Axilla Research Articles

Chyle Leak Management in the Setting of Tissue Expander Breast Reconstruction with Acellular Dermal Matrix: Case Series and Literature Review.

Chylous leakage is a rare surgical complication most frequently encountered following operations involving the neck and thorax. Even more rare are axillary chyle leaks secondary to breast cancer involving the axillary lymph nodes. Anatomic variability in the termination of the thoracic duct may play a role in the susceptibility some individuals may have to this type of leakage. There is no consensus on the definitive management of these complications, especially in the context of breast reconstruction. Here, we report our experience in the management of chylous leakage in three patients who underwent left axillary lymph node dissection and immediate breast reconstruction with the use of tissue expanders and acellular dermal matrix. Descriptions of each case are followed by a review of the relevant literature. We also present an original treatment algorithm. Two of three patients with suspected chylous leakage secondary to intraoperative injury to the axillary region underwent definitive diagnosis by clinical examination and drain fluid triglyceride analysis, followed by conservative management with a low-fat diet. The third patient was diagnosed clinically with no fluid analysis. All leakages resolved through conservative means, with no need to return to the operating room for surgical exploration and repair. Based on our experience, we believe that patients with suspected chylous leakage secondary to axillary lymph node dissection in the context of breast reconstruction can be safely and effectively managed by conservative management in the acute postoperative period. If these measures are insufficient, surgical management may be necessary.

MYOEPITHELIAL CARCINOMA OF SOFT TISSUES OF THE RIGHT AXILLARY REGION WITH METASTASIS TO THE CECUM: A CLINICAL CASE

Relevance: Myoepithelial carcinoma is a morphologically diverse tumor that arises either de novo or due to the malignant transformation of its benign counterpart, myoepithelium. These are relatively lesser-known lesions rarely found in the head and neck area. Myoepithelial carcinoma (MC) is a rare malignancy primarily found in the salivary gland. MK can be confused with many other tumors outside the salivary glands, as a wide range of cytomorphological and immunohistochemical features characterizes them. Soft tissue MCs are extremely rare, although a salivary gland MC is relatively common and well-known with similar morphology. The histogenesis of soft tissue MC is still unknown. The tumor may have myoepithelial differentiation but is not derived from myoepithelial cells. Due to the rarity of soft tissue MCs, the number of studies and data on this tumor’s clinical and pathological characteristics are limited. In addition, the limited number of diagnostic criteria and prognostic parameters makes diagnosing and treating soft tissue MC difficult. The article describes a rare case of MC, formed from the soft tissues of the axillary region, with metastasis to the cecum. The purpose was to describe the imaging and clinicopathological features of axillary myoepithelial carcinoma of soft tissues with metastasis to the cecum and to form an understanding of this disease. Methods: A rare case of soft tissue CM of the axillary region with metastasis to the cecum is described. A 57-year-old woman complained of lymphadenopathy in the right axillary region in October 2020. Results: According to ultrasound examination, the lymph node is up to 3.0x3.5 cm in the right axillary region. Based on histopathological and immunohistochemical (IHC) data, on 02/03/2022, the final diagnosis was made: MK of the soft tissues of the right axillary region. According to positron emission tomography/computed tomography (PET/CT), after 4 months, a local focus of active accumulation was detected in the projection of the cecum, with an adjacent enlarged regional lymph node of the paracolic group. On January 18, 2023, surgical treatment was performed in the following volume: “Right-sided hemicolectomy.” Histological examination confirmed MC. According to the multidisciplinary team’s (MDG) decision, the patient received 3 courses of targeted therapy. Conclusion: This case report raises awareness and improves MC diagnostics and treatment.

Poland syndrome: a case report

Poland syndrome is characterized by the absence or hypoplasia of other chest muscles: small pectoral muscle, anterior tightened muscle, grandorsal muscle, and deltoid muscle. Anomalies of the thoracic cage: agenesis or hypoplasia of one or more costal segments, pectus carinatum, excavatum, clavicular hypoplasia, pulmonary herniation. Abnormalities of the mammary region: agenesis or hypoplasia of the breast, areola and nipple. The reported incidence of Poland’s syndrome ranges from 1 in 7,000 to 1 in 100,000. Males are affected more frequently by a 2:1 to 3:1 ratio Poland’s syndrome has also been diagnosed in 1 of 19,000 mammograms. The right side of the body was found to be involved in 60% to 75% of patients - associated malformations: genitourinary malformations, cardiac malformation, hepatic and biliary tract malformations. Case report Our case involves a 7-month-old boy with no medical history of cardiac or respiratory complaints. This is a male child with around 65cm height, and 7kg weight. There is no family history of consanguineous marriage and no family history of congenital anomalies. All siblings are alive and healthy. The child’s milestones are within normal limits. There is aplasia of the right sternocostal head and clavicular heads and abdominal head of the pectoralis major muscle, there is a hypoplasia of the right nipple and breast and absence of subcutaneous fat on the same side. Ribs are visible on the right chest wall. Physical examination shows no history of hand and digit anomaly and no rib anomalies. Chest wall asymmetry with right chest wall showing depression on axillary floor. The anterior axillary fold is absent. On attempting abduction of the shoulder, it shows the absence of the sternocostal head of the pectoralis major.

Pre-expanded Brachial Artery Perforator Propeller Flap: An Addition to the Armamentarium for Postburn Axillary Contracture Reconstruction

Background: Postburn axillary contracture is a common complication that leads to functional impairment and unsatisfactory aesthetic outcomes. This article aims to present our experience with axillary contracture reconstruction using pre-expanded brachial artery perforator propeller (BAPP) flaps and provide a systematic review of other regional or free flaps. Methods: This retrospective study included patients who underwent postburn axillary contracture reconstruction using pre-expanded BAPP flaps from 2015 to 2022. Data on the flap characteristics and function of the affected shoulders were recorded. A systematic review was conducted by retrieving studies that assessed the outcomes of regional or free cutaneous/fasciocutaneous flaps for treating axillary contracture from PubMed, Web of Science, EMBASE, and Scopus published before October 1, 2023. Results: Twelve pre-expanded BAPP flaps measuring up to 26 cm × 11 cm (mean, 116.9 cm 2) survived completely with no major complications, and the donor sites were closed primarily. The average range of shoulder abduction increased from 77.9° to 141.7° (p=0.002). The systematic review included 34 articles, reporting 12 regional and three free flaps. The most reported flaps were the thoracodorsal artery perforator flap, scapular flap, and parascapular flap. The overall complication rate ranged from 0 to 25%, and the average change in shoulder abduction ranged from 72.5° to 99.4°. Conclusions: Pre-expanded BAPP flaps can be effectively used for reconstructing postburn anterior axillary fold contracture. The donor site availability and the specific axillary contracture type should be considered when selecting a regional or free flap.

A pilot trial of personalized neoantigen pulsed autologous dendritic cell vaccine as adjuvant treatment in hepatocellular carcinoma.

e16264 Background: The primary treatment for hepatocellular carcinoma (HCC) is radical surgery. However, HCC has a high propensity to recur postoperatively and no standard adjuvant therapies have been approved. This Phase I trial aims to evaluate the safety and efficacy of an adjuvant personalized neoantigen pulsed autologous dendritic cell vaccine (Neo-DCVac-02) in patients with HCC. Methods: Eligible patients had histologically confirmed high-risk HCC after radical surgery. After obtaining the necessary baseline biopsy specimens and PBMCs of appropriate quality for DNA and RNA sequencing, neoantigen prediction, screening and synthesis were performed. Subsequently, leukapheresis was performed and DCs were isolated and cultured. DCs were then pulsed with neoantigen peptides to produce Neo-DCVac-02. On day 0, patients were treated with cyclophosphamide at a dose of 250 mg/m2. The prepared Neo-DCVac-02 vaccine was administered subcutaneously to the axillary and inguinal regions bilaterally on day 1, followed by daily administration of GM-CSF at a dose of 0.075 mg for 5 days (days 2-6). The primary objectives of this study were to assess feasibility and safety/tolerability. Secondary objectives included evaluation of immune responses (via vaccine response: IFNγ ELISpot), relapse-free survival (RFS) and overall survival (OS). Results: A total of 32 patients provided informed consent to initiate the process of personalized neoantigen discovery, of which 26 (81%) met the requirements for successful product selection for clinical manufacturing. Feasibility was demonstrated with 13 patients receiving Neo-DCVac-02. 13 patients did not receive the neoantigen vaccine (7 due to progressive disease, 6 due to withdrawal of informed consent because of COVID-19). The treatment was well tolerated with no grade 2+ treatment-related adverse events (TRAEs). The most common Grade 1 TRAEs were injection site reactions (75%), rash (16.7%), fatigue (8.3%), neutropenia (8.3%), and headache (8.3%). Five of 13 evaluable patients showed increased antigen-specific T-cell activity and more than 50% of the neoantigen peptides in Neo-DCVac-02, and sustained cellular responses were observed up to one year. Increases in T-cell activation/co-stimulation seen after treatment with Neo-DCVac-02, as demonstrated by flow cytometric analysis, suggest immune priming. At a median follow-up of 29.7 months, median RFS was not reached, with 1- and 2-year RFS of 84.6% and 60%, respectively, and all patients are alive. Patients with a strong immune response had a longer median relapse-free survival (not reached) compared to patients with a weak immune response (17.6 months, P = 0.003). Conclusions: These data demonstrate that Neo-DCVac-02 is safe, well tolerated and capable of inducing durable antigen-specific lymphocyte immune responses that may correlate with delayed HCC recurrence. Clinical trial information: NCT04147078 .

Kawasaki Disease in a 5-Year-Old Boy: A Rare Vasculitis Syndrome Presenting with Mucocutaneous Manifestations

Kawasaki disease (KD) is a rare, self-limiting vasculitis predominantly affecting children under the age of five. We report a case of a 5-year-old boy presenting with fever, generalized maculopapular rash, peeling of lips, erythematous oral mucosa, lymphadenopathy, and nail changes. The patient was admitted to the pediatric ward with a 3-day history of low-grade fever, rash, and vomiting episodes. Physical examination revealed bilateral lymphadenopathy in the cervical, axillary, and inguinal regions. Laboratory investigations showed elevated white blood cell count, neutrophilia, platelet count, alkaline phosphatase, aspartate aminotransferase, C-reactive protein, and erythrocyte sedimentation rate. The antistreptolysin O titer was positive, indicating recent streptococcal infection. Based on the clinical presentation and diagnostic criteria, a diagnosis of Kawasaki disease was established. The patient was treated with intravenous ceftriaxone, azithromycin, pantoprazole, and supportive therapy, including paracetamol, antihistamines, zinc, and topical calamine lotion. After 15 days of treatment, the patient showed improvement and was discharged with a planned follow-up. This case highlights the importance of early recognition and prompt treatment of Kawasaki disease to prevent potential complications, such as coronary artery aneurysms. Increased awareness among pediatricians is crucial for timely diagnosis and management of this rare vasculitis syndrome, especially in developing countries where cases may go undetected

Cutaneous adverse events to systemic anticancer therapies : Hand-foot syndrome and nail changes

Hand-foot syndrome (HFS) and nail changes are frequent adverse events of anticancer therapies. To provide areview of current evidence in HFS and nail disorders associated with medical tumor treatment. Basis is the current German S3guideline "Supportive therapy in oncologic patients" and literature on this topic published since the guideline was finalized. Two variants of HFS are distinguished: achemotherapy-associated and akinase-inhibitor-associated variant. In the first form, painful erythema, blisters and ulceration can occur, also in other areas with ahigh number of sweat glands such as axillary and inguinal regions. Thus, the secretion of toxic substances through sweat glands is aproposed pathogenetic mechanism. For the second form, which results in callus-like painful thickening of the horny layer on areas of mechanic pressure, avascular mechanism is proposed. For prophylaxis of HFS, avoidance of mechanical stress, regular cleaning of predisposed areas, and also urea- and diclofenac-containing ointments are recommended; in case of infusions (taxanes, doxorubicine), cooling of hands and feet during infusion is recommended. In case of manifest HFS, dose reduction or prolongation of intervals of the associated treatment are recommended. Nail changes often develop under therapy with chemotherapeutic agents but also under treatment with agents such as checkpoint inhibitors or under targeted therapy. Different components of the nail unit may be involved such as the nail matrix, nail bed, nail plate, hyponychium, lunula and proximal and lateral nail folds. This work gives insight into the pathophysiology of HFS and nail disorders that develop under systemic oncologic treatments and gives recommendations for prophylaxis and treatment.

A review of surgical and reconstructive techniques for hidradenitis suppurativa.

Hidradenitis suppurativa (HS) is an inflammatory follicular dermatological condition that typically affects the intertriginous and anogenital regions of the apocrine gland-bearing skin. The management of this chronic and recurring disease necessitates a combination of lifestyle changes, medication, and surgical approaches to achieve the best possible outcomes. While medical treatments are recommended for this multimodal disease, surgical therapy, which is the gold standard of treatment for HS, has proven to be the most effective treatment because it provides long-lasting local disease control, reduces the recurrence of lesions, and ensures complete healing of lesions. In the last decade, there has been exponential growth in research into various surgical techniques and reconstructive care, enabling patients to have more surgical options. There is a wide range of surgical management procedures available, such as incision and drainage, deroofing, excisional surgery, carbon dioxide laser therapy, and skin tissue-sparing excision with electrosurgical peeling. Among these surgical procedures, wide surgical excision is the best option since it can eradicate all the affected lesions. Meanwhile, the preferred approach to reconstruction at various anatomical locations remains debatable. Here, we review a variety of surgical treatments and reconstructive techniques for HS, particularly various flap techniques for the axillary, gluteal, and inframammary regions.

Effectiveness of secukinumab for overlapping hidradenitis suppurativa and ankylosing spondylitis

AbstractHidradenitis suppurativa is a chronic inflammatory disease of the hair follicle that affects the axillary and gluteal regions. Hidradenitis can coincide with other inflammatory diseases, such as ankylosing spondylitis. We present a patient suffering from an overlap of both conditions, who had a rapid improvement with secukinumab.

CASE PRESENTATION: A COMPLEX CLINICAL SCENARIO IN A 43–YEAR–OLD MALE WITH DEVICE–RELATED COMPLICATIONS

Abstract A 43 yo male presented with an exposed pocket of his ICD in the right prepectoral and axillary region, along with total exposure of the lead electrodes up to the fixation sleeves.The patient, a known carrier of double–outlet right ventricle, underwent surgical correction. At the age of one, he received a dual–chamber pacemaker in the left prepectoral region due to AVB. Due to recurrent sustained ventricular tachycardias an ICD was implanted in the right prepectoral region, with removal of the left–sided pacemaker and concurrent abandonment of the ventricular pacing lead. In October 2019, he was admitted for a recurrence of pocket erosion.Device extraction was proposed but declined by the patient. Subsequently, he was referred to our institution for device removal. After heart team discussion, the patient was offered a transvenous lead extraction, with potential cardiothoracic surgical intervention if transvenous extraction proved to be challenging.An attempt was made to extract the leads using a transvenous approach. The procedure proceeded without complications, and the leads were released from adhesions up to the superior vena cava. However, there was an adhesion point at this location that was not overcome by mechanical dilation.Due to this limitation, a few days later, a cardiothoracic surgical intervention was performed to complete the lead wires‘ extraction using an invasive approach. In this context, a cardiac resynchronization device CRT–P was reimplanted in the left prepectoral region with epicardial electrodes. The patient underwent submuscular subclavian implantation of a SCID.The patient presented with a new pocket erosion of the CRT–P.Considering the high infection risk, It was therefore decided to implant a leadless device following electroanatomic mapping of the right ventricle, as there were surgical patches in the septal region. This approach aimed to identify the optimal anchoring site for the device. Subsequently, he will go extraction of the generator of the CRT–P.The decision to forgo biventricular stimulation was made, because of the elevated infectious risk.Complications associated with implantable devices pose an increasingly significant challenge in managing young patients with cardiac arrhythmias. Only through an integrated approach and proactive sharing of knowledge and expertise can we significantly improve clinical outcomes and the quality of life for this increasingly relevant population.

Abstract PO1-28-05: Preventive Microsurgery in Breast Cancer Treatment

Abstract Relevance: Breast cancer (breast cancer) ranks first among all oncological diseases in women in the world. In 2020, 2.3 million people worldwide were diagnosed with breast cancer. The most common complication after radical breast surgery is violation of lymph outflow in the form of lymphatic edema (lymphedema) of the limb. The probability of developing lymphedema according to scientific literature is from 12 to 60%. Treatment of this complication is carried out conservatively and surgically. According to a review of international experience, a preventive microsurgical technique for restoring lymph outflow from the upper limb – the application of lymphovenous anastomoses (LVA) has a positive result for the prevention of lymphedema, similar to a sentinel lymph node biopsy and can be considered as an addition to standard axillary lymph dissection (ALD). Objective: To evaluate the effectiveness of preventive microsurgical application of LVA after ALD in breast cancer. Methods: From August 2022 to June 2023, 44 operations were performed with preventive microsurgical application of lymphovenous anastomoses on the basis of the Department of Tumors of the Female Reproductive System of the Central Clinical Hospital “RZD-Medicine”, Moscow. In 39 patients, surgery was performed during the primary treatment: disease stage cT1-4N1-3M0. Organ-preserving resection with lymph node dissection (9),mastectomy with lymph node dissection (30). In 14 patients, a biopsy of the sentinel lymph node was performed at the first stage; according to the result of a lesion of 2 or more, ALD and LVA were performed. In 5 patients, ALD was performed for local recurrence of the disease in the axillary region. All patients underwent immediate microsurgical restoration of lymphatic outflow from the upper limb during one operation in the axillary region after the stage of lymph node dissection. A fluorescent dye was used for reverse mapping of lymphatic pathways from the upper limb. Isotopes + fluorescent dye were used to determine the sentinel lymph node. Lymphatic venous anastomoses were applied end-to-end, end-to-side, side-to-side and by the Optocus technique. Results: The median follow-up was 5.5 months. The duration of the operation increased by an average of 70 minutes: at the same time, the ALD time increased by an average of 14 minutes for gentle skeletization of the veins for the subsequent application of LVA. In 4 patients, the integrity of the recipient vein was damaged during lymph node dissection and restored microsurgically. No surgical complications were observed. The average duration of lymphorrhea in the postoperative period was 2.3 days (without LVA 13.9 days). Conclusions: The preventive microsurgical technique for restoring lymph drainage from the upper limb has a number of technical limitations, requires special training and microsurgical equipment. Nevertheless, the technique is safe, feasible and effective in the early postoperative period. The application of LVA led to a significant decrease in lymphorrhea in the postoperative period, a reduction in hospital stay, but an increase in the duration of the operation. Longer follow-up is required to assess the overall effect of LVA on the incidence of lymphedema. Citation Format: Vladimir Vorotnikov, Alexander Soynov, Alexander Soynov, Regina Pakhomova, Alexandra Gugnina, Sardor Abdugafforov, Sofia Kim, Tornike Mchedlidze. Preventive Microsurgery in Breast Cancer Treatment [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-28-05.

Abstract PO1-20-12: CD8+ Tumor Infiltrating Lymphocytes Turn a Cold Tumor Hot in Metastatic Breast Cancer

Abstract Introduction: Turning “cold” tumors “hot” is considered essential for immune-oncology therapies to be effective. Bria-IMT is an allogenic human cancer cell line with antigen presenting cell activity (SV-BR-1-GM) designed to overcome the immune-suppressive tumor microenvironment. However, until now there has not been proof that “cold” tumors can become “hot” with this therapy. Using Zr-89 crefmirlimab berdoxam, a zirconium-89 labelled truncated antibody specific to human CD8α and developed for CD8 ImmunoPET, we image before and after Bria-IMT therapy administration to assess the baseline status as well as changes in CD8 cell presence after initiation of therapy. Here we present the first evidence that cold tumors can become hot on treatment with Bria-IMT combined with an anti-PD-1 checkpoint inhibitor (CPI), showing CD8+ cells increased over baseline using CD8 ImmunoPET. Case: After informed consent, a 61 year-old Hispanic female, enrolled in the ongoing randomized phase 2 Bria-IMT trial in advanced heavily pretreated metastatic breast cancer (MBC) (NCT03328026). Her history included MBC in May 2020, ductal type, grade 3, triple negative breast cancer (TNBC) with 6 prior lines of therapy including a Trop-2-directed antibody-drug conjugate and 6 lines of chemotherapy. Precision medicine testing identified no actionable targets. All prior therapies had progressive disease as their best response. The subject was randomized to start the CPI after 2 cycles of Bria-IMT to “train” the host immune system before proceeding with combination immune-oncology therapy. Baseline testing revealed the subject to be anergic to candida and SV-BR-1-GM inoculation. However, by cycle 3 delayed-type hypersensitivity to SV-BR-1GM developed. Interestingly the subject matched SV-BR-1-GM at 2 HLA loci: DRB3*02:02 and DRB1*11:04 which in previous publications is associated with greater clinical benefit. Tumor markers were stable or decreased slightly including CEA (25% decrease) and CA 15-3 (43% decrease). Circulating Tumor Cells (CTCs) and Cancer Associated Macrophage Like cells (CAMLs) also improved. Standard imaging at baseline showed 3 main sites of disease including a large right breast mass, multiple right axillary lymph nodes and a right lower lobe mass with CD8 ImmunoPET uptake in these areas similar to the blood pool. On the follow-up CT imaging, all of these lesions increased in size with newly appreciated pulmonary nodules. The right lower lobe mass showed increased CD8 ImmunoPET accumulation with an SUV of 5.8 (close to the liver background) as compared to an SUV of 2.2 at baseline. The lesions in the right breast and right axilla remained at blood pool levels. There was an increase in CD8 ImmunoPET uptake in bilateral inguinal lymph nodes reaching an SUV of 4.8 as compared to SUV 2.2 at baseline. In addition, there were non-enlarged lymph nodes in bilateral axillary regions that also showed increased radio-tracer accumulation reaching an SUV of 9.5 as compared to SUV 4.9 at baseline. Conclusion: This subject demonstrated a mixed response of metastatic lesions on CD8 ImmunoPET with encouraging changes in peripheral blood tumor markers and CTCs. The nonspecific nodal localization of CD8 ImmunoPET may indicate a systemic activation of CD8 positive lymphoid cells. This shows the value of CD8 ImmunoPET in identifying lesions that are progressing on treatment versus pseudo progression. It also provides support that the Bria-IMT + CPI combination immune-based therapy can result in an increase of CD8+ tumor infiltrating lymphocytes in breast cancer metastatic sites as well as an increase in lymphoid organs. This advance may aid in triaging patients, adjudicating pseudo-progression and predicting clinical benefit of immune based therapies. Citation Format: Russ Kuker, Frances Valdes-Albini, Giuseppe Del Priore, Aazim Arif, Kristin Schmiedehausen, Carmen Calfa. CD8+ Tumor Infiltrating Lymphocytes Turn a Cold Tumor Hot in Metastatic Breast Cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-20-12.

Severe BCG immune reconstitution inflammatory syndrome lymphadenitis successfully managed with pre-antiretroviral counseling and a non-surgical approach: a case report

BackgroundBacillus Calmette-Guérin (BCG) reactions are the most common cause of immune reconstitution inflammatory syndrome (IRIS) in HIV-positive infants who initiate antiretroviral therapy (ART). There is limited evidence regarding the incidence of BCG-IRIS; however, reports from outpatient cohorts have estimated that 6–9% of infants who initiated ART developed some form of BCG-IRIS within the first 6 months. Various treatment approaches for infants with BCG-IRIS have been reported, but there is currently no widely accepted standard-of-care.Case PresentationA 5-month-old male HIV-exposed infant BCG vaccinated at birth was admitted for refractory oral candidiasis, moderate anemia, and moderate acute malnutrition. He had a HIV DNA-PCR collected at one month of age, but the family never received the results. He was diagnosed with HIV during hospitalization with a point-of-care nucleic acid test and had severe immune suppression with a CD4 of 955 cells/µL (15%) with clinical stage III disease. During pre-ART counseling, the mother was educated on the signs and symptoms of BCG-IRIS and the importance of seeking follow-up care and remaining adherent to ART if symptoms arose. Three weeks after ART initiation, he was readmitted with intermittent subjective fevers, right axillary lymphadenopathy, and an ulcerated papule over the right deltoid region. He was subsequently discharged home with a diagnosis of local BCG-IRIS lymphadenitis. At six weeks post-ART initiation, he returned with suppurative lymphadenitis of the right axillary region that had completely eviscerated through the skin without signs of disseminated BCG disease. He was then started on an outpatient regimen of topical isoniazid, silver nitrate, and oral prednisolone. Throughout this time, the mother maintained good ART adherence despite this complication. After 2.5 months of ART and one month of specific treatment for the lymphadenitis, he had marked mass reduction, improved adenopathy, increased CD4 count, correction of anemia, and resolution of his acute malnutrition. He completely recovered and was symptom free two months after initial treatment without surgical intervention.ConclusionsThis case details the successful management of severe suppurative BCG-IRIS with a non-surgical approach and underlines the importance of pre-ART counseling on BCG-IRIS for caregivers, particularly for infants who initiate ART with advanced HIV.

Psychosocial effects of hidradenitis suppurativa in the literature: A systematic review.

Hidradenitis suppurativa (HS) is an inflammatory disorder characterized by painful, deep follicular nodules, abscesses, sinus tracts, and scarring, most commonly presenting in the inguinal, axillary, and anogenital regions. This condition substantially decreases quality of life in affected individuals, resulting in higher rates of psychiatric disorders including depression, anxiety, suicidality, and substance use. The detrimental effects of HS are well documented by dermatologists, as individuals with HS make up a large proportion of the patients that they see daily. However, it is unclear whether psychiatrists are aware of the degree of psychosocial impairment present in HS patients. It is important that those in the field of psychiatry and behavioral medicine are aware of this condition and are comfortable managing it from a psychosocial perspective. This systematic review chronicles the existing literature on the psychosocial effects of HS and assesses the extent to which dermatology journals review these effects in comparison to psychiatry or behavioral medicine.

Erythrasma of the Vulva: An Invisible Dermatosis.

Erythrasma is a prevalent superficial bacterial infection typically caused by Corynebacteria species and preferentially affecting intertriginous sites including axillary, interdigital, and inguinal skin folds. However, erythrasma of the vulva is uncommon, with only 2 cases previously reported. Although erythrasma can be diagnosed clinically using Woods lamp examination, it may not always be considered in the differential diagnosis for patients presenting with persistent vulvar pruritus. We report 12 cases of vulvar erythrasma identified by histopathology, with a review of clinical and histologic features. The mean patient age was 60.1yr and the mean patient BMI was 30.5. Five of 12 patients presented with pruritic rash. The time from symptom onset to diagnosis was 9mo in 1 case, >18mo in 4 cases, and unknown in the remaining cases. The characteristic histologic features were compact orthokeratosis and mild perivascular chronic inflammation. In all 12 cases, Periodic Acid-Schiff-diastase (PAS-D) staining highlighted intracorneal filamentous rods which were not readily appreciable on H&E. After the diagnosis of erythrasma, 4 patients were treated with topical lincomycin, of whom 3 had clinical improvement in symptoms. One patient was treated with topical macrolide antibiotic and also reported improvement in symptoms. Consideration of erythrasma on the differential for patients presenting with vulvar rash and pruritus may shorten the time to diagnosis and treatment, minimize patient discomfort, and reduce the scope and cost of diagnostic testing.

Ectoparasites Infestation to Small Ruminants and Practical Attitudes among Farmers toward Acaricides Treatment in Central Region of Java, Indonesia.

Ectoparasite infestations are one of the major problems affecting goat and sheep farming. Disease resulting from these infestations can cause changes in physical appearance, such as severe lesions on the skin, and economic consequences in the form of significantly reduced selling prices. This study aimed to determine the prevalence of ectoparasites in the Boyolali district, Central Java, Indonesia. A total of 651 sheep and goats were surveyed in this study. The parasites were collected via skin scraping, twister, or manually from clinically infected goats and sheep in traditional farms. All of the ectoparasites collected were successfully identified. The prevalence of ectoparasites in ruminants in Boyolali was 97.8% (637/651). The species make-up was as follows: Bovicola caprae 97.8% (637/651), Linognathus africanus 39% (254/651), Haemaphysalis bispinosa 3.5% (23/651), Ctenocephalides spp. 0.2% (1/651), and Sarcoptes scabiei 5.2% (34/651). The predilection sites were in the face, ear, and leg areas, and in the axillary, dorsal, abdomen, and scrotum regions of the surveyed animals. An evaluation of farmers' attitudes to ectoparasites was performed using a questionnaire. The findings of this study imply that animals in the investigated area are highly exposed to ectoparasite infestations. Given the importance of ectoparasites in both livestock and human communities, specifically in the health domain, more research into appropriate control strategies is necessary.

Prevention of Postoperative Skin Disorders and Pressure Injuries in the Neurosurgical Park Bench Position Surgery: A Prospective Cohort Study.

Background In neurosurgical procedures where the park bench position is employed, the risk of perioperative pressure injuries is elevated due to the limited contact surface area, with the head and part of the upper torso extending beyond the surgical table. This study aimed to examine the effects of preventative measures against such injuries, proposing a potential standard for postural fixation in these surgeries. Methods Conducted at a medical center, from January 2017 to March 2023, this prospective cohort study involved participants aged 20 and above who underwent neurosurgical procedures in the park bench position under general anesthesia. The focus was on comparing the incidence of pressure injuries between intervention and control groups. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Results Out of 65 patients enrolled, 28 were assigned to each of the intervention and control groups. The control group experienced 17 instances of postoperative pressure injuries and skin disorders in areas prone to pressure, such as the axillary and greater trochanter regions. Conversely, the intervention group reported no such incidents, underscoring the efficacy of meticulous surgical positioning and management of bodily pressure, temperature, humidity, and microclimate. Conclusion Implementing preventive measures in neurosurgical park bench procedures significantly reduces the incidence of postoperative pressure injuries and skin disorders. These findings advocate for the adoption of standardized postural fixation protocols in such surgeries, potentially influencing global clinical practices in neurosurgery.

A Multi-Target Identification and Positioning System Method for Tomato Plants Based on VGG16-UNet Model

The axillary buds that grow between the main and lateral branches of tomato plants waste nutrients and lead to a decrease in yield, necessitating regular removal. Currently, these buds are removed manually, which requires substantial manpower and incurs high production costs, particularly on a large scale. Replacing manual labor with robots can lead to cost reduction. However, a critical challenge is the accurate multi-target identification of tomato plants and precise positioning for axillary bud removal. Therefore, this paper proposes a multi-target identification and localization method for tomato plants based on the VGG16-UNet model. The average intersection and pixel accuracies of the VGG16-UNet model after introducing the pretrained weights were 85.33% and 92.47%, respectively, which were 5.02% and 4.08% higher than those of the VGG16-UNet without pretrained weights, achieving the identification of main branches, side branches, and axillary bud regions. Then, based on the multi-objective segmentation of the tomato plants in the VGG16-UNet model, the regions of the axillary buds in the tomato plants were identified by HSV color space conversion and color threshold range selection. Morphological dilation and erosion operations were used to remove noise and connect adjacent regions of the same target. The endpoints and centroids of the axillary buds were identified using the feature point extraction algorithm. The left and right positions of the axillary buds were judged by the relationship between the position of the axillary bud centroid and the position of the main branch. Finally, the coordinate parameters of the axillary bud removal points were calculated using the feature points to determine the relationship between the position of the axillary bud and the position of the branch. Experimental results showed that the average accuracy of the axillary bud pruning point recognition was 85.5%.

Mutation analysis and clinical profile of South African patients with Neurofibromatosis type 1 (NF1) phenotype.

Neurofibromatosis type 1 (NF1) is an autosomal dominant genetic condition with complete age-dependent penetrance, variable expressivity and a global prevalence of ∼1/3,000. It is characteriszed by numerous café-au-lait macules, skin freckling in the inguinal or axillary regions, Lisch nodules of the iris, optic gliomas, neurofibromas, and tumour predisposition. The diagnostic testing strategy for NF1 includes testing for DNA single nucleotide variants (SNVs), copy number variants (CNVs) as well as RNA analysis for deep intronic and splice variants, which can cumulatively identify the causative variant in 95% of patients. In the present study, NF1 patients were screened using a next-generation sequencing (NGS) assay targeting NF1 exons and intron/exon boundaries for SNV and NF1 multiple ligation-dependent probe amplification (MLPA) analysis for CNV detection. Twenty-six unrelated Southern African patients clinically suspected of having NF1, based on the clinical diagnostic criteria developed by the National Institute of Health (NIH), were included in the current study. A detection rate of 58% (15/26) was obtained, with SNVs identified in 80% (12/15) using a targeted gene panel and NF1 gene deletion in 20% (3/15) identified using MLPA. Ten patients (38%) had no variants identified, although they met NF1 diagnostic criteria. One VUS was identified in this study in a patient that met NF1 diagnostic criteria, however there was no sufficient information to classify variant as pathogenic. The clinical features of Southern African patients with NF1 are similar to that of the known NF1 phenotype, with the exception of a lower frequency of plexiform neurofibromas and a higher frequency of developmental/intellectual disability compared to other cohorts. This is the first clinical and molecular characterisation of a Southern African ancestry NF1 cohort using both next-generation sequencing and MLPA analysis. A significant number of patients remained without a diagnosis following DNA-level testing. The current study offers a potential molecular testing strategy for our low resource environment that could benefit a significant proportion of patients who previously only received a clinical diagnosis without molecular confirmation.

Macrophage Polarization and Crosstalk between Macrophages and Other Cells in Hidradenitis Suppurativa

Hidradenitis suppurativa (HS), also known as acne inversa, is a chronic inflammatory disease characterized by the development of inflammatory nodules, abscesses, and pus-discharging tunnels in areas such as the axillary, inguinal, gluteal, and perianal regions. The pathogenesis of HS remains unclear, but it is being increasingly recognized to rely on the dysregulation of inflammatory responses. Central to this process are macrophages, which have emerged as key players in the inflammatory milieu of HS. These cells orchestrate inflammation via polarization and significantly influence the functions of neighboring cells. This review briefly describes macrophage polarization and crosstalk between macrophages and other cells in patients with HS with the aim of providing new therapeutic strategies for the clinical management of HS.