Coin-shaped Lesions Research Articles

Higher Expression of Lympho-epithelial Kazal-type-Related Inhibitor-1 Fragments and Decreased Desquamation in the Lesional Skin of Nummular Eczema.

Nummular eczema, a chronic dermatitis characterized by coin-shaped lesions, was first documented in 1857. However, its pathophysiological characteristics are still not well known. To investigate differences in the regulation of the desquamation process in the stratum corneum of lesional and nonlesional skin of patients with nummular eczema and healthy control subjects, tape-stripped stratum corneum samples from patients with nummular eczema and healthy volunteers were analysed using immunofluorescence staining and western blot analysis. In the nummular eczema lesional skin, expression of desmoglein-1, desmocollin-1, and corneodesmosin exhibited a disorganized, dense or partially diffuse non-peripheral pattern with increased intensity, compared with the peripheral patterns observed in healthy or nonlesional skin, suggesting the impaired desquamation process in nummular eczema. Furthermore, although the expression of the desquamation-related serine proteases, kallikrein-related peptidase 7 and 5, was increased in nummular eczema lesional skin, the immunofluorescence staining of lympho-epithelial Kazal-type-related inhibitor-1, an endogenous inhibitor of various kallikrein-related peptidases, and its fragments were significantly increased in the nummular eczema lesional skin, suggesting its contribution to the inhibition of corneodesmosomal degradation. Therefore, the increased detection of corneodesmosomal proteins in nummular eczema lesions may be due to the increased amount of the fragments of lympho-epithelial Kazal-type-related inhibitor-1, which could contribute to delayed desquamation.

Nummular eczema with Helicobacter pylori: A rare case treated with Ayurvedic protocol

Abstract Nummular eczema is a rare presentation of the most common dermatological ailment atopic dermatitis. With its multiple coin-shaped lesions, it is usually perceived and managed as Kushtha (spectrum of skin disease) in Ayurveda. However, in certain conditions, this management may not suffice. This article focuses on a newly discerned relationship of nummular eczema with Helicobacter pylori and how the incorporation of Krimi Chikitsa (microorganisms) led to successfully manage such a case. The need for such an exploration resulted when there was no Upashaya (relief) seen in the conventional Kushtha treatment in this case. This single case study calls for a need for continuous updating of knowledge as well as strongly ascertains the need to analyze Upashaya and Anupashaya (favorable and unfavorable treatment and intervention) in a treatment.

Lipidomics Profile Change of Skin Surface Lipids in Nummular Eczema

Nummular eczema (NE), first introduced by Devegie in 1857, is chronic dermatitis characterized by oval or coin-shaped lesions with distinct boundaries, usually accompanied by severe pruritus (Leung et al., 2020). Although, its pathophysiological characteristics are still scarcely available, various factors have been reported to be implicated such as nutrition, infection, alcohol intake, dry skin, contact irritation and sensitivity (Bonamonte et al., 2012). Besides controlling inflammation, management is aimed at reducing skin dryness and restoring the skin barrier, which improves xerosis and irritation (Leung et al., 2020).

32472 An unexpected postsurgical phenomena: Postsurgical nummular eczema; a case series and review of the literature

Nummular eczema (NE), an eczematous dermatosis characterized by coin-shaped lesions, has several etiologies including allergic, inflammatory, autoimmune, and idiopathic. NE has been described postoperatively following breast reconstruction. We present a series of 4 cases illustrating a novel association of NE in the postsurgical setting, including never-described cases of NE presenting after total knee arthroscopy and lumpectomy without breast reconstruction. On average, our patients were 78 years old and developed NE limited to the postsurgical area 3 years after surgery.

Coin-shaped corneal endothelial scar in herpes zoster ophthalmicus: a case report

BackgroundHerpes zoster ophthalmicus includes a wide spectrum of lesions at the ocular surface, including epithelial, stromal, endothelial keratitis, and uveitis. Thus far, the occurrence of corneal endothelial disorder in herpes zoster ophthalmicus and the causative virus have not been confirmed, and the differential diagnosis and establishment of therapeutic strategies are challenging. Corneal endothelial coin-shaped lesions are well known to occur in cytomegalovirus-related corneal endotheliitis but have not been reported in patients with herpes zoster ophthalmicus.Case presentationA 39-year-old Asian female was referred to our ophthalmology department with recurrent anterior uveitis accompanied by coin-shaped corneal endothelial scar-like lesions that appeared after right facial herpes zoster. Diffuse corneal stromal haziness was mostly limited in the anterior stroma. The coin-shaped corneal endothelial lesions were separate from stromal lesions and showed a high-reflective scar-like line in sections of anterior segment optical coherence tomography. Anterior uveitis recurred each time she discontinued oral antiviral drug treatment for 12 months after the first event, but was remitted by the maintenance medications of combined topical ganciclovir gel with oral valaciclovir, at a dose lower than the usual adult dose, for acute or recurrent zoster-associated anterior uveitis. Corneal endothelial function remained normal and corneal endothelial and stromal lesions were unchanged throughout the treatment and follow-up period.ConclusionsIn patients with a history of facial herpes zoster with coin-shaped corneal endothelial scar accompanying recurrent anterior uveitis, suspicion for active varicella-zoster virus is warranted, and prolonged intake of oral antiviral agents is required despite varicella-zoster virus DNA not being detected in aqueous humor.

Use of specific acupuncture techniques in lingering nummular eczema: A case report

Abstract Background Nummular eczema (NE) is an inflammatory skin disease characterized by pruritic coin-shaped lesions and a long-lasting and easy-relapsing course, which severely decreases patients’ quality of life. This case was designed to observe the effects of specific acupuncture techniques on pruritic NE management. Case presentation A 22-year-old female was first diagnosed with pruritic NE three years earlier. No allergies were found in the patch test; while emotional stress would trigger and aggravate the NE. External application of 0.1% tacrolimus failed to reverse this condition over a long period of treatment. Treatment & outcomes An individualized acupuncture treatment protocol was identified. Half needling and encircling needling were applied at local eczematous lesions, with routine needling at meridian points, once per week, for 12 treatment sessions. All outcome measures, including the Eczema Area and Severity Index, Visual Analogue Scale score for pruritus, Self-Rating Anxiety Score, and Dermatology Quality Life Index, substantially improved over 6 months from pre-treatment to 3 months post-treatment. Conclusion Acupuncture might be a promising non-pharmacological treatment method for patients with NE, especially for those with emotional stress. A randomized controlled trial with an adequate sample size and rigorous study design is required to verify the results of the study.

231 Analysis of corneodesmosomal proteins in nummular eczema skin

Nummular eczema, a chronic dermatitis characterized by coin-shaped lesions, was first introduced by Devegie in 1857. In spite of its long history, data regarding its corneodesmosomal components are hardly available in the current literature. We performed this study to investigate whether the distribution of corneodesmosomal components and surface areas of corneocytes in nummular eczema skin lesions are different from those found in healthy skin. Tape-stripping was used to acquire corneocytes from a disease group (n = 24 cases both lesional and non-lesional skin) and a control group (n = 15).

Dupilumab treatment of nummular dermatitis: A retrospective cohort study

To the Editor: Nummular dermatitis is an idiopathic eczematous eruption characterized by pruritic, coin-shaped lesions typically involving the extremities and, less commonly, the trunk. Although topical therapy is the mainstay of management, treatment escalation may be required in severe cases. Dupilumab is a human monoclonal antibody against the interleukin 4 receptor α subunit that has shown efficacy for moderate to severe atopic dermatitis.1 We present a retrospective cohort study of our institutional experience with dupilumab for nummular dermatitis.

The effect of topical application of 0.15% ganciclovir gel on cytomegalovirus corneal endotheliitis

Background/aimsThe aim of this study was to evaluate the therapeutic efficacy and drug transfer of topical application of 0.15% ganciclovir (GCV) gel on cytomegalovirus (CMV) corneal endotheliitis.MethodsThis study is a...

Clinical features and management of cytomegalovirus corneal endotheliitis: analysis of 106 cases from the Japan corneal endotheliitis study

AimsThe purpose of this study is to elucidate the clinical manifestations and the current treatment status of cytomegalovirus (CMV) endotheliitis via a large case series obtained from a national survey...

Relationship between the number of cytomegalovirus in anterior chamber and severity of anterior segment inflammation

To characterize the cytomegalovirus-associated anterior segment inflammation and to determine whether the number of cytomegalovirus is significantly correlated with the disease characteristics. Retrospective consecutive case series. Seventy-three patients with refractory anterior segment inflammation due to iridocyclitis, corneal endotheliitis and keratouveitis were studied. All the patients were suspected to have cytomegalovirus infection and had undergone real-time PCR of the aqueous humor to determine the amount of cytomegalovirus DNA. Cytomegalovirus DNA was detected in 24 of the 73 cases. The cytomegalovirus copy number was significantly correlated with the number of recurrent episodes and glaucoma treatment levels, but was not significantly correlated with the disease type. A high cytomegalovirus copy number was a significant risk factor for IOP elevation [Odds ratio (OR) per logarithm CMV amount: 2.5 (95% confidence interval (CI) 1.1-5.4), presence of coin-shaped lesions (2.3 (1.3-4.0)), recurrent inflammation (2.1 (1.3-3.5)), and reduction of endothelial cell densities (1.7 (1.2-2.5))]. An IOP elevation [OR 18.2 (95% CI 2.2-153.0)], reduction of endothelial cell densities [13.2 (2.9-60.0)], and recurrent inflammations [11.9 (2.5-56.6)], but not the disease type, were significant predictors of the presence of >10(3)copies/ml cytomegalovirus in the aqueous. Measurements of the cytomegalovirus DNA amount is useful for evaluating the severity of the anterior segment inflammation.

Mapping owl’s eye cells of patients with cytomegalovirus corneal endotheliitis using in vivo laser confocal microscopy

To produce a two-dimensional reconstruction map of owl's eye cells using in vivo laser confocal microscopy in patients with cytomegalovirus (CMV) corneal endotheliitis, and to demonstrate any association between owl's eye cells and coin-shaped lesions observed with slit-lamp biomicroscopy. Two patients (75- and 77-year-old men) with polymerase chain reaction-proven CMV corneal endotheliitis were evaluated in this study. Slit-lamp biomicroscopy and in vivo laser confocal microscopy were performed. Images of owl's eye cells in the endothelial cell layer were arranged and mapped into subconfluent montages. Montage images of owl's eye cells were then superimposed on a slit-lamp photo of the corresponding coin-shaped lesion. Degree of concordance between the confocal microscopic images and slit-lamp photos was evaluated. In both eyes, a two-dimensional reconstruction map of the owl's eye cells was created by computer software using acquired confocal images; the maps showed circular patterns. Superimposing montage images of owl's eye cells onto the photos of a coin-shaped lesion showed good concordance in the two eyes. This study suggests that there is an association between owl's eye cells observed by confocal microscopy and coin-shaped lesions observed by slit-lamp biomicroscopy in patients with CMV corneal endotheliitis. The use of in vivo laser confocal microscopy may provide clues as to the underlying causes of CMV corneal endotheliitis.

Clinical Significance of Owl Eye Morphologic Features by In Vivo Laser Confocal Microscopy in Patients With Cytomegalovirus Corneal Endotheliitis

To demonstrate the clinical significance of owl eye morphologic features observed by in vivo laser confocal microscopy in patients with cytomegalovirus (CMV) corneal endotheliitis. Observational case series. participants: Six eyes of 6 patients (6 men; mean age, 73.3 years) with cytomegalovirus corneal endotheliitis diagnosed by clinical manifestations together with polymerase chain reaction from aqueous humor samples. intervention: All patients were examined by slit-lamp biomicroscopy and in vivo laser confocal microscopy. main outcome measures: Clinical manifestations were summarized by reviewing medical records. Selected confocal images of corneal layers were evaluated qualitatively for shape and degree of light reflection of abnormal cells and deposits. All patients had long histories of anterior uveitis with intraocular pressure elevation, corneal edema with keratic precipitates, and decrease of endothelial cell densities. Coin-shaped lesions were observed by slit lamp only in 1 patient at the first visit and in 2 additional patients at subsequent follow-up. In all patients, confocal microscopy demonstrated reduced subepithelial nerves, subepithelial opacity, increased reflectivity of keratocytes, highly reflective dots, and needle-shaped bodies. Owl eye morphologic features were observed consistently in all patients at the initial visit, and highly reflective round bodies were detected in 5 patients; most notably, these confocal features were reversible after resolution of endotheliitis. Owl eye morphologic features and highly reflective round bodies observed by confocal microscopy may be useful as an adjunct for the noninvasive diagnosis of cytomegalovirus corneal endotheliitis. Reversibility of these features after resolution of endotheliitis may be useful for monitoring the therapeutic effects without multiple anterior chamber tap.

Reply: Coin-shaped epithelial lesions following an acute attack of erythema multiforme minor with confocal microscopy findings

Dear Editor, We thank Jain et al.[1] for their interest in our article.[2] We do agree that these lesions do improve with topical steroids. What is important here is the presence of additional systemic features like skin eruptions or involvement of a mucosa. In our patient, there were skin eruptions and painful buccal mucosal ulcers following a viral illness. Herpes simplex virus-induced erythema multiforme (EM) minor constitutes 15-60% of EM minor. The treatment is a combination of acyclovir and oral steroids.[3] Treatment with oral steroids along with oral acyclovir is definitely justified in our case. In contrast, we do see cases of EM minor with only ocular involvement in the form of coin-shaped lesions which will definitely improve only with topical steroids just like the case described by Jain et al.[1] As we have described the confocal microscopy findings speculating an immunological mechanism in the development of these coin-shaped lesions on the cornea, these lesions will definitely respond to topical steroids.

Recurrent Cytomegalovirus Corneal Endotheliitis after Penetrating Keratoplasty

To report a case of recurrent cytomegalovirus (CMV) corneal endotheliitis after penetrating keratoplasty. Penetrating keratoplasty (PK) was performed in a 49-year-old man with bullous keratopathy. Pigmented keratic precipitates (KPs) were found in the corneal endothelium of the graft 13 days after surgery, with the subsequent appearance of coin-shaped lesions. Confocal microscopy was performed on the corneal endothelium. Aqueous humor was analyzed for viral DNA by polymerase chain reaction (PCR). CMV DNA was detected from the excised corneal button, and aqueous humor revealed positive results for CMV and HSV1 by PCR. Confocal microscopy showed large corneal endothelial cells, consistent with the typical owl's eye morphology of CMV endotheliitis. After systemic ganciclovir was administered, the pigmented KPs and coin-shaped lesions gradually decreased. Stress from surgery and corticosteroid usage can revitalize CMV activity. PCR and confocal microscopy are valuable for the diagnosis of CMV corneal endotheliitis.

Coin-shaped epithelial lesions following an acute attack of erythema multiforme minor with confocal microscopy findings

We report an interesting ocular finding of bilateral multiple coin-shaped epithelial lesions along with the confocal microscopy findings in a patient following an acute attack of erythema multiforme (EM) minor. A 30-year-old male presented with a history of watering and irritation in both eyes of three days duration. He was diagnosed to have EM minor and was on oral acyclovir. Slit-lamp examination revealed multiple coin-shaped epithelial lesions. Confocal microscopy showed a corresponding conglomerate of hyper-reflective epithelial lesions. The corneal lesions resolved over six weeks with oral steroids and acyclovir. An immunological mechanism is suspected.

Cytomegalovirus as an Etiologic Factor in Corneal Endotheliitis

To investigate clinical manifestations and response to antiviral therapy of 8 patients with cytomegalovirus (CMV)-induced corneal endotheliitis who were diagnosed and treated at 2 university hospitals in Japan. Retrospective, consecutive, multicenter case series. Eight eyes of 8 patients diagnosed with active CMV corneal endotheliitis at Kyoto Prefectural University of Medicine and Ehime University School of Medicine. The diagnosis was made based on the detection by polymerase chain reaction assay of CMV, but not herpes simplex virus (HSV) and varicella zoster virus (VZV) DNA, in the aqueous humor from the affected eye. Retrospective review of the clinical manifestations and responses to antiviral treatment. Patient profiles, including duration of corneal endotheliitis, systemic disease, intraocular pressure, and clinical manifestation of anterior and posterior segments. The clinical response to systemic and topical antiviral treatment was evaluated by slit-lamp examination. Corneal endothelial density was examined by specular microscopy. The average observation period after CMV detection was 10.4 months (range, 2-24 months). None of the patients had systemic immunodeficiency. Corneal manifestations included linear keratic precipitates associated with multiple coin-shaped lesions and local corneal stromal edema. Of the 8 patients, 4 had undergone penetrating corneal transplantation. Systemic ganciclovir therapy was used in 7 patients, and in 1 patient, valacyclovir was administered, with the corneal endotheliitis responding quickly to the early administration of galovir. At the final examination, 6 eyes had a clear cornea, but 2 eyes had bullous keratopathy. Besides HSV and VZV, CMV must be considered as an etiologic agent in patients with corneal endotheliitis. Cytomegalovirus corneal endotheliitis may be a newly identified clinical entity of reactivated CMV in the anterior chamber of individuals free of accompanying systemic symptoms.

Demonstration of “Owl’s Eye” Morphology by Confocal Microscopy in a Patient With Presumed Cytomegalovirus Corneal Endotheliitis

To report confocal microscopic observations of characteristic corneal endothelial lesions in a patient with presumed cytomegalovirus (CMV) corneal endotheliitis. Case report. A 77-year-old, immunocompetent man was admitted with corneal edema, keratic precipitates, and coin-shaped lesions in the right eye. Confocal microscopy was performed to examine the corneal endothelium. Polymerase chain reaction (PCR) was used to identify viral DNA in an aqueous humor sample. CMV DNA was detected by PCR. Confocal microscopy showed large corneal endothelial cells with an area of high reflection in the nucleus surrounded by a halo of low reflection. This "owl's eye" morphology is characteristic of CMV infection. Topical and intravenous ganciclovir treatment resulted in rapid resolution of the corneal precipitates and edema, followed by disappearance of the owl's eye morphology. Confocal microscopy can detect the owl's eye morphology in the corneal endothelium of patients with presumed CMV corneal endotheliitis.

Giant Pulmonary Hamartoma—A Rare Presentation of a Common Tumor

Hamartomata, the most common benign tumors of the lung, are rarely symptomatic and usually come to clinical attention as coin-shaped lesions on a routine plain chest roentgenogram. We report a case of a 63-year-old woman presenting with reduced endurance on exercise. The plain chest roentgenogram showed a tumor in the left chest. After clinical work-up, the patient underwent radical tumor resection through a lateral thoracotomy. The resected tumor, with two separate nodules, measured 26 x 25 cm and weighed 3.2 kg. The histopathology work-up showed pulmonary hamartoma.

Cytomegalovirus in Aqueous Humor From an Eye With Corneal Endotheliitis

To report cytomegalovirus (CMV) DNA in aqueous humor from a patient with unilateral corneal endotheliitis. Case report. A 51-year-old man presented with unilateral corneal endotheliitis with linear keratic precipitates and coin-shaped lesions. Tear and aqueous humor samples were subjected to polymerase chain reaction to look for DNA from herpes simplex virus (HSV), varicella zoster virus (VZV), and CMV. Aqueous humor from the diseased eye contained DNA from CMV but not HSV or VZV. Its specificity was confirmed by Southern blot tests. Intravenous ganciclovir treatment resulted in the localization of his corneal edema and the reduction in keratic precipitates. There was severe destruction of corneal endothelial cells. CMV DNA was not detected in tears or control samples. In this healthy man with corneal endotheliitis, we detected CMV DNA in aqueous humor from the affected eye, but not HSV or VZV. This suggests that CMV may cause corneal endotheliitis in patients without immunodeficiency.