Diffuse Erythema Research Articles

Lisinopril-Induced Pemphigus Foliaceus in a Patient with Diabetes Mellitus and Kaposi-Juliusberg Varicelliform Eruption

Abstract Drugs have often been implicated as the cause of pemphigus. Lisinopril is a drug of the angiotensin-converting enzyme inhibitor class primarily used in the treatment of hypertension, congestive heart failure, heart attacks, and also in preventing renal and retinal complications of diabetes mellitus. Various side-effects have been described in the English medical literature related to lisinopril, but only one case with pemphigus foliaceus as an adverse reaction to lisinopril. To the best of our knowledge, we present the second case of lisinopril-induced pemphigus foliaceus complicated with Kaposi-Juliusberg varicelliform eruption in a patient diabetes mellitus type II. A 60-year-old man presented with diffuse erythema on the face, trunk and extremities. Disseminated erosions, 2-5 mm in diameter, and umbilicated vesicles were present. Erosions with remnants of the blister roof were partially found on the trunk. Semiannular erosions were present. On the posterior part of the trunk (paravertebral and vertebral) there were inifiltrated, partially grouped, sharply delineated yellowish-reddish plaques, up to 2 cm in diameter. Direct and indirect immunofluorescence test as well as histological analysis revealed a drug-induced pemphigus foliaceus. After treatment of Kaposi-Juliusberg eruption and impetiginization, lisinopril was discontinued. Rapid involution of the skin lesions, was observed. Since, only minor skin lesions still persisted after 6 months of follow-up and treatment, the diagnosis of druginduced pemphigus foliaceus was established. It usually takes 1 - 6 months for angiotensin-converting enzyme inhibitors to induce pemphigus. All drugs taken by the patient, including homeopathic agents, over-the-counter drugs, and even medications that were discontinued should be taken into consideration. Medical history taking should be repeated in cases where there is no response to therapy.

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Case Reports: A 25 y/o nonsmoker, atopic male presented with 3 days of viral-like symptoms. CT chest was negative for pulmonary embolism, but revealed scattered ground glass opacities (GGO). He developed acute respiratory failure, initially placed on BiPAP and then emergently intubated (pH 7.14, paCO2 86, paO2 83 on FiO2 1). Peak airway pressures were above 60mmHg and he required paralytics. Bronchoscopy revealed thick secretions and diffuse mucosa erythema. Studies showed 12% eosinophils (64/mm3) on BAL, acute inflammation on cytology, and cor pulmonale on echocardiogram. Chest CT revealed pneumomediastinum and GGO. All immunology, microbiology and viral studies were negative.He was liberated from ventilation after 2 days, and made a rapid recovery on IV steroids and nebulized albuterol. Spirometry, lung volumes and diffusing capacity 4 weeks after discharge were normal. Cor pulmonale was resolved on repeat echocardiogram. CT chest showed resolution of pneumomediastinum and GGO. His alexithymia score was 53 per the 20 question Toronto Alexithymia Scale (TAS-20).Near fatal asthma (NFA) is defined as sudden onset respiratory arrest, need for mechanical ventilation, paCO2 of >50mmHg or pH <7.3 in asthmatic patients1. Mortality rate in those requiring mechanical ventilation is 16.5%2. Pathologically, predominant eosinophilia, remodeling with acute and chronic inflammation and an eosinophilic BAL (average 54/mm3) is seen3.Alexithymia is a psychological trait of difficulty recognizing body sensations and describing emotions which can blunt the perception of the severity of symptoms, such as dyspnea. It is seen in 36% of known asthmatic patients with NFA and can be detected by TAS-204. However, alexithymia has not been found to be associated with newly diagnosed asthmatic patient with NFA.This unique initial presentation of NFA with no clear history of asthma is not described in literature. Our patient’s atopic history, acute respiratory failure with increased airway resistance, barotraumas, increased BAL eosinophils and response to corticosteroid therapy highly suggests asthma presenting with NFA. Alexithymia may have led to under recognition of his symptoms.

Hemospray for Life-Threatening Gastrointestinal Bleeding Secondary to Ulcer Disease: First Case Report in the United States Presidential Poster

Purpose: Acute upper GI hemorrhage causes 300,000 annual U.S. hospital admissions with a mortality rate of 10%. In some cases, hemostasis is difficult to achieve secondary to anatomy or severe bleeding which is not amenable to currently available therapies. Hemospray powder (Cook Endoscopy) is a novel approach currently pending FDA approval for hemostasis of nonvariceal peptic ulcer bleeding. Hemospray is a granular, mineral blend nanopowder with clotting abilities which acts by increasing the concentration of clotting factors, activating platelets, and forming a mechanical plug on an injured blood vessel. Here we report the first case in the U.S. in which Hemospray was used to treat a patient in the clinical setting. Our patient was a 13yo male with metastatic rhabdomyosarcoma with pancreatic head mass and biliary obstruction secondary to CBD stricture. Patient underwent ERCP with fully covered SEMS placement. Subsequently, he redeveloped jaundice along with vomiting. EGD revealed that the stent had migrated distally and embedded into the contralateral duodenal wall, with a large bleeding ulcer where the stent was embedded. There was also diffuse erythema and edema with oozing proximal to this area. Endoscopic therapy was not feasible and patient underwent IR embolization of the gastroduodenal artery. Over the next week, patient was monitored in the PICU and required multiple blood transfusions. He also developed thrombocytopenia requiring platelet transfusions. Despite repeat IR embolization and medical therapy with PPI and octreotide drips, active bleeding persisted. The surgical service deemed him a non-surgical candidate. Given his life-threatening condition with persistent active bleeding and no feasible medical or surgical option, we obtained approval for use of Hemospray. EGD was performed revealing erythematous, edematous, friable antral mucosa with a mosaic pattern. An adherent clot was seen at the pyloric channel and removed with irrigation and aspiration, revealing an oozing ulcer. The duodenum was also erythematous and edematous. There was diffuse oozing in the antrum and duodenum along with re-identification of the duodenal ulcer, not amenable to conventional therapy. A total of 25 to 30 grams of Hemospray powder was applied to the duodenal ulcer site, the proximal duodenum, the antrum, and the pyloric channel site. After application, there was no evidence of oozing or active bleeding. The patient tolerated the procedure well and he was discharged home six days later with no further episodes of bleeding. To our knowledge, this is the first successful use of Hemospray for the management of upper gastrointestinal bleeding outside of a clinical trial.

Vulvar Psoriasis in Adults and Children

There are limited data on psoriasis as it affects the vulva in the medical literature. This observational study aimed to describe the symptoms, signs, and management of vulvar psoriasis in adults and children in a private vulvar disease referral practice. A review of the existing literature on vulvar psoriasis was used to generate inclusion criteria of a chronic noninfective erythematous vulvitis without vaginal involvement. Between January 2009 and October 2011, 201 patients presenting with these criteria were coded as having psoriasis in a computerized database where standardized data were collected. In 194 of these patients, adequate data were available to include in the study. Only 12.3% of the patients presented with psoriasis as a provisional diagnosis with a mean symptom duration of 4.5 years (range = 6 weeks to 35 years). The most common presentation was a pruritic, bilaterally symmetrical, erythematous, nonscaly, well-demarcated macular eruption or slightly raised plaque (82.5%). Of the remaining patients, 9.2% presented with only diffuse symptomatic erythema, whereas 8.2% were symptomatic without erythema. In 64.9% of the patients, evidence of psoriasis was found on other parts of the skin. Initial induction treatment with potent topical corticosteroid followed by a maintenance treatment with less potent topical steroids and other psoriasis-specific treatment such as tar creams and calcipotriol resulted in a suppression of disease in 93.8% of the patients during a mean follow-up duration of 8.9 months (range = 1 month to 7.25 years). Vulvar psoriasis is a difficult diagnosis that should be considered in patients presenting with a chronic erythematous vulvitis without vaginitis. It is a chronic relapsing skin condition that requires long-term management.

Cutaneous vasculitis in ulcerative colitis mimicking Henoch–Schönlein purpura

To the best of our knowledge, no cases of ulcerative colitis (UC) mimicking Henoch–Schönlein purpura (HSP) have been reported so far. During a 28-year period 5635 patients were followed up at our Pediatric Rheumatology Unit and 357 had HSP according to the European League Against Rheumatism, the Paediatric Rheumatology International Trials Organisation and the Paediatric Rheumatology European Society validated classification criteria. At the same period, 148 patients with IBD according to the European Society for Paediatric Gastroenterology, Hepatology and Nutrition criteria were followed up at the Pediatric Gastroenterology Unit in our University Hospital. Only two of them had vasculitis, as an extra intestinal manifestation of UC mimicking HSP, and fulfilled both disease criteria. A 2-year old girl had bloody diarrhoea, severe abdominal pain, arthritis in ankles, petechiae and palpable purpura not related to thrombocytopenia in lower limbs. A 5-year old boy had bloody diarrhoea, palpable purpura in buttocks, lower limbs, penis and scrotum associated with arthritis in knees, orchitis in right testicle and periarticular swelling in hands and feet. Their ileocolonoscopy showed diffuse mucosal erythema, oedema, friability and multiple irregular ulcers, and histopathological examination of colonic specimen revealed diffuse chronic mucosal inflammation, crypt distortion and crypt abscesses suggesting ulcerative colitis. There were no signs of intestinal vasculitis in both cases. In conclusion, this is the first study in a paediatric population that evidenced palpable purpura associated with UC mimicking HSP.

Open-label, phase II trial of afatinib, with or without vinorelbine (V), for the treatment of HER2-overexpressing inflammatory breast cancer (IBC).

TPS650 Background: IBC is an aggressive and rare form of BC (1–6% cases). Despite recent treatment advances, prognosis remains poor, with 3-yr survival rate of 40 vs 85% in non-IBC. IBC commonly lack ER/PR and more frequently harbour HER2 gene amplification (~40%), and EGFR overexpression (~30%) associated with poor prognosis. Recent data reported clinical efficacy of lapatinib, a reversible EGFR/HER2 inhibitor, in trastuzumab (T) naïve/resistant HER2 positive IBC. Afatinib is an irreversible ErbB Family Blocker with preclinical activity in T-resistant cell lines, HER2-positive tumor xenografts and HER2-negative SUM 149 xenograft model derived from an IBC cell line. Its clinical efficacy was shown in heavily pre-treated, HER2-positive metastatic BC pts who progressed after T, with PR in 10% and clinical benefit in 46% of pts. The purpose of this biomarker-driven study is to investigate efficacy and safety of afatinib alone and in combination with V upon progression on afatinib monotherapy and the genomic changes that occur through treatment in pts with T pretreated or naïve HER2-positive IBC. Methods: Pts are recruited in 2 parallel cohorts of 20 pts each: T-naïve and T failure. Key eligibility criteria: histologically-confirmed HER2-positive BC; investigator-confirmed IBC characterized by diffuse erythema and oedema (peau d’orange) while dermal lymphatic emboli or palpable mass are not necessary for diagnosis; no prior anti-HER2 therapy except T in the T failure cohort; no prior V; ECOG 0–2. All pts start afatinib monotherapy (40 mg/d oral) in 4-week cycles (Part A). Upon disease progression, pts may receive afatinib (40 mg/d) + V (IV 25 mg/m2/week) (Part B). Primary endpoint: Clinical Benefit Rate (CR, PR or SD) for ≥6 months. Secondary endpoints: objective response rate, PFS, OS and safety. Endpoints are assessed separately for Part A and Part B. Fresh biopsy and blood samples are taken prior to treatment and upon progression in Part A, to explore predictive markers of response/resistance to afatinib, to describe the IBC population which may benefit most, and for next generation sequencing and proteomic analysis. Enrollment ongoing since Aug 2011.

A prospective study of breast lymphedema: frequency, symptoms, and quality of life

Although lymphedema of the arm is a well-known complication of breast and axillary surgery, breast lymphedema has received scant attention. We sought to prospectively characterize breast lymphedema's incidence, associated symptoms, clinical course, and impact on quality of life. Subjects were enrolled prospectively from a consecutive sample of patients undergoing non-mastectomy breast procedures (excisional biopsy or wide local excision ± lymph node removal) and followed for signs and symptoms of lymphedema in the operated breast. Symptoms and distress were serially assessed with 11-point linear analog scales. Breast lymphedema was diagnosed independent of symptoms, based on the distribution and degree of edema and erythema. One hundred twenty-four women were followed for a median of 11 months, and breast lymphedema was diagnosed in 38 (31%) women. Breast lymphedema was more frequent after breast surgery with axillary node removal (49%) compared to breast surgery alone (0%), p < 0.0001. Breast lymphedema involved multiple quadrants in most women and was characterized by edema in 100% and erythema in 79%. Patients with breast lymphedema were significantly more likely than women without breast lymphedema to report symptoms of breast heaviness (65% vs 22%, p < 0.0001), redness (62% vs 29%, p = 0.0006), and swelling (59% vs 22%, p < 0.0001), but symptom-associated distress was low overall. Three of 32 breast lymphedema patients with clinical follow-up developed chronic edema. Breast lymphedema occurs in approximately one-half of women who undergo breast surgery with axillary node removal. The condition is characterized by diffuse skin edema and erythema as well as self-reported symptoms with a low level of distress.

Unusual presentation of MALT lymphoma as diffuse gastric erythema

Unusual presentation of MALT lymphoma as diffuse gastric erythema

A Case of Idiopathic Recurrent Duodenojejunitis

There are various etiologies of duodenojejunitis such as Henoch-Schönlei purpura (H-S purpura), vasculitis, Crohn's disease, celiac sprue, ischemia, lymphoma, Zollinger-Ellison syndrome, bacteria or parasite infection, radiation, drug induced jejunitis, eosinophilic jejunitis, and toxins. A 31-year-old man presented with left upper quadrant pain. He did not have febrile sense, hematochezia, melena, diarrhea, arthralgia and hematuria. He had neither drug history nor traveling history. Esophagogastroduodenoscopy showed diffuse mucosal erythema and segmental hemorrhagic erosions on the distal area to the descending portion of the duodenum and proximal jejunum, which were commonly observed in the gastrointestinal involvement of H-S purpura. However, he showed no skin lesions, joint and urologic problems until the discharge. Autoimmune markers such as antinuclear antibody and antineutrophil cytoplasmic antibody were negative. Celiac and mesenteric angiogram showed no vascular abnormality. After the administration of oral prednisolone 40 mg daily for therapeutic trial, abdominal pain and endoscopic lesions were improved. He experienced relapses of same episode without skin lesions 16 times during follow-up of 8 years, which were also treated with prednisolone. The abdominal computed tomography during the follow-up also showed no significant finding. We report a case of primary recurrent duodenojejunitis similar to the gastrointestinal involvement of H-S purpura without purpura.

Two Cases of Cercarial Dermatitis in An Italian Lake

Cercarial dermatitis (also named Swimmer's itch or Clam-digger's disease) was first described about 80 years ago, but today its impact is increasing and it is considered an emerging disease. This represents a hypersensitive or allergic reaction to Trichobilharzia spp, clinically characterized by initial erythema and cutaneous itching, followed by macular or papular eruptions, itching and occasionally diffuse erythema or urticaria. We report two cases of patients affected by a cercarial dermatitis after bathing in Lake Vico (Central Italy). We highlight these cases for the rarity of this dermatitis and its increasing prevalence, also in previously non-affected geographical areas, associated to a high level of social discomfort.

Moribund Stomach

Question: A 75-year-old Caucasian man sustained traumatic rib fractures with right-sided pneumothorax and right hip fracture after falling off a ladder. He underwent tube thoracostomy and repair of his hip fracture, and was doing relatively well until he suffered cardiopulmonary arrest 4 days later. He was successfully resuscitated after about 15 minutes and transferred to the intensive care unit. Mechanical ventilation and vasopressor support was required postresuscitation. Before cardiopulmonary arrest, there was no documented evidence of hypotension or tachycardia, and the triggering event was considered to be aspiration with attendant respiratory failure. It was discovered that the patient had a significant, 3-g decline in his hemoglobin over the preceding 24 hours, associated with some coffee-ground output from the nasogastric tube. The patient underwent emergent esophagogastroduodenoscopy (Supplementary Videos 1 and 2). He was found to have severe ulcerative esophagitis. There was no evidence of active bleeding. There was loss of normal mucosal vascular pattern throughout the entire stomach, and multiple diminutive ulcers and subepithelial hemorrhage, noted in the proximal and mid corpus (Figure A, B). Examination of the duodenum up to the third portion revealed diffuse patchy mucosal erythema. What is the diagnosis explaining these endoscopic findings? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The endoscopic findings are consistent with acute and diffuse ischemic insult due to the low-flow state resulting from the patient's cardiopulmonary arrest and persistent shock. In this patient, the low-flow state likely persisted for some time after resuscitation given the need for multiple vasopressors. Clinical ischemia of the stomach is very rare in view of its rich vascular supply and intramural anastomoses. It has been shown that both arterial and venous circulation must be compromised before gastric ischemia ensues.1Abdu R.A. Garritano D. Culver O. Acute gastric necrosis in anorexia nervosa and bulimia Two case reports.Arch Surg. 1987; 122: 830-832Crossref PubMed Scopus (96) Google Scholar Lee et al2Lee T.C. Lin J.T. Liang C.W. et al.Ischemic gastropathy: leopard skin in the stomach.Endoscopy. 2005; 37: 927Crossref PubMed Scopus (6) Google Scholar have previously reported ischemic gastropathy on endoscopy performed after cardiac arrest. Most other cases of gastric ischemia reported in the literature have been in the setting of acute massive gastric dilatation, either in the setting of gastric volvulus or binge eating associated with primary eating disorders.1Abdu R.A. Garritano D. Culver O. Acute gastric necrosis in anorexia nervosa and bulimia Two case reports.Arch Surg. 1987; 122: 830-832Crossref PubMed Scopus (96) Google Scholar Increased intragastric pressure >20 cm H2O, which exceeds venous pressure, results in gastric mucosal ischemia and necrosis.3Edlich R.F. Borner J.W. Kuphal J. et al.Gastric blood flow Its distribution during gastric distention.Am J Surg. 1970; 120: 35-37Abstract Full Text PDF PubMed Scopus (43) Google Scholar The predominantly mid corpus distribution of ischemic ulcerations in this case is likely explained by the watershed area of gastric vascular supply. Hemodynamic instability during esophagogastroduodenoscopy precluded us from obtaining biopsies. This patient had increasing intra-abdominal pressure as confirmed by increasing bladder pressures, and an emergent laparotomy was undertaken. The patient was found to have extensive ischemic changes involving the gastrointestinal tract as well as other intra-abdominal viscera, further corroborating an ischemic etiology from a low-flow state as the explanation for these rare endoscopic findings. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJlOTgwNDI3NjJjMGIwZDA1NDJlYWVkZDliN2U3NTg2ZCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjgxMjM3MjAyfQ.g2MPoxwS8j4vCybyxrQqE4z1baeTznOcJYrZ8JTooBo7slmg_dpz8iVBioS-U3Ut4xyif46aqf5Dygdh0Q_TMJVnV2QNsPG4XtiXgoGfHrIvasOUJ8AGwnQpsN5FHf25GXg9JG8VHy2MXbgc6vjXJAVvAuNRbd7hoJ6XHAGvGO8Z4HxsJ80LKYzUuj1fffkS0Cu2EkEvhEwJDQPps3JBtmpvAiODiwsSnd6IzlKrBUZVMHrJ_bxlwwqHVLY-a6rEUc6Lj16NfuZ46VvzfbLD6-vUrrrGz72_zIetKTtJ2F4qzgDuYkkeDwOqAuyEWeK404vvdgv0A4Od1PMyWCawIw Download .mp4 (16.33 MB) Help with .mp4 files Supplementary Video 1eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIxMDlmZWQwZDQ2YmU3M2EzNWQwZTE1MWVmOTIzODYwMCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjgxMjM3MjAyfQ.VlOIh7RMAdyyzik17pNvAp9gHD1go1tfVICZsIUR_IG3O_RDWKpvTEUeRbxR_p49LwkVlyG7HvbdgccwvN1n_D46lcvuOG1_0Vwf4ZAADJEC1So2VnxAJsnOPTgR37MkJ-8dB7M2gHhPEMD8tEU0QzZeFqEORX4oSXPF9zFVVPqQ-Op8WBRsKySy5WLvowQ_UrnT69KjBHd3-eg0owUpBm1_eLUFl6ksgWlCRZyb2sATPBl_UuiYSomNSTgl5lLA3q5QqUVonqqM9-0OQJrBsBhmCNmLAsuTze1aNDq0Xm5Z_L5Zj-tVFCDRPGWFsLRGlCRVC0b_lQrOJAbSpGLN5w Download .mp4 (4.3 MB) Help with .mp4 files Supplementary Video 2

Successful Tolerance of Deferasirox Following Desensitization for Significant Skin Rash

Abstract 5280 BACKGROUND:Deferasirox is an oral iron chelator that has become available in recent years. The long term tolerability profile of deferasirox is still being evaluated, however a common side effect is skin rash, which may occur in up to 10% of patients. This is usually mild to moderate and resolves with continued treatment. More severe rash may require interruption of therapy and reintroduction of deferasirox at a lower dose followed by gradual dose escalation. A short course of corticosteroids may be used. Occasional cases of angioedema have been reported for which cessation of deferasirox is recommended but re-introduction is difficult. We report three patients with hypersensitivity to deferasirox, two manifested as NCI CTC grade 3-skin rash and one as grade 1-skin rash. All were able to tolerate deferasirox following desensitization. METHODS:Two patients with β thalassaemia major and one with congenital sideroblastic anemia, all with transfusional iron overload, experienced skin rash to deferasirox and received a desensitization protocol, given orally as follows:Solution 1 (deferasirox 1.25 mg/ml):1 ml given days 1–32 ml given days 4–65 ml given days 7–9Followed by Solution 2 (deferasirox 12.5 mg/ml)1 ml given days 10–122 ml given days 13–155 ml given days 16–18The dose of deferasirox was subsequently increased by 125 mg/day every week until the desired dose was reached.RESULTS: Case 1:A 23 year-old female with b thalassaemia major, non-compliant with deferoxamine, was switched to deferasirox 1500 mg/day (20mg/kg/day). Nine days after starting deferasirox she experienced a low grade fever, extensive erythematous maculopapular rash and facial edema. Deferasirox was discontinued. Two days later the rash had progressed; prednisone was started at 50 mg/day and the rash resolved within 1 week. While still tapering prednisone (20 mg/day), deferasirox was re-started at 500 mg/day. The rash recurred within 2 days and deferasirox was discontinued. One year later the desensitization protocol was given and well tolerated without the development of skin rash; she is currently receiving deferasirox 1500 mg/day without difficulty. Case 2:A 21 year-old female with b thalassaemia major, non-compliant with deferoxamine, was switched to deferasirox 1500mg/day (20mg/kg/day). Ten days after starting deferasirox she developed diffuse erythema multiforme. Deferasirox was stopped and prednisone started at 1mg/kg/day with marked improvement. Five days later, still on prednisone in full doses, she was re-challenged with deferasirox 500 mg/day. The rash recurred and deferasirox was discontinued. One year later, the desensitization protocol was given and well tolerated without the development of skin rash. She is currently receiving deferasirox 1500mg/day without difficulty. Case 3:A 23 year-old female with congenital sideroblastic anemia receiving deferoxamine was switched to deferasirox 1500mg/day (20mg/kg/day) for ease of administration. Eight days after starting deferasirox she developed a maculopapular rash confined to the palms of the hands and soles of the feet, but associated with severe pruritis. Deferasirox was stopped and the patient declined prednisone. She resumed deferoxamine and was offered the deferasirox desensitization protocol. Desensitization was given successfully but required a three day extension of treatment with solution 1 (2ml) because of recurrent rash, which resolved over the following two days with the temporary addition of benadryl. She is currently receiving deferasirox 150mg/day on weekly dose escalation without difficulty. CONCLUSION:Deferasirox is often the chelation agent preferred by patients given its ease of administration. Given its documented reduction in total body iron, with promising effects on the removal of myocardial iron, the use of this agent is increasing. However, skin rash is a side effect that may limit the use of deferasirox in some patients. To our knowledge, this is the first report of a protocol that may successfully desensitize patients with hypersensitivity reactions to deferasirox, allowing them to tolerate this agent in therapeutic doses. Disclosures:Leitch:Novartis Corporation: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau.

Sonographic Features of Inflammatory Breast Cancer

D t c s i Inflammatory breast carcinoma (IBC) is an aggressive form of invasive breast cancer characterized by diffuse erythema and edema (peau d’orange) of the breast, often without an underlying mass. IBC is usually a diagnosed on clinical examination with variable and nonspecific imaging findings. This aggressive cancer takes its name from the associated inflammatory-like symptoms that arise primarily from cancer cells blocking dermal lymphatics.1 The earliest documentation of IBC was in 1814, by Sir Charles Bell, who described a purple color on the skin over a breast tumor and shooting pains that were associated with the tumor.2 In 1924, Lee and Tannenbaum3 described “inflammatory breast cancer.” Dermal lymphatic invasion in IBC was described by Taylor and Meltzer in 1938.4 The possibilty of intraparenchymal lymphatic involvement being diagostic for IBC, in the absence of dermal lymphatic involveent, has also been suggested.5 According to the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) program, the incidence of IBC in 9 geographic areas of the United States was 6% among white women with breast cancer and 10% among black women with breast cancer between 1975 and 1981.6 Lower percentages were observed by other investigators, ranging from 0.5% to 1.3%.7-10 This difference may be related o the inclusion of locally advanced breast cancer cases mong IBC cases in the SEER database, resulting in an apparntly greater incidence of IBC. In a review of more recent EER data, from 1988 to 2000, investigators reported that BC comprised 2% of all breast malignancies.11 The incidence of IBC increased from 2.0% to 2.5% between 1988 and 1990 and 1997 and 1999, whereas the incidence of locally advanced breast cancers and non-T4 cancers decreased. The cause of the increase in the incidence of IBC is not known, but possible theories include heightened awareness, im-

Phentermine Induced Ischemic Colitis

Purpose: Introduction: Weight loss medications have historically been cautiously supported due to adverse side effects such as pulmonary hypertension and valvular heart disease. In 1997 the FDA withdrew the combination of fenfluramine and dexfenfluramine from the market due to these adverse events. Phentermine, a commonly prescribed medication for short-term weight loss, works as a sympathomimetic and is an amphetamine derivative that remains available for prescription. We report a unique case of severe ischemic colitis following the use of phentermine in a patient with no other risk factors for ischemia. Case Presentation: A 57 year old female GI nurse presented to the emergency room complaining of bilateral lower quadrant abdominal pain followed by hematochezia two hours later. Digital rectal exam in the ER revealed bright red blood. Past medical history was unremarkable for any risk factors for gastrointestinal ischemia aside from well-controlled hypertension on a single antihypertensive. Phentermine had been prescribed five months prior at a dose of 30mg daily for weight loss. A colonoscopy was performed and showed diffuse contiguous erythema, superficial ulceration, and edema from the mid sigmoid colon to the mid transverse colon. A strictured area was also appreciated in the descending colon. The rectal and proximal colonic mucosa were normal. Biopsies obtained showed patchy mucosal hemorrhage and necrosis and confirmed the diagnosis of ischemic colitis. Phentermine had been held on admission and all symptoms resolved within 48 hours with supportive care. Two months later the patient remains asymptomatic and has not resumed her weight loss supplement. Discussion: There is one case report of ischemic colitis following fenfluramine in combination with dexfenfluramine. There is, however, only one published case report of phentermine in association with ischemic colitis that only involved a small segment at the splenic flexure. Gastrointestinal bleeding is not listed as a possible side effect of this commonly prescribed medication. Phentermine has been associated with ischemic neurologic events such as transient ischemic attacks and cerebral infarcts and could, through similar physiology, cause gastrointestinal ischemia. This unique case describes an instance of severe ischemic colitis following the use of phentermine involving almost the entire left colon and highlights the need for heightened awareness to identify patients and inform providers of the risk of gastrointestinal ischemia from this medication.

Crusted rosacea-like demodicidosis in an HIV-positive female

To the Editor: In 2009 a female patient, 19 years old, presented with reagent serology for human immunodeficiency virus (HIV); no treatment was given. Facial lesions appeared during pregnancy, 2 months after diagnosis of the HIV infection; they progressively worsened. She was given corticosteroids and antihistamines orally for a suspected allergic reaction, but her condition did not improve. She presented with pruritus and diffuse facial erythema, grayish crusted lesions, and adjacent papules and pustules (Fig 1, A).

Postoperative spinal infection mimicking systemic vasculitis with titanium-spinal implants.

BackgroundSecondary systemic vasculitis after posterior spinal fusion surgery is rare. It is usually related to over-reaction of immune-system, to genetic factors, toxicity, infection or metal allergies.Case DescriptionA 14 year-old girl with a history of extended posterior spinal fusion due to idiopathic scoliosis presented to our department with diffuse erythema and nephritis (macroscopic hemuresis and proteinuria) 5 months post surgery. The surgical trauma had no signs of inflammation or infection. The blood markers ESR and CRP were increased. Skin tests were positive for nickel allergy, which is a content of titanium alloy. The patient received corticosteroids systematically (hydrocortisone 10 mg) for 6 months, leading to total recess of skin and systemic reaction. However, a palpable mass close to the surgical wound raised the suspicion of a late infection. The patient had a second surgery consisting of surgical debridement and one stage revision of posterior spinal instrumentation. Intraoperative cultures were positive to Staphylococcus aureus. Intravenous antibiotics were administered. The patient is now free of symptoms 24 months post revision surgery without any signs of recurrence of either vasculitis or infection.Literature ReviewSystemic vasculitis after spinal surgery is exceptionally rare. Causative factors are broad and sometimes controversial. In general, it is associated with allergy to metal ions. This is usually addressed with metal on metal total hip bearings. In spinal surgery, titanium implants are considered to be inert and only few reports have presented cases with systemic vasculitides. Therefore, other etiologies of immune over-reaction should always be considered, such as drug toxicity, infection, or genetic predisposition.Purposes and Clinical RelevanceOur purpose was to highlight the difficulties during the diagnostic work-up for systemic vasculitis and management in cases of posterior spinal surgery.

Bilateral Upper and Lower Eyelid Severe Psoriasiform Blepharitis: Case Report and Review of Literature

The purpose of the present study is to describe a case of severe, psoriasiform blepharitis by means of a case report and literature review. A 44-year-old man developed chronic blepharitis and tearing months after bilateral cataract surgery. Exam showed diffuse quad-eyelid erythema, discharge, edema, madarosis, and scale. He also had insufficient tear drainage due to bilateral upper eyelid cicatricial punctal atresia with bilateral lower eyelid punctal stenosis. Biopsy of the lower eyelids exhibited psoriasiform hyperplasia. Topical 0.1% tacrolimus achieved improvement but caused some subjective eye irritation. Psoriasiform dermatitis manifesting on the eyelids is rare, may be associated with insufficient tear drainage, and may respond favorably to 0.1% tacrolimus.

Giardiasis Confined to the Terminal Ileum

A 46-year-old woman presented with complaints of loose stools for 2 months and unintentional weight loss of 20 lbs. She had a medical history of irritable bowel syndrome, endometriosis, and fibromyalgia. Her medications included hyoscyamine, calcium carbonate, and norethindrone acetate. Physical examination, vital signs, and complete blood count were all within normal limits. To further evaluate her symptoms, we performed esophagogastroduodenoscopy and colonoscopy studies. Esophagogastroduodenoscopy showed that she had a normal duodenum, that her stomach had mild diffuse erythema, and that she had a normal esophagus.

Severe kerion with dermatophytid reaction presenting with diffuse erythema and pustules

Severe kerion with dermatophytid reaction presenting with diffuse erythema and pustules

Relationship between endoscopic findings of the pouch and bowel frequency after restorative proctocolectomy in ulcerative colitis

Background and aim: Pouchitis is one of the late complications of restorative proctocolectomy in ulcerative colitis (UC) and is associated with increased bowel frequency. The present study aimed to clarify the endoscopic findings that are associated with bowel frequency. Patients and methods: The macroscopic and microscopic features in the ileum proximal to the pouch, the pouch, and the remnant short rectum in 100 endoscopies on 63 patients were studied retrospectively. Results: Four of 28 (14%) patients had inflammatory changes in the proximal ileum. Sixty-seven percent of patients showed an abnormal appearance of the pouch. Granularity, friability, presence of mucus, erythema, and erosions were significantly related to bowel frequency. ‘Endoscopic pouch activity index’ (EPAI), which is the number of positive findings of diffuse erythema, mucus, friability, ulcer, erosion, and granularity, was strongly associated with bowel frequency (P < 0.0001). Patients without macroscopic inflammation in the rectum had significantly lower bowel frequency than those with mild or moderately active inflammation (P = 0.0294 and 0.0183, respectively). Multivariate analysis revealed that ‘endoscopic pouch activity index’ and histological grade of pouch inflammation were significant factors (P = 0.0004 and P = 0.0429, respectively) influencing bowel frequency. Time–course study demonstrated that changes in EPAI and macroscopic grade of the rectum were significantly related to alteration in bowel frequency (P = 0.0120 and 0.0244, respectively). Conclusion: Erythema, mucus discharge and granularity were significantly related to bowel frequency. EPAI may be useful to evaluate endoscopic pouch inflammation.