Efficacy was seen in 77.8% of group A patients as compared to 50% in group B patients(p=0.014). Conclusion: Oral Fluconazole two doses of 150 mg/week (total 300mg/week) for two consecutive weeks wasfound more effective than oral itraconazole.

COMPARISON OF MONTHLY PULSE OF ORAL AZITHROMYCIN WITH DAILY DOXYCYCLINE IN THE TREATMENT OF MODERATE ACNE VULGARIS

Objective: To compare oral Azithromycin with oral Doxycycline in treatment of moderate Acne Vulgaris. Study design: Randomized control trial Place and duration of the study: Dermatology Department , Pak Emirates Military Hospital, Rawalpindi from 1st August 2017 till 31st January 2018. Materials and methods: A total of 92 patients with moderate Acne were selected from Dermatology outpatient department (OPD) Pak Emirates Military Hospital Rawalpindi, after written informed consent. Patients were randomly allocated to one of the two treatment groups: Group A and Group B by lottery method. Patients in group A were given oral Azithromycin 500 mg daily for four consecutive days each month for 03 months and patients in group B were given oral Doxycycline 100 mg daily for 03 months. Patients were reviewed monthly for 03 months and Acne Severity Index (ASI) was recorded at baseline, at one month and three months. The primary outcome measured was more than 50% decrease from baseline in ASI within 3 months of treatment, using Global Acne Grading System (GAGS). Results: Mean age of patients in group A was 21.80 + 4.64 years whereas mean age of patients in group B was 21.61 + 4.48 years. In group A mean pre-treatment ASI was 24.83 + 3.15 and mean post-treatment ASI was 10.15 + 1.7. In group B mean pre-treatment ASI was 25.30 ± 2.96 and mean post-treatment ASI was 9.86 + 1.58. Conclusion: Azithromycin is comparable to Doxycycline in terms of mean change in ASI, in the treatment of moderate Acne Vulgaris.

Comparison Of Efficacy Of Permethrin 5% Cream With Crotamiton 10% Cream In Patients With Scabies

BACKGROUND

Scabies is a common dermatological presentation in Pakistan. Permethrin and Crotamiton both are used widely for treating scabies. As there is no local study available regarding comparison of efficacy of Permethrin and Crotamiton in patients of scabies, current study was undertaken. The objective of the study was to compare the efficacy of 5% Permethrin with 10% Crotamiton in patients of scabies.

METHODS

A Randomized control trial was conducted at Dermatology Department, Military Hospital, Rawalpindi. One hundred and sixty patients with scabies (diagnosis made by scraping the burrows to extract mite, larva or eggs and to see under light microscope) were randomly assigned either to Permethrin or Crotamiton group. Patients were followed over for 4 weeks to determine the effectiveness of either treatment.

RESULTS

A total of 160 patients were included in the study with a mean age of 45.49±17.047 years and ranging from 13-65 years. One hundred and one patients (63.1%) were male and remaining 59 patients (26.9%) were female. Treatment was effective in 81.3% patients being treated with 5% Permethrin and 53.8% in 10% Crotamiton group. Comparison of treatment showed superiority of 5% Permethrin over 10% Crotamiton (p=0.001). There was no effect of age and gender on this outcome difference.

CONCLUSIONS

Our study concludes that 5% Permethrin cream is significantly superior to 10% Crotamiton cream in treating patients of scabies (81.3% vs. 53.8%, p=0.001).

Unusual skin mass (primary cutaneous mucinous carcinoma)

Primary mucinous carcinoma of the skin is a rare malignant tumour of sweat gland origin. Diagnostic concerns include its deceptively benign appearance in some cases and the difficulty in differentiating it from secondary mucinous carcinoma of skin metastasising from a primary source elsewhere. A case of a 75-year-old man is reported who presented with a slowly growing painless mass near the lateral canthus of the right eye for about 2 years. Clinically, a diagnosis of basal cell carcinoma was made whereas histopathology revealed mucinous carcinoma of the skin. The primary source of the tumour could not be found on detailed physical examination and laboratory investigations. Immunohistochemistry, performed later, was consistent with primary cutaneous mucinous carcinoma.

ASSESSMENT OF PRACTICE AT RETAIL PHARMACIES IN PAKISTAN: EXTENT OF COMPLIANCE WITH THE PREVAILING DRUG LAW OF PAKISTAN

The main objective of this study was to assess the practice at retail pharmacies in Pakistan and to compare the same in rural and urban areas. The maintenance of pharmacy and drug inspectors' visit was also assessed. This cross sectional study was conducted in Abbottabad, Pakistan during October-November, 2012. A sample of 215 drug sellers or drug stores was selected by employing convenient sampling method. With a response rate of 91.6%, 197 drug sellers participated in this study. All the drug sellers were male. Overall, 35% (n = 197) of the drug sellers did not have any professional qualification. A majority of the drug sellers were involved in various malpractices like selling of medicines without prescription (80.7%), prescribing practice (60.9%), prescription intervention (62.4%) and selling of controlled substances (66%) without a license for selling it. These malpractices were significantly higher in rural area than that in urban area.

Chronic plaque psoriasis: streptococcus pyogenes throat carriage rate and therapeutic response to oral antibiotics in comparison with oral methotrexate

OBJECTIVE

To determine the throat carriage rate of Streptococcus pyogenes in patients having chronic plaque psoriasis and the effect of antibiotics as compared with that of oral methotrexate.

DESIGN

Quasi-experimental study.

PLACE AND DURATION OF STUDY

Dermatology Department, Combined Military Hospital, Abbottabad, from January to December 2006.

PATIENTS AND METHODS

Forty patients and 40 age and gender-matched controls were selected. Throat swab for culture of Streptococcus pyogenes was taken from each patient and control. All patients were treated with oral Penicillin V 250 mg, 6 hourly, and oral Rifampicin, 600 mg daily, for 10 days. Pre- and posttherapy 'Psoriasis Area and Severity Index' (PASI) were compared. Thirty of these 40 patients were later given oral methotrexate, 5-10 mg weekly, for 04 weeks and pre- and post-therapy PASI were compared. Chi-square and paired-samples t-test were used for data analysis.

RESULTS

Throat swab cultures were positive for Streptococcus pyogenes in 05 (12.5%) patients and none (0%) of the controls (p=0.02). Mean pre- and postantibiotic therapy PASI were 15.92 +/- 05.94 and 15.19 +/- 06.17 respectively (p=0.078). Mean pre- and postmethotrexate PASI were 15.81 +/- 5.55 and 8.79 +/- 4.19 respectively (p < 0.01).

CONCLUSION

Throat carriage of Streptococcus pyogenes is common in patients with chronic plaque psoriasis. Short-term antibiotic treatment has no role in routine treatment of chronic plaque psoriasis. However, it would be worthwhile to consider the effects of long-term antibiotics on chronic plaque psoriasis.

Gorlin-Goltz syndrome

A 12 years old girl was presented with bilateral swellings on angle and body of mandible. On general physical examination, there were polydactyly and papular lesions on arm. Histopathology of mandibular lesions revealed odontogenic keratocysts. Marsupialization of the cysts followed by enucleation was done. The patient was reviewed every six months and there was no recurrence at the end of two years.

Real time and accelerated stability studies of Tetanus toxoid manufactured in public sector facilities of Pakistan

Tetanus is an acute illness represented by comprehensive increased inflexibility and spastic spasms of skeletal muscles. The poor quality tetanus toxoid vaccine can raise the prevalence of neonatal tetanus. WHO has taken numerous steps to assist national regulatory authorities and vaccine manufacturers to ensure its quality and efficacy. It has formulated international principles for stability evaluation of each vaccine, which are available in the form of recommendations and guidelines. The aim of present study was to ensure the stability of tetanus vaccines produced by National Institute of Health, Islamabad, Pakistan by employing standardized methods to ensure constancy of tetanus toxoid at elevated temperature, if during storage/transportation cold chain may not be maintained in hot weather. A total of three batches filled during full-scale production were tested. All Stability studies determination were performed on final products stored at 2-8°C and elevated temperatures in conformance with the ICH Guideline of Stability Testing of Biological Products. These studies gave comparison between real time shelf-life stability and accelerated stability studies. The findings indicate long-term thermo stability and prove that this tetanus vaccine can remain efficient under setting of routine use when suggested measures for storage and handling are followed in true spirit.

Multiple disseminated pyogenic granulomas

Pyogenic granulomas (Granuloma telengiectaticum) or lobular capillary haemangioma are classically described as solitary lesions, occurring in young individuals, usually at the site of previous trauma, with a tendency to recur after treatment. We describe an unusual case of multiple disseminated pyogenic granulomas in an elderly male caucasoid of Pakistani origin in whom more than 400 lesions occurred de novo without any antecedent history of trauma or skin disease, responded well to treatment and showed no tendency for recurrence. Multiple eruptive pyogenic granulomas are probably a rare subset of the disease, which can occur at any age, arise de novo or in association with a skin or systemic disease and do not exhibit a tendency to recur after treatment.

Clinical pattern of vitiligo

All new cases of vitiligo reporting to Dermatology Outpatient of Combined Military Hospital, Panu Aqil, were included in the study. Of the 230 patients, 124 were male (53.9%) and 106 were female (46.1%). Males were more commonly affected. The disease affected all age groups. Mean age at presentation was 27.02 + 18.34 years and age at presentation ranged from 5.5 months to 82 years. The mean age at onset was 22.03 + 16.97 years with majority 30.4% (n=70), developing vitiligo in first decade of life. Generalized vitiligo was the most common type (n=132, 57.4%) followed by focal (n=53, 23%) and acro-facial vitiligo (n=16, 7%). Head and neck was the most common initial site of onset (n=100, 43.48%). Koebner phenomenon was observed in 72 patietns (31.3%), family history was present in 64 patients (27.8%) and 16 patients (7%) had associated diseases.

Harlequin ichthyosis in two siblings

Harlequin ichthyosis is a rare and extremely severe form of congenital ichthyosis. The affected neonates usually do not survive beyond first few days after birth, but several long-term survivals have been noted. The inheritance is thought to be autosomal recessive. It has recently been shown that the vast majority of affected individuals are homozygous for mutations in the ABCA12 gene, which cause a deficiency of the epidermal lipid transporter and result in hyperkeratosis and abnormal barrier function. Prenatal diagnosis is possible. We report a case of a newborn with Harlequin ichthyosis, a product of consanguineous marriage, with a history of similar disease leading to early neonatal death previously in a sibling.

Zinc deficiency in patients with persistent viral warts

OBJECTIVE

To determine the association of low serum zinc levels with persistent, progressive or recurrent viral warts.

STUDY DESIGN

A comparative study.

PLACE AND DURATION OF STUDY

Dermatology outpatient department of Combined Military Hospital, Abbottabad in collaboration with Department of Chemical Pathology, Army Medical College, Rawalpindi, from June 2006 to May 2007.

METHODOLOGY

Seventy five patients having warts of more than six months duration, more than 10 in number, who either not responded to or had recurrence after previous treatments for viral warts and not having other chronic dermatological or systemic illness were included in the study after informed consent. Seventy five age and gender matched healthy individuals were taken as control. Serum zinc analysis was carried out by atomic absorption spectrometry using Perkin elmen (USA) apparatus. Independent sample t-test was used to compare mean zinc levels in microgram/litre with significance at p < 0.05.

RESULTS

Age of the patients as well as controls ranged from 12-65 years with a mean of 25.88 + 8.90 years. Serum zinc level was low in 42 (56%) patients and 24 (32%) controls (p=0.003). Among the patients, serum zinc level ranged from 695-1090 micro-gram/litre with a mean of 804.38 + 100.60, whereas the level ranged from 690-1100 microgram/litre with a mean of 836.17 + 91.04 among controls (p 0.044).

CONCLUSION

Zinc deficiency is associated with persistent, progressive or recurrent viral warts in the studied patients. Randomized controlled trials with careful dose adjustment of oral zinc sulphate may be helpful to formulate guide lines to manage such patients.

Nutrition in critically ill obese patients

Critically ill obese patients require timely nutrition in the intensive care unit. Hypocaloric, high protein nutritional feeding might have a role in critically ill obese patients. Although critically ill obese patients need special medical and nutritional care as do nonobese patients in the ICU, there are some differences in the literature about the initiation, routes, and nature of nutritional support. This article reviews the norms of nutritional care among critically ill obese patients and the differences between these patients and those with a normal BMI.

Paraneoplastic Addisonian pigmentation and acquired ichthyosis as presenting features of multiple myeloma

Black brown hyperpigmentation of the mucosae, sunexposed skin, palmar creases and frictional sites (Addisonian pigmentation) is characteristic of Addison disease. However, it can also occur as a paraneoplastic manifestation of tumours like bronchogenic carcinoma. Acquired ichthyosis starts later in life and can also be a paraneoplastic presentation. We report a unique combination of paraneoplastic Addisonian pigmentation and acquired ichthyosis as presenting features in a patient with undiagnosed multiple myeloma. To the best of our knowledge this combination of paraneoplastic dermatosis has not been documented before in multiple myeloma. It is concluded that the presence of more than one suspicious dermatosis may be an indicator of being paraneoplastic requiring necessary work-up.

Lupoid cutaneous leishmaniasis: a report of 16 cases

BACKGROUND

Lupoid cutaneous leishmaniasis (CL) is known as the chronic form of CL. However, keeping its clinical presentation in view, there is a need to revisit this form of disease.

AIMS

To redefine/describe lupoid CL in view of clinical features.

METHODS

It was a case series seen in Muzaffarabad (Pakistan) from Jan 2006 to May 2008. All patients clinically suggestive and consistent with laboratory diagnosis of CL were registered. Patients of all age groups and either sex having cutaneous lesions resembling lupus vulgaris or lupus erythematosus on the face or elsewhere were included in the study. Those having chronic fluctuating/relapsing course or scarring within the lesions were also included. Various demographic features of the patients and clinical patterns were recorded. Descriptive statistics were used for analysis.

RESULTS

Of 254 registered patients of CL, 16 (6.3%) were diagnosed as lupoid CL. None of the patients had scarred lesions. Age ranged from 38 to 75 (55 + 15.11) years and duration of lesions varied from 4 to 32 (14.25 + 07.59) weeks. All patients had lesions over the face. Thirteen (81.25%) had a large solitary plaque extending over the nose and a large part of the cheeks and three (18.75%) had multiple lesions. Lesions were central/nasal in two (12.5%), unilateral/asymmetrical in four (25%) and bilateral/symmetrical in 10 (62.5%). Morphological patterns included erythematous/infiltrated (7), psoriasiform (6), ulcerated/crusted (2) and Discoid lupus erythematosus (DLE)[G1] like (1).

CONCLUSION

Lupoid CL is not strictly a chronic form of disease, which presents on the face from the very onset and shows no scarring or recurrence.

Treatment of toxic epidermal necrolysis (TEN) with low dose intravenous immunoglobulin in child

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN, Lyell's disease) are severe, episodic, acute mucocutaneous reaction that may be caused by various factors particularly drugs. Treatment is primarily supportive care and there are no specific therapy regimens. Intravenous immunoglobulin (IVIG) has recently been shown to be a useful and safe therapy in paediatric patients with SJS/TEN, though no such case has so far been reported from Pakistan. The authors report the experience with low dose IVIG (0.1 g/kg/day for four consecutive days for treating a 3 years old boy with toxic epidermal necrolysis with favourable outcome without early complications.

A clinicopathological study of urethritis in males

OBJECTIVE

To determine the etiology and frequency of different types of urethritis in adult males.

STUDY DESIGN

A case series.

PLACE AND DURATION OF STUDY

The Dermatology Department of PNS Shifa Hospital, Karachi, from June 2004 to December 2007.

METHODOLOGY

One hundred male patients having complaints of urethral discharge and dysuria reporting in the skin OPD were included in the study. Patients who had received systemic treatment for their complaints and those who had other systemic infections were excluded. A detailed history including history of sexual contact was taken. Dermatological examination including examination of external genitalia was also performed. All these patients were subjected to complete physical examination, complete urine examination, urethral pus for gram staining and culture, endo-urethral swab with urethral loop for seeing Chlamydia antigen by fluorescent microscopy, cultures for ureaplasma and Wet mount specimen microscopy for trichomonas along with HIV (serum ELISA) test. Non-gonococcal urethritis was diagnosed on the presence of more than five polymorphonuclear leucocytes per high power field in at least five fields of Gram stained urethral smear, in the absence of Gram negative diplococci.

RESULTS

The mean age was 29.2 + or - 5.8 years. Seventy (70%) cases were diagnosed as gonococcal urethritis and 30 (30%) cases as non-gonococcal urethritis (NGU). History of illicit sexual exposure was available in 25 (25%) patients. The interval period between initiation of symptoms and reporting of patient in gonococcal urethritis was 4 to 30 days (mean 12.8 days) and 4 days to 2 months (mean 20.7 days) in non-gonococcal urethritis. The patients with gonococcal urethritis presented with purulent discharge in 66 (84%) cases, and dysuria in 49 (70%) cases. In the NGU group, 25 (80%) cases had mucoid discharge and 18 (65%) had dysuria. in 70%, Neisseria gonorrhoeae was isolated, Chlamydia trachomatis in 16%, ureaplasma in 8%, and Trichomonas vaginalis in 4%. No organism could be detected in 2% cases. HIV test was negative in all cases.

CONCLUSION

Gonococcal urethritis was the commonest urethritis seen followed by Chlamydia infection in the studied group of adult males.

Different faces of gastroparesis

AIM: To test the hypothesis that pain and affect rather than impaired emptying determine symptom severity in patients with gastroparesis.

METHODS: Adult patients with documented gastroparesis were enrolled prospectively in a single center and asked to complete the Gastroparesis Cardinal Symptom Index (GCSI), Hospital Anxiety and Depression Scale (HADS), the Short Form 12 (SF-12) as quality of life index, rate pain severity and answer 10 open-ended questions.

RESULTS: A total of 55 patients (44 women) participated. Idiopathic (n = 29) or diabetic (n = 11) gastroparesis and connective tissue disease (n = 8) were the most common underlying causes. Antiemetics (n = 30) and prokinetics (n = 32) were most often prescribed. Seventeen patients used opioids on a daily basis. Nausea and/or vomiting (n = 28), pain (n = 24) and bloating (n = 14) were most commonly listed as dominant symptoms. Patients subjectively attributed symptom improvement to nutritional and dietary therapy (n = 11), prokinetics (n = 11), antiemetics (n = 10) or analgesic agents (n = 3). In univariate analyses, the physical subscore of the SF-12 and HADS, but not gastric emptying delay or symptom duration significantly correlated with disease severity as measured by the GCSI. In multivariate analyses, the combination of vomiting, bloating and depression best predicted the overall impact on quality of life.

CONCLUSION: The study confirms the importance of pain and affect in gastroparesis, which requires novel approaches to improve more effectively the quality of life in patients with this disorder.

Discriminative value of anorectal manometry in clinical practice

Guidelines recommend anorectal manometry in patients with fecal incontinence and chronic constipation. However, limited evidence supports the utility of manometric testing. We retrospectively reviewed tracings obtained between November 2005 and May 2008. A total of 298 patients (86% women; average age 52 years) were included. The main indications were incontinence (51%) and constipation (42%). Patients suffering from incontinence were older and had lower resting and squeeze pressure compared to continent patients. However, the discriminative power of manometric pressure data was poor, with low sensitivity and specificity. An abnormal straining pattern suggesting dyssynergic defecation was seen in 43% of constipated patients compared to 13% of patients with fecal incontinence. A concordance between manometric patterns and the balloon expulsion test was seen in 72%. The low sensitivity and specificity of manometric parameters does not support the routine use of anorectal manometry in patients with defecation disorders.

Risk factors for scabies among male soldiers in Pakistan: case-control study

Being a preventable disease, good control of scabies can be achieved by identification of risk factors. During the 3-month period February 2006-April 2006 we carried out a case-control study on 200 patients with scabies and 200 controls to identify risk factors for scabies among male soldiers in Pakistan. We identified risk factors for the infestation using logisitic regression analysis. Itching in family/dormitory mates, infrequent bathing, infrequent changing of clothes, low education, sharing beds and being away from the barracks were identified as significant risk factors for scabies, while overcrowding, large family size and sharing of towels and hospitalisation were not.

Why dermatology patients are hospitalized? A study from Pakistan

In most countries, there are no specified protocols or guidelines for admitting dermatology patients and admission criteria depend on assessment and sometimes the whim of the dermatologist. Although the severity and extent of the disease are the commonest reasons for hospitalizing dermatology patients, sometimes other factors also operate to provide comfort to the patient. This study was carried out to determine the reasons for hospitalizing patients on dermatology beds in secondary care hospitals of Pakistan. A questionnaire comprising patients' demographic data, diagnosis, specific reasons for hospitalization and length of hospital stay was sent to dermatologists of 10 secondary care hospitals in the country. The data received in response were processed and analyzed using the SPSS-10 computer program. A total of 310 patients were included in the study. Patient age ranged from 1 to 87, mean 28.87+/-12.32 years. The severity and extent of the disease (n=122; 39.3%), outpatient treatment failure (n=57; 18.4%) and need for further observation and/or investigations (n=51; 16.5%) were the most common reasons for hospitalizing these patients. Hospital stay of the patients ranged from 2 to 30, mean 9.82+/- 6.43 days. Scabies (n=56; 18.1%), chickenpox (n=52; 16.8%) and eczema (n=41; 13.2%) were the most common diagnoses.

Dermatosis neglecta in a case of multiple fractures, shoulder dislocation and radial nerve palsy in a 35-year-old man: a case report

INTRODUCTION

Dermatosis neglecta is an often misdiagnosed and under-diagnosed condition. In dermatosis neglecta, a progressive accumulation of sebum, sweat, keratin and other dirt and debris, occurs due to inadequate local hygiene resulting in a localized hyperpigmented patch or a verrucous plaque. Vigorous rubbing with alcohol-soaked gauze or soap and water results in a complete resolution of the lesion. This is the first case of dermatosis neglecta reported in a patient with multiple traumatic injuries.

CASE PRESENTATION

We report a case of a 35-year-old male Caucasian of Pakistani origin, with multiple fractures, neurological deficit and immobility sustained in a fall, leading to the development of dermatosis neglecta of the left hand.

CONCLUSION

Early and prompt clinical recognition of this condition eliminates the need for aggressive diagnostic and therapeutic procedures.

Comparison of 30% salicylic acid with Jessner's solution for superficial chemical peeling in epidermal melasma

OBJECTIVE

To compare the efficacy and safety of Jessner's solution with 30% salicylic acid as superficial chemical peeling agents in treating epidermal melasma in Asian skin.

STUDY DESIGN

Double blind, randomized, interventional comparative study.

PLACE AND DURATION OF STUDY

Department of Dermatology, Combined Military Hospital, Malir Cantt, Karachi, from January to December 2004.

PATIENTS AND METHODS

Sixty consenting patients with epidermal melasma were randomly divided into two groups. Group A was treated with Jessner's solution and Group B with 30% salicylic acid. Baseline Melasma Area Severity Index (MASI) score was noted and peeling started at 2-weekly intervals. Sunscreen in morning and moisturizer at night were prescribed in all patients. MASI score and adverse effects were recorded biweekly. Treatment was stopped at 12 weeks and patients were followed-up at 4 weekly intervals for further 12 weeks. Final MASI score and adverse effects were noted at the end of follow-up period. Mean MASI scores were compared using paired sample t-test and one-way ANOVA.

RESULTS

Difference in baseline, treatment end and follow-up end MASI scores was not statistically significant between the two groups (p 0.54, 0.26, and 0.55 respectively). On the other hand, within group analysis of difference between pre and posttreatment MASI score was highly significant in both groups (p<0.0001). Adverse effects were mild and comparable in both groups.

CONCLUSION

Jessner's solution and 30% salicylic acid are equally effective and safe peeling agents for use in epidermal melasma in Asian skin.

Papulonecrotic tuberculids associated with uveitis

Papulonecrotic tuberculids represent an immunological expression of an internal focus of tuberculosis in an individual with a moderate or high degree of immunity. It responds to anti-tuberculosis treatment and is characterized by an eruption of necrotizing papules occurring in symmetrical crops, particularly affecting the elbows, knees, buttocks and face. A case of papulonecrotic tuberculids associated with immune mediated unilateral uveitis is reported in which all investigations were negative for tuberculosis except a strongly positive tuberculin test. There was an excellent response to anti-tuberculosis treatment. The association of immune mediated uveitis with papulonecrotic tuberculids has not been described before.

Localized lesions in secondary syphilis

The clinical manifestations of secondary syphilis are variable and can mimic many skin diseases, mostly being generalized and symmetrical in distribution. Localized lesions of secondary syphilis are rarely seen in dermatology clinics. We report an unusual presentation wherein a patient had localized lesions over face and soles only. There is a need for increased awareness on the part of physicians to recognize new patterns of syphilitic infection, together with a willingness to consider the diagnosis of syphilis in patients with unusual clinical features.

Onset of chilblains in relation with weather conditions

BACKGROUND

Chilblains or perniosis is a moderately severe form of cold injury, localized to peripheral parts of the body, which occurs after exposure to non-freezing temperatures and damp conditions. Although inter-individual variations exist with respect to susceptibility to develop chilblains, no study has been carried out in this region to determine the role of different weather conditions either alone or in combination, in predisposing the susceptible individuals to chilblains. The objective of this study was to determine the relationship between weather conditions and onset of chilblains at a moderately cold weather station.

METHODS

This study was conducted at the Department of Dermatology, Combined Military Hospital, Abbottabad, from Dec 2004 to Mar 2005. All patients fulfilling the clinical criteria for diagnosis of chilblains were included in the study. These patients were interviewed and examined thoroughly. A specially designed proforma was filled for each patient separately. Meteorological department was contacted for record of weather conditions. Onset of chilblains in each patient was related with weather conditions of that particular month. Computer programme SPSS 10 was used for statistical analysis.

RESULTS

Out of 111 patients, 67 (60.4%) were males and 44 (39.6%) were females. Eighty nine (80.2%), 90 (81.1%) and 90 (81.1%) patients had onset in relation with lower temperature (< 10 degrees C), relatively low atmospheric pressure (< 1500 kpa) and higher relative humidity (> 60%) respectively. There was statistically significant relationship of weather conditions with onset of chilblains when different groups, i.e., elderly and young, males and females, locals and non locals, outdoor workers and those remaining inside most of the time and those having disease of longer or shorter duration were compared.

CONCLUSION

The cold weather conditions that can be endured by humans depend on combination of the duration and the extent of the exposure, in addition to physiological adaptive changes. However, susceptibility to chilblains increases when ambient temperature is less than 10 degrees C and relative humidity is more than 60%. Elderly, females, outdoor workers and those having chronic or recurrent episodes of chilblains are less tolerant to cold weather and develop the disease under lesser ambient cold.

Onset of adult varicella in relation to rural or urban origin and its complications

OBJECTIVES

To determine area of origin of adult varicella patients, whether rural or urban, to compare the mean interval between leaving the area of origin and onset of varicella in adults of rural origin in comparison with those of urban origin and to observe its complications.

STUDY DESIGN

A cross-sectional study.

PLACE AND DURATION OF STUDY

Combined Military Hospital, Abbottabad, from January to December 2006.

PATIENTS AND METHODS

All patients over the age of 18 years, presenting with acute illness clinically, suggestive of varicella were included in the study. A specially designed proforma was filled for each patient separately, which included demographic features as well as area of origin, whether rural or urban, and the age at which they left the area of origin. These patients were examined, treated and assessed clinically on regular basis for the progress of the disease as well as for its possible local or systemic complications. Data analysis was done by using statistical programme SPSS-10.

RESULTS

Out of 9155 adult patients, 156 (1.70%) had varicella, including 128 (82.1%) males and 28 (17.9%) females. Origin was rural in 125 (80.1%) and urban in 31 (19.9%) patients. Mean interval between leaving area of origin and developing varicella in those of rural origin was 01.79+/-01.78 years and that in patients of urban origin was 03.37+/-05.72 years (p+/-0.009). None of the patients developed any complication of the disease.

CONCLUSION

Varicella in adults is generally a benign illness. It is more common among adult males of rural origin and the interval between leaving the area of origin and onset of varicella in these patients is significantly less as compared to that in adults of urban origin.

Drug induced linear IgA disease with unusual features: Koebner phenomenon, local insulin sensitivity and annular blister of the nipples

Linear IgA disease is an autoimmune subepidermal bullous disease in which linear IgA deposits are found at the basement membrane zone. It is classically idiopathic but may be drug induced. We report on a patient with drug induced linear IgA disease who exhibited certain unusual and interesting clinical features including isomorphic Koebner response, annular blister of the nipples and local insulin sensitivity. To the best of our knowledge, these clinical features have not yet been reported in linear IgA disease.

Granulomatous cheilitis: sustained response to combination of intralesional steroids, metronidazole and minocycline

Various conservative methods for treatment of labial swelling in patients with granulomatous cheilitis have been attempted, often with only moderate success. We report a case of granulomatous cheilitis who showed excellent sustained response to combination of intralesional steroids, metronidazole and minocycline for initial one month followed by prolonged maintenance treatment with minocycline alone.

Juvenile onset classical pityriasis rubra pilaris: every patient may not require systemic therapy

Juvenile onset classical Pityriasis Rubra Pilaris (PRP), although rare, is the most common presentation of PRP in children. It has good prognosis and resolution over a few months. Use of potentially hazardous systemic drugs in a disease, that is likely to resolve spontaneously, needs to be assessed carefully. We report a 09 years old boy suffering from this rare disorder, whose disease is well under control with emollients and a combination of diluted topical steroids and keratolytics, for over 06 months.

Hydroa vacciniforme in an adolescent girl

Hydroa vacciniforme (HV) is a rare photosensitivity disorder with onset in childhood. Recurrent vesicles, bullae and crusting occur on sun-exposed skin that heals with vacciniform scarring. This rare disorder is hereby reported in an adolescent girl who developed a severe episode of hydroa vacciniforme on a hot sunny day during harvesting season. She had repeated episodes afterwards in succession until she was appropriately sun-screened. Her lesions healed without scarring because of early reporting, short-lived episodes, early diagnosis and response to appropriate therapy.