Acute Rash Research Articles

Risk Factors and Distribution of Infectious Diseases among the Older Adults on a Pilgrimage to Arba’een Mass Gathering

Objectives: To determine the syndromic symptoms associated with infectious diseases in the older adults attending the Arba’een pilgrimage mass gathering. Design: A cross-sectional study. Setting(s): Outpatient clinics during the Arba’een pilgrimage. Participants: A total of 200 subjects were randomly chosen among the older adults attending outpatient clinics during the Arba’een pilgrimage in Iraq in 2022. Outcome measures: The syndromic symptoms of infectious diseases, including acute fever and rash, influenza-like syndrome, severe acute respiratory syndrome (SARS), food poisoning, acute diarrhea, bloody diarrhea, and chronic cough were evaluated using a valid checklist provided by the Center for Disease Control and Prevention (CDC) and the Ministry of Health (Iran). Multiple logistic regression analysis was carried out to estimate the crude and adjusted odds ratios (AORs) with 95% confidence intervals. Results: The mean age of the participants was 68.3 years, with nearly 60% of the participants being men. Among 72 (29.4%) mask users, 71% changed masks in less than 8 hours. The most common syndromic symptom was flu-like illness (42%). In the final analysis, not using a mask (AOR=1.5, 1.1 – 4.7), diabetes (AOR=3.01, 1.4 – 7.7), and smoking (AOR=1.75, 1.02 – 3.8) increased the risk of the flu-like syndrome and severe respiratory disease symptoms. Conclusions: Flu and respiratory illnesses are common among the aging population attending Arba’een mass gatherings. To prevent potential outbreaks, it is necessary to perform a differential diagnosis of respiratory diseases such as influenza and coronavirus disease 2019 (COVID-19).

Acute generalized exanthematous pustulosis: European expert consensus for diagnosis and management.

Acute generalized exanthematous pustulosis (AGEP) is a rare, usually drug-induced, acute pustular rash. Despite the lack of strong data supporting the effectiveness of topical or systemic corticosteroids in this drug reaction, they are widely used. More generally, there is no consensus on the diagnostic modalities and the management of patients with AGEP. We aimed to provide European expert recommendations for the diagnosis and management or patients with AGEP. Members of the ToxiTEN group of the European Reference Network (ERN)-skin, all dermatologists and/or allergologists with expertise in drug reactions, elaborated these recommendations based on their own experience and on a review of the literature. Recommendations were separated into the following categories: professionals involved, assessment of the diagnosis of AGEP, management of the patient and allergological work-up after the acute phase. Consensus was obtained among experts for the list of professionals involved for the diagnosis and management of AGEP, including the minimum diagnostic work-up, the setting of management, the treatments, the modalities and the timing of allergological work-up and follow-up. European experts in drug allergies propose herein consensus on the diagnosis and management of patients with AGEP. A multidisciplinary approach is warranted, including dermatologists, allergologists and pharmacovigilance services.

P.042 Anti-HMG Coenzyme A reductase antibody (anti-HMGCR) myopathy: case review of two pediatric patients from a single center

Background: Necrotizing anti-HMGCR myopathy is rare in children. Pediatric cases are not typically associated with statin use or malignancy. Methods: Retrospective chart review (January 2009 to December 2023) identified cases of anti-HMGCR myopathy at our hospital. Results: Two patients were identified. Patient A, presented at 8 yo with a 2 year history of proximal muscle weakness. His CK was 4,840 U/L (normal <205 U/L) with a high anti-HMGCR antibody titre. His Childhood Myositis Assessment Scale (CMAS) score was 33/52. Monthly IVIG was started and his muscle strength and CK improved. Two years later, weekly methotrexate was started for persistent mild CK elevation (602 to 869 U/L). At 11 years old, 3 years after diagnosis, his CMAS score was 47 and he could participate in soccer with mild fatigue. Patient B, presented at 8 yo with acute proximal weakness, rash and CMAS 13/52. His CK was 20,185 U/L with elevated anti-HMGCR antibody titre. He received oral corticosteroids, weekly methotrexate and monthly IVIG. At 10 yo, 2 years after diagnosis, he is asymptomatic with CMAS 51. He is maintained on methotrexate monotherapy. Conclusions: Anti-HMGCR antibody myopathy requires prompt diagnosis to obviate muscle necrosis and long-term complications. Our patients showed clinical and CMAS improvement with treatment.

Clinical and laboratory profiles of systemic lupus erythematosus patients in a new rheumatology clinic in southwestern Nigeria.

The aims were to study the sociodemographic characteristics of patients presenting to the clinic and to study the clinical and serological pattern of systemic lupus erythematosus (SLE) in a new rheumatology clinic of a predominantly Yoruba population. This was a retrospective, cross-sectional study conducted over 7 years (January 2017 - December 2023). Patients who satisfied the 1997 American College of Rheumatology (ACR) and/or the 2012 Systemic Lupus International Collaborating Clinics (SLICC) classification criteria were enrolled using their medical records. Patients with overlap syndromes and other inflammatory or noninflammatory rheumatic diseases were excluded from the study. Their sociodemographic, clinical, laboratory, and treatment data were retrieved from their medical records and analysed using IBM SPSS version 23.0 software. A total of 65 patients were diagnosed with SLE with a frequency of 15.8%. The mean age ±SD of the patients at presentation was 33.85 years ±11.01 and the female to male ratio was 9.8 : 1. The median (IQR) duration of symptoms at presentation was 7.0 months (3-24). The common clinical presentations included synovitis (86.2%), acute cutaneous rash (53.8%), oral ulcers (52.3%), nonscarring alopecia (50.8%), and serositis (47.7%). Proteinuria was seen in 37.7% of the patients and the predominant renal histopathological feature was Class IV. Antinuclear antibody was 100% positive with 50.94% of the patients having a titre of 1 : 5,120 and above. Anti-double-stranded deoxyribonucleic acid and anti-Smith antibodies each had 50% prevalence. Dyslipidaemia was found in 76.7% of the patients. The study's findings are largely consistent with similar studies done in Africa. Further prospective multi-centred studies are needed to further determine the epidemiological characteristics of the disease in Nigeria with a multi-ethnic population.

Role of epinephrine in attenuating cytokine storm, decreasing ferritin, and inhibiting ferroptosis in SARS-CoV-2

BackgroundSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the virus responsible for coronavirus disease 2019. It presents one of the most threatening pandemics in the history of humanity. The mortality and morbidity represent an unprecedented challenge to the modern medical era. SARS-CoV-2 results in acute respiratory distress syndrome, high concentrations of proinflammatory mediators, cytokine storm (CS) due to massive release of cytokines, hypercoagulation, and hemoglobin disintegration. Dysregulation of iron homeostasis, iron overload as indicated by high ferritin level, and ferroptosis are major factors in the pathogenesis of the disease. We report a case of SARS-CoV-2 in which the use of epinephrine (Epi) resulted in an unexpected attenuation of CS, decreasing ferritin level and inhibiting ferroptosis.Case presentationA 64-year-old male patient with a history of multiple medical comorbidities had been diagnosed with SARS-CoV-2. Further evaluation showed marked increase in inflammatory markers, severe hyperferritinemia, and lymphopenia in laboratory blood tests. The characteristic score of CS was strongly positive, and in addition to regular treatment, the patient received Epi due to development of acute generalized skin rash, severe itching, and edema of lips and tongue. Epi may have successfully terminated not only the acute cutaneous condition, but also have attenuated CS, decreased ferritin level, and other inflammatory markers in addition to complete patient’s recovery.ConclusionEpinephrine may attenuate CS and inhibit ferroptosis which is an iron-dependent, non-apoptotic mode of cell death. Epi interacts with ferric and/or ferrous iron and built a stable complex that impedes activation of beta-adrenergic receptors. Epi may cause marked decrease of ferritin and other inflammatory markers. Epi may be used to decrease iron overload which is associated with many medical diseases like type 2 diabetes mellitus and cardiometabolic diseases such as coronary heart disease and cerebrovascular disease. As a new clinical indication extensive studies are required for further assessment and possible therapeutic uses.

Abstract 13309: Severe Cardiomyopathy as Harbinger of Multisystem Inflammatory Syndrome From Epstein Barr Infection

Introduction: Multisystem inflammatory syndrome in adults (MIS-A) is a rare condition characterized by multiple organ injury after a viral infection. Features include fever, elevated inflammatory markers, evidence of acute viral infection, and at least three of the following clinical criteria: peri/myocarditis or acute ventricular dysfunction, rash, encephalopathy, shock, and gastrointestinal symptoms. This is a case of nonischemic cardiomyopathy (NICMP) as a MIS-A manifestation after an Epstein-Barr viral (EBV) infection. Description of Case: A 38 year-old female, with a recent pneumonia, presented with two weeks of fever, dyspnea, hemoptysis, fatigue, and right leg swelling. Initial ECG showed sinus tachycardia. Laboratory testing showed leukocytosis 15.5k/uL, NT pro BNP 6470 pg/mL, C-reactive protein 234 mg/L, lactic acid 3.7 mmol/L, creatinine 1.5 mg/dL (baseline 0.7 mg/dL), AST 372 U/L, ALT 658 U/L. RSV, influenza, COVID-19, HIV, hepatitis B/C, and urine antigens were undetected. Imaging showed deep vein thrombosis in right leg veins and bilateral pulmonary emboli with infarcts. Heparin infusion was started. A transthoracic echocardiogram showed biventricular systolic failure with an ejection fraction of 20%. Coronary angiography showed no coronary artery disease. Cardiac MRI showed dilated NICMP with minimal late gadolinium enhancement. The nadir of her cardiac index was 1.2 L/min/m 2. She was started on nitroprusside infusion for early-stage cardiogenic shock. Extensive workup for thrombophilia, autoimmune, amyloidosis, infectious causes were all normal except for an elevated EBV early antigen IgG which indicated past infection within a few months, aligning with patient’s reported pneumonia symptoms before presentation. She clinically improved and was bridged to heart failure guideline directed medical therapy and apixaban on discharge. Discussion: Though MIS-A has been reportedly associated with COVID-19, EBV can cause MIS, with severe cardiomyopathy, nephropathy, hepatopathy, and pulmonary infarcts requiring intensive cardiac care, in a normal young adult.

Concurrent Acute, Subacute, and Chronic Cutaneous Rashes in a Patient with Systemic Lupus Erythematosus

A 35-year-old woman with systemic lupus erythematosus presented with diffuse rashes. On exam, rashes of three different morphologies were seen throughout her body. A review of the cutaneous manifestations of lupus and the efficacy of belimumab for cutaneous lupus is provided.

Acute erythematous rash: what is the diagnosis?

Acute erythematous rash: what is the diagnosis?

First-line regorafenib with nivolumab and chemotherapy in advanced oesophageal, gastric, or gastro-oesophageal junction cancer in the USA: a single-arm, single-centre, phase 2 trial

The addition of nivolumab to chemotherapy improves survival in patients with advanced oesophagogastric (oesophageal, gastric, or gastro-oesophageal junction) adenocarcinoma; however, outcomes remain poor. We assessed the safety and activity of regorafenib in combination with nivolumab and chemotherapy in the first-line treatment of advanced oesophagogastric adenocarcinoma. This investigator-initiated, single-arm, phase 2 trial in adult patients (aged ≥18 years) with previously untreated, HER2-negative, metastatic oesophagogastric adenocarcinoma was done at the Memorial Sloan Kettering Cancer Center (New York, NY, USA). Eligible patients had measurable disease or non-measurable disease that was evaluable (defined by Response Evaluation Criteria in Solid Tumours [RECIST] version 1.1) and Eastern Cooperative Oncology Group performance status of 0 or 1. Patients received FOLFOX chemotherapy (fluorouracil [400 mg/m2 bolus followed by 2400 mg/m2 over 48 h], leucovorin [400 mg/m2], and oxaliplatin [85 mg/m2]) and nivolumab (240 mg) intravenously on days 1 and 15, and oral regorafenib (80 mg) on days 1-21 of a 28-day cycle. Treatment was continued until disease progression (defined by RECIST version 1.1), unacceptable toxicity, or withdrawal of consent. The primary endpoint was 6-month progression-free survival in the per-protocol population (ie, all participants who received a dose of all study treatments). The regimen would be considered worthy of further investigation if at least 24 of 35 patients were progression free at 6 months. Safety was assessed in all participants who received at least one dose of any study treatment. This trial is registered with ClinicalTrials.gov, NCT04757363, and is now complete. Between Feb 11, 2021, and May 4, 2022, 39 patients were enrolled, received at least one dose of study drug, and were included in safety analyses. 35 patients were evaluable for 6-month progression-free survival. Median age was 57 years (IQR 52-66), nine (26%) patients were women, 26 (74%) were men, 28 (80%) were White, and seven (20%) were Asian. At data cutoff (March 3, 2023), median follow-up was 18·1 months (IQR 12·7-20·4). The primary endpoint was reached, with 25 (71%; 95% CI 54-85) of 35 patients progression free at 6 months. Nine (26%) of 35 patients had disease progression and one (3%) patient died; the death was unrelated to treatment. The most common adverse event of any grade was fatigue (36 [92%] of 39). The most common grade 3 or 4 adverse events were decreased neutrophil count (18 [46%]), hypertension (six [15%]), dry skin, pruritus, or rash (five [13%]), and anaemia (four [10%]). Serious treatment-related adverse events occurred in ten (26%) patients, which were acute kidney injury (three [8%]), hepatotoxicity (two [5%]), sepsis (two [5%]), dry skin, pruritus, or rash (one [3%]), nausea (one [3%]), and gastric perforation (one [3%]). There were no treatment-related deaths. Regorafenib can be safely combined with nivolumab and chemotherapy and showed promising activity in HER2-negative metastatic oesophagogastric cancer. A randomised, phase 3 clinical trial is planned. Bristol Myers Squibb, Bayer and National Institutes of Health/National Cancer Institute.

MEKiAUTO: A multicenter phase 1 study of combination therapy with the MEK inhibitor, cobimetinib, immune checkpoint blockade, atezolizumab, and the autophagy inhibitor hydroxychloroquine (HCQ) in KRAS-mutated advanced malignancies.

45 Background: Autophagy, a catabolic cell survival process, is upregulated when cancer cells undergo MEK inhibition (MEKi) in preclinical models of pancreas adenocarcinoma (PDAC), and may function as a pathway of resistance. Simultaneous inhibition of the MEK and autophagy pathway in preclinical PDAC models has demonstrated anti-tumor and immune modulating effects. MEKiAUTO evaluated the tolerability and safety of combination cobimetinib, HCQ, and atezolizumab at three dose levels (DL), in advanced KRAS-mutated malignancies. Methods: This multicenter phase I study used the time-to-event continual reassessment method (TITE-CRM) with the primary objective of estimating the maximum tolerated dose (MTD) of the combination of cobimetinib (DL1 and DL2: 40mg; DL3: 60mg PO daily; on days 1-21); HCQ (DL1-DL3: 600mg PO BID), without (DL1) or with (DL2 and DL3) atezolizumab (840mg IV on days 1 and 15) every 28 days, in patients with advanced KRAS-mutated malignancies who had received at least one prior line of therapy (N=18). The secondary objective was to evaluate safety. Exploratory analysis included interrogating the MEK, autophagy, and key molecular pathways. Results: A total of 14 patients with PDAC were enrolled at Columbia University and Brown University between 02/24/20 through 03/15/22. The median age was 58, 57% were female. Of the 10 evaluable patients for dose limiting toxicity ((DLT); >80% drug adherence and ≥4 week of follow-up), 4 experienced a DLT (3 out of 8 at DL1 and 1 out of 2 at DL2). The estimated MTD is dose level 1 with an estimated probability of DLT 0.37. Grade 3 or higher treatment-related adverse events occurred in 7 of 14 (50%) patients with elevation in AST and ALT (14%), acute kidney injury, hypokalemia, anemia, rash, and CPK increase (7% each). One grade 5 multi-organ failure and acute kidney injury occurred at DL1 possibly related to cobimetinib. Clinical benefit was observed in 5 of 14 (36%) patients, all of whom experienced stable disease as best response. The median PFS and OS for overall population was 7.7 weeks (95%CI: 6-NA) and 20.7 weeks (95%CI: 15.6-46.1). Patients with KRASG12R (N=7) had a trend toward longer OS (mOS: 20.9 vs 16.4 weeks) than patients with KRASnon-G12R mutations (N=7). Correlative analysis on paired tumor specimens using single nucleus RNAseq, multiplex immunofluorescence, and pathway analysis will discuss putative mechanisms of resistance. Conclusions: Combination cobimetinib, HCQ and atezolizumab had limited tolerability and efficacy in advanced KRAS-mutated PDAC. Patients with KRASG12R had a trend towards improved OS versus KRASnon-G12R mutations. Correlative analysis for pharmacodynamic and resistance mechanisms will be discussed. Funding: Roche-Genentech. Clinical trial information: NCT04214418 .

A Network Meta-Analysis of Randomized Clinical Trials to Assess the Efficacy and Safety of Antiviral Agents for Immunocompetent Patients with Herpes Zoster-Associated Pain

BACKGROUND: The most refractory symptom of herpes zoster (HZ) is pain. Approximately 90% of people who have HZ suffer from pain. Early use of antiviral medications has been found to reduce pain across all stages of the disease. Although many antiviral agents via oral or intravenous administration were recommended by clinical practice, the best approach to prevent HZ-associated pain remains uncertain. OBJECTIVES: The purpose of this study was to compare the efficacy and adverse events of various antiviral agents used for the treatment of HZ-associated pain through a network meta-analysis. STUDY DESIGN: A systematic review and meta-analysis. SETTING: The Cochrane Register of Controlled Trials, Embase, and PubMed were searched from inception to Feb 2020. METHODS: Randomized clinical trials evaluating antiviral agents currently available for treating HZ-associated pain were included. We extracted data in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and conducted network meta-analyses with random-effects models. The primary outcome was the presence of acute pain at the end of anti-virus treatment, and the secondary outcomes included the presence of pain at 28-30 days after the onset of the acute herpetic rash, the presence of postherpetic neuralgia (PHN), and any other adverse events. RESULTS: A total of 17 randomized control trials with 5,579 participants were included in this study. According to the results of the network meta-analysis, for the treatment of acute pain, there was no significant difference between oral acyclovir and intravenous acyclovir. Furthermore, oral famciclovir was the most effective treatment concerning both the odds ratio (OR) (superior to placebo OR = 0.25; 95% CI: 0.13~0.48) and the surface under the cumulative ranking curve (SUCRA) values of 0.84 for the treatment of acute pain among all the oral antiviral agents. For the presence of pain at 28-30 days, no significant difference was observed in efficacy between all antiviral treatments and placebo concerning the OR; however, oral valaciclovir ranked first (SUCRA values of 0.96). For the presence of NPH, oral famciclovir was determined to be the most effective (SUCRA values of 0.77) treatment with an efficacy of 0.42 (95% CI: 0.18~0.99) versus placebo. For adverse events, there was no significant difference between oral antivirals and placebo; however, intravenous acyclovir ranked last with a score of OR 4.31 (95% CI: 1.26~14.75) versus placebo. LIMITATIONS: The distribution of severity of pain was different in various studies; then, the lack of availability of individual data prevented us from analyzing the effects of the risk factors. CONCLUSIONS: For the treatment of acute pain and PHN, oral famciclovir was the most effective treatment among all the oral antiviral agents. For alleviating pain after 28-30 days, oral valaciclovir appeared to be the most effective among all antiviral agents. Additionally, all oral antiviral agents were well tolerated. Clinical Trial Registration Information: PROSPERO under the identification CRD42020212834 KEY WORDS: Herpes zoster, antiviral agents, acyclovir, famciclovir, valaciclovir, efficacy, pain, network meta-analysis Given the intrinsic nature of the secondary literature analysis in this study, the Ethics Committee of Chongqing Medical University’s Second Hospital waived the ethical approval.

Measles virus transmission patterns and public health responses during Operation Allies Welcome: a descriptive epidemiological study

On Aug 29, 2021, Operation Allies Welcome (OAW) was established to support the resettlement of more than 80 000 Afghan evacuees in the USA. After identification of measles among evacuees, incoming evacuee flights were temporarily paused, and mass measles vaccination of evacuees aged 6 months or older was introduced domestically and overseas, with a 21-day quarantine period after vaccination. We aimed to evaluate patterns of measles virus transmission during this outbreak and the impact of control measures. We conducted a measles outbreak investigation among Afghan evacuees who were resettled in the USA as part of OAW. Patients with measles were defined as individuals with an acute febrile rash illness between Aug 29, 2021, and Nov 26, 2021, and either laboratory confirmation of infection or epidemiological link to a patient with measles with laboratory confirmation. We analysed the demographics and clinical characteristics of patients with measles and used epidemiological information and whole-genome sequencing to track transmission pathways. A transmission model was used to evaluate the effects of vaccination and other interventions. 47 people with measles (attack rate: 0·65 per 1000 evacuees) were reported in six US locations housing evacuees in four states. The median age of patients was 1 year (range 0-26); 33 (70%) were younger than 5 years. The age distribution shifted during the outbreak towards infants younger than 12 months. 20 (43%) patients with wild-type measles virus had rash onset after vaccination. No fatalities or community spread were identified, nor further importations after flight resumption. In a non-intervention scenario, transmission models estimated that a median of 5506 cases (IQR 10-5626) could have occurred. Infection clusters based on epidemiological criteria could be delineated into smaller clusters using phylogenetic analyses; however, sequences with few substitution count differences did not always indicate single lines of transmission. Implementation of control measures limited measles transmission during OAW. Our findings highlight the importance of integration between epidemiological and genetic information in discerning between individual lines of transmission in an elimination setting. US Centers for Disease Control and Prevention.

A case report on overlap syndrome: diagnostic and management challenges

Overlap syndromes are inflammatory rheumatic conditions in which patients show clinical manifestations suggestive of multiple distinct immune diseases. This case report discusses a complex instance involving Sjögren’s disease, rheumatoid arthritis (RA), and systemic lupus erythematosus (SLE) in a woman in her 30s. Lupus nephritis, a severe kidney inflammation associated with SLE, and diffuse alveolar hemorrhage (DAH), a life-threatening lung complication characterized by bleeding into the alveolar spaces, further complicated her clinical course. Initially presenting with acute lower limb pain, swelling, and rash, suggesting systemic involvement beyond RA, laboratory findings of hypocomplementemia and renal involvement raised suspicion of SLE. The subsequent development of polyserositis, mesenteric vasculitis, and DAH underscored the complexity of her condition. This case highlights the importance of a holistic approach that integrates clinical expertise, advanced diagnostics, and tailored therapeutic interventions to optimize patient outcomes. Early recognition and prompt management of complications are crucial in mitigating morbidity and improving prognosis, emphasizing the need for vigilant monitoring and interdisciplinary collaboration in the management of connective tissue diseases.

CD12 Citalopram-induced drug reaction with eosinophilia and systemic reaction confirmed by patch testing

Abstract A 46-year-old man was referred for investigation of an acute widespread rash and fever that started 4 weeks after commencing citalopram. Clinical and histological features were consistent with drug reaction with eosinophilia and systemic reaction (DRESS). He was not on any other medication, had no known allergies and had not previously taken a selective serotonin reuptake inhibitor (SSRI). Six months after resolution, he was patch tested to the extended British Baseline Series and citalopram (crushed tablet in 50% petrolatum). Readings on days 2 (D2) and 4 (D4) were positive for citalopram (D2 ++ and D4 +++). To investigate possible crossreactivity, he was subsequently patch tested to fluoxetine, paroxetine and sertraline (crushed tablets in 50% petrolatum), which showed a positive reaction to paroxetine [D2 (–) and D4 (+)]. Patch tests to citalopram and paroxetine were negative with no irritancy in a normal volunteer. SSRIs are extensively and increasingly used for depression and other mental health problems; 45 000 000 UK prescriptions were issued in the last financial year. Despite such widespread use, cutaneous adverse drug reactions (CADRs) appear to be rare. From 1998 to 2022, the Medicines and Healthcare products Regulatory Agency recorded 16 586 adverse reactions to citalopram, of which only 1077 (6.5%) were cutaneous. Various rashes have been reported to arise from SSRI treatment, ranging from maculopapular eruptions to toxic epidermolysis necrolysis/Stevens–Johnson syndrome. There have been isolated reports of DRESS from fluoxetine, sertraline and escitalopram (the S-enantiomer of citalopram). To our knowledge, this is the first reported case of citalopram-induced DRESS. The sensitivity and specificity of patch tests in the diagnosis of delayed CADR varies according to the drug and rash. We have found case reports of positive patch tests to sertraline and paroxetine following maculopapular exanthems. Our findings highlight a diagnostic role for patch tests with an extemporaneous preparation in SSRI-induced DRESS. SSRIs have diverse chemical structures, and we speculate that patch tests may be of benefit in identifying a safer alternative should further SSRI treatment be needed.

Pattern of systemic lupus erythematosus in NIGERIA: a multicentre descriptive hospital-based study.

Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory disease with manifestations ranging from mild to life-threatening organ dysfunction. There is wide variability in the reported incidence and prevalence rate globally, particularly in low and middle-income countries. Nigeria had very few isolated reports of SLE from private and public hospitals Therefore, we conducted this large multi-center descriptive study to determine the sociodemographic, clinical profile, laboratory patterns, and treatment among Nigerian lupus patients. A retrospective hospital-based study of all SLE patients seen over 4years (January 2017 to December 2020) was conducted at 20 rheumatology clinics spread across the 6 geopolitical zones of Nigeria. All patients 18years and above satisfying the American College of Rheumatology (ACR) 1997 and/or the Systemic Lupus International Collaboration Clinics (SLICC) 2012 classification criteria for SLE were enrolled. Patients with other Rheumatic and Musculoskeletal Diseases (RMDs) not in keeping with SLE and Patients with incomplete data were excluded. Data was analysed using SPSS version 23.0 software. A total of 896 patients with SLE were included in the final analysis with a mean age ± SD of 34.47 ± 11 and a female to male ratio of 8.1:1. Synovitis was reported by 61.6% of patients, while 51%, 19.9% and11.4% patients reported acute, sub-acute and chronic lupus rashes respectively. ANA was positive in 98.0% with titers ranging from 1:80 to 1:64,000. SLE is not rare in Nigeria. Most patients were female in their 3rd to 4th decades of life. There is a delayed presentation to a rheumatology facility. Arthritis and mucocutaneous manifestations were the most frequent presentation. Key Points •This study presents the first national data on SLE in Nigeria •This study showed that SLE is not rare in Nigeria in contrast to previous reports •There appear to be ethnic disparity in the frequency of lupus among Nigerians •Nigerians with lupus have very high titer of ANA.

Acute diffuse rash on trunk

Acute diffuse rash on trunk

The protective roles of liraglutide on Kawasaki disease via AMPK/mTOR/NF-κB pathway.

Kawasaki disease (KD) is an acute febrile rash illness among children of unknown etiology, with coronary artery injury. The main purpose of this study was to investigate the protective effects of liraglutide on KD, and elucidate the underlying mechanisms. The candida albicans water-soluble fraction (CAWS)-induced coronary arteritis of mouse KD model in vivo and tumor necrosis factor α (TNF-α) induced endothelial cell injury of human umbilical vein endothelial cell (HUVEC) model in vitro were used to explore the anti-inflammation and anti-apoptosis effects of liraglutide on KD. In vivo results showed that liraglutide could significantly alleviate the coronary artery injury of KD mice, as evidenced by the reduction of inflammatory infiltration around the coronary arteries, downregulation of inflammatory cytokines and chemokines expressions, and decrease of TUNEL (Terminal deoxynucleotidyl transferase dUTP nick end labeling) positive cell rates. The results in vitro also displayed that liraglutide could markedly relieve the inflammatory of TNF-α induced HUVECs through downregulating the expressions of inflammatory and chemokine indicators as well as inhibit TNF-α induced HUVEC apoptosis by the less ratio of apoptotic cells, the more loss of mitochondrial membrane potential (△Ψm), the lower level of intracellular reactive oxygen species (ROS), and the more ratio of BCL-2/BAX. Further in vivo and in vitro studies demonstrated that liraglutide could rescue endothelial cell injury through AMPK/mTOR/NF-κB pathway. In conclusion, liraglutide could play protective roles on KD through inhibiting endothelial cell inflammation and apoptosis via the activation of AMPK/mTOR/NF-κB pathway.

A 43-year-old male with acute right upper quadrant pain and skin rash.

A 43-year-old male presented with acute right upper quadrant pain, nausea, and itchy skin rash for two hours. Physical examination revealed abdominal tenderness and itchy abdominal skin lesions that are compatible with urticaria. The patient’s blood pressure was 95/55 mmHg, pulse rate was 122 beats/minute, body temperature was 37.1 C degrees, and partial oxygen saturation was 96% in the room air. He had no history of recent trauma or chronic disease. Laboratory test results were within normal limits except for increased white blood cell count (14.79 K/uL, reference range; 4-10 K/uL). Abdominal ultrasound (US) was performed, and the US revealed abdominal free fluid and a thin-walled lobulated cystic lesion in the liver dome. For further evaluation, contrastenhanced abdominal computed tomography (CT) was obtained. CT showed a thin-walled cystic lesion with lobulated contours in the liver, pericystic fat stranding, perihepatic free fluid, and right pleural effusion (Figure 1).

Herpes Zoster: a case series with different manifestations

Background: The incidence of herpes zoster appears to correlate inversely with the host's ability to mount a cellular immune response. The disease is characterized clinically by an acute rash with herpetiform blisters on the skin and mucous membranes. This case series presented the different clinical presentations of herpes zoster infection in three patients with different underlying diseases in the ophthalmic, trigeminal, cervical, and thoracic dermatomes. Case Presentation: Three cases of herpes zoster were observed in this case series. The first case involved the ophthalmic division of the trigeminal nerve. The second case involved the cervical nerve, and the last case involved the thoracic nerve. All had undergone varicella infection in childhood and suffered from various states leading to immunosuppression. Tzanck smears were performed in all cases, which showed multinucleated giant cells. After treatment following the herpes zoster protocol, all cases healed without complications. Conclusion: Reactivation of the varicella-zoster virus may occur spontaneously or when host immunity is weakened. Increasing age, a physical trauma (including dental procedures), psychological stress, malignancy, and immunocompromised conditions, including transplant recipients, pregnancy, and HIV infection, are predisposing factors for varicella-zoster virus reactivation.

Enzalutamide-Induced Acute Maculopapular Rash in Treatment of Metastatic Prostate Cancer: First Case Report from a Tertiary Cancer Care Center of North India.

Enzalutamide is a new potent inhibitor of the signaling pathway for the androgen receptor with a half-life of 5.8 days. It has been on the market for the treatment of metastatic castration-resistant prostate cancer since November 2013.We report a case of acute generalized exanthematous maculopapular rash induced by enzalutamide. In summary, newer androgen receptor blockers have a propensity to cause skin related adverse effects. Most common among these are apalutamide. Enzalumatamide, per se, is a safe drug and has not been associated frequently in causing maculopapular rash. Few cases has been reported. In all these cases, the drug was discontinued and 2nd line therapy was instituted. In this report, Enzalutamide was withheld for 10 days and anti-histaminics was instituted. After a full recovery, Enzalutamide was reinstituted in treatment.A 62-year-old male patient with no significant medical history, was diagnosed in March 2020 with metastatic prostatic adenocarcinoma. Baseline PSA was 456 ng/ml. PSMA PET scan showed evidence of multiple bony metastasis. He was started on Degarelix subcutaneous injection with oral abiraterone initially. PSA level showed initial decreasing trend till September 2021 followed by sudden increase. Intramuscular Injection leuprolide was started and initial responses were good followed by later rise of PSA from January. Tab Xtandi (Enzalutamide) was added to the regimen from 31.1.22. Three days after starting enzalutamide treatment, the patient experienced an acute skin reaction. It is about of the plaques covered with widespread millimetric non-follicular papules. Enzalutamide was stopped after appearance of rashes to avoid further serious adverse effects. Anti-histaminics were started. Complete resolution of skin lesions occurred within 10 days. Tab Enzalutamide was reinstituted on 11th day after stoppage and on complete resolution of skin resolutions. According to the CTCAE 5.0 criteria, these skin rash was graded as grade 2. In view of evidence in literature and clinical improvement after stoppage, the acute drug reaction was attributed to enzalutamide.Uro oncologist can be confronted with adverse skin drug reactions attributable to new therapeutic molecules. The slow resolution of symptoms seems be due to the long half-life of enzalutamide. It should not be withdrawn from therapy owing to these effects. Rather, it should be with stopped for 10-14 days. Basic treatment with anti-histaminics or topical steroids may be enough to warranty the resolution of symptoms, and the drug (Enzalutamide) can be continued thereafter.