Hutchinson's Sign Research Articles

Clinical and Histopathological Investigation of Pediatric Melanonychia: A Single-Center Retrospective Case Series.

The natural history of pediatric melanonychia and the necessity of biopsy for ruling out melanoma are debated in the literature. We hypothesize that there is a low rate of malignant nail pathology among pediatric patients undergoing nail bed biopsy for melanonychia. We performed a retrospective chart review of 54 pediatric patients (age <18 years) at a single institution who presented with melanonychia and underwent nail bed biopsy from 2007 to 2022. Data points collected included patient demographics, medical history, physical exam findings, pathology reports, and clinical photos. Univariate and multivariate analyses were performed to assess for risk factors associated with high-risk pathology findings. The average age of melanonychia onset was 5.5 years (SD 4.4). The average age of first biopsy was 7.8 years (SD 4.3). On physical exam, 27 patients had at least four features concerning for melanoma (asymmetry, border irregularity, color heterogeneity, diameter > 1/3 of nail, evolving color, evolving diameter, Hutchinson's sign). The most common pathology diagnoses were melanocytic nevus (35%), atypical intraepidermal melanocytic proliferation (AIMP) with benign features (24%), subungual lentigo (22%), and AIMP with concerning features (17%). There were no cases of melanoma in situ or invasive malignant melanoma. On multivariate regression, the only significant risk factor associated with more concerning pathology (AIMP with concerning features) was the calendar year in which biopsy was performed (coefficient = -0.34, P = 0.016). There was no association between physical exam features and high-risk pathology. Twelve patients had surgical re-excision of the lesion, 6 of which were due to incomplete excision of AIMP with concerning features and 6 of which were due to recurrence. Our case series did not find any cases of melanoma in situ or malignant melanoma arising from pediatric melanonychia. Atypical intraepidermal melanocytic proliferation with concerning features was associated only with the year in which the biopsy was performed, which may reflect the improved understanding of pediatric melanonychia as often benign despite concerning features on pathology. The decision to perform a nail matrix biopsy in pediatric melanonychia should be based on a collaborative discussion between the patient's parents, dermatologist, and plastic surgeon.

Shingles without hutchinson sign developing herpes zoster ophthalmicus and preseptal cellulitis

A previously healthy 69-year-old man presented to an emergency room with a vesicular rash on his right forehead in line with shingles (herpes zoster) secondary to varicella-zoster virus. The patient was negative for the Hutchinson sign, a rash involving the tip of the nose or nasal ridge, which indicates an increased risk of herpes zoster ophthalmicus (HZO). Only around 10-20% of shingles cases develop HZO, which is an emergent vision-threatening disease [1]. The patient reports history of chickenpox and denies any immunocompromising conditions [2]. He was sent home on a course of oral valaciclovir. Four days later he was brought to the emergency room with an enlarged, crusting rash encompassing the right side of his forehead to the eyelid with blurry vision and severe eyelid edema (Figure 1A). The rash was spread along the ophthalmic distribution of the trigeminal nerve completely within the V1 dermatome, indicating HZO.

Herpes Zoster Keratouveitis : Are We Late in Dealing with It?

Introduction : Herpes zoster ophthalmicus (HZO) is the viral involvement of the ophthalmic division of the trigeminal nerve. The ocular disease affects approximately 50% of HZO cases and is an ophthalmologic emergency due to the risk of vision loss if not quickly treated. This case reports the ocular complication resulting from delayed management of herpes zoster.&#x0D; Case Illustration : A 25-year-old woman presented with the decreased vision for one week. Physical examination revealed erythema, crusts, and multiple vesicles in the upper quadrant of the left face, with a positive Hutchinson sign. Ophthalmic examination showed a visual acuity of 0.6 on the left, with ciliary injection, a multiple dots pattern, and stromal edema in the left eye. Fine and fibrillar keratic precipitates were also present. The patient had previously received oral acyclovir 5x400 mg/day for five days after the onset of symptoms. The patient was given oral acyclovir 5x800 mg/day, amitriptyline 25 mg PO/day, homatropine ED 1 gtt/day, ofloxacin ED 4 gtt/day, Prednisolone acetate ED 4 gtt/day for the left eye.&#x0D; Discussion : Early management of HZO within 72 hours of rash onset is optimal. The Hutchinson sign, characterized by herpetic lesions around the nose tip, indicates nasociliary branch involvement and increases the risk of ocular involvement. Delayed or inadequate treatment can lead to various ocular complications. The prognosis is unpredictable and dependent on long-term sequelae.&#x0D; Conclusion : HZO keratouveitis, can result in stromal scarring or endothelial dysfunction, potentially requiring surgery if therapy is inadequate. Early recognition of ocular involvement is crucial to prevent complications and increase practitioner awareness.

Looking Beyond the Hutchinson Sign: A Retrospective Study of Clinical Factors Indicating the Presence and Invasiveness of Nail Unit Melanoma in Patients With Longitudinal Melanonychia.

The data underlying this article are available in the article.Longitudinal melanonychia (LM) presents a challenge because nail unit melanoma (NUM) must be considered as a differential diagnosis. Because nail matrix biopsy may result in nail dystrophy, it is important to distinguish NUM from LM. To provide evidence of previously reported clinical factors indicative of NUM in patients with LM. This was a retrospective study of patients who presented with LM and had biopsy-confirmed NUM from 2005 to 2021. Benign LM was either confirmed by biopsy or considered benign if followed without the need for biopsy. Clinical factors associated with LM and NUM were compared by multivariate regression. A total of 177 patients (97 LM and 80 NUM) were included. Multivariate regression showed that high band color intensity (p = .0031), variegation (p = .0005), nail plate splitting (p = .0017), Hutchinson sign (p = .0027), and band change (p = .001) correlated with malignancy. Nail plate splitting was associated with Breslow thickness. Malignancy should be suspected and biopsy performed in patients with LM and high band color intensity, variegation, nail plate splitting, Hutchinson sign, and band change.

Clinicopathological and prognostic features of subungual melanoma in situ

Objective: To investigate the clinicopathological characteristics, immunohistochemical profiles, molecular features, and prognosis of subungual melanoma in situ (SMIS). Methods: Thirty cases of SMIS were collected in Fudan University Shanghai Cancer Center, Shanghai, China from 2018 to 2022. The clinicopathological characteristics and follow-up data were retrospectively analyzed. Histopathologic evaluation and immunohistochemical studies were carried out. By using Vysis melanoma fluorescence in situ hybridization (FISH) probe kit, combined with 9p21(CDKN2A) and 8q24(MYC) assays were performed. Results: There were 8 males and 22 females. The patients' ages ranged from 22 to 65 years (median 48 years). All patients presented with longitudinal melanonychia involving a single digit. Thumb was the most commonly affected digit (16/30, 53.3%). 56.7% (17/30) of the cases presented with Hutchinson's sign. Microscopically, melanocytes proliferated along the dermo-epithelial junction. Hyperchromatism and nuclear pleomorphism were two of the most common histological features. The melanocyte count ranged from 30 to 185. Most cases showed small to medium nuclear enlargement (29/30, 96.7%). Pagetoid spread was seen in all cases. Intra-epithelial mitoses were identified in 56.7% (17/30) of the cases. Involvement of nailfold was found in 19 cases, 4 of which were accompanied by cutaneous adnexal extension. The positive rates of SOX10, PNL2, Melan A, HMB45, S-100, and PRAME were 100.0%, 100.0%, 96.0%, 95.0%, 76.9%, and 83.3%, respectively. FISH analysis was positive in 6/9 of the cases. Follow-up data were available in 28 patients, and all of them were alive without disease. Conclusions: SMIS mainly shows small to medium-sized cells. High melanocyte count, hyperchromatism, nuclear pleomorphism, Pagetoid spreading, intra-epithelial mitosis, nailfold involvement, and cutaneous adnexal extension are important diagnostic hallmarks. Immunohistochemistry including SOX10 and PRAME, combined with FISH analysis, is valuable for the diagnosis of SMIS.

Clinical Features and Risk Factors for Complications of Facial Herpes Zoster in Inpatients

Background: Few studies have been reported on facial herpes zoster and the risk factors for its complications. Objective: This study aimed to investigate the clinical features and risk factors with facial herpes zoster. Methods: We examined the medical records of 676 patients with facial herpes zoster during a 10-year-period from 2011 to 2020. We assessed the proportion of ocular complications, Ramsay-Hunt syndrome, and postherpetic neuralgia in patients with facial herpes zoster according to several clinical factors including age, sex, dermatomes, underlying disease, and time to initiate antiviral treatment. Results: The incidence of ocular complications was significantly higher in males (Odds ratia [OR], 2.59; 95% CI, 1.26~5.32), and with involvement of ophthalmic branches of the trigeminal nerve (V1: OR, 14.28; 95% CI, 3.62~56.29; V1 inclusion: OR, 20.68; 95% CI, 7.99~53.55), underlying diseases (OR, 1.70; 95% CI, 1.08~2.68) and positive Hutchinson's sign (OR, 3.59; 95% CI, 1.72~7.49). Ramsay-Hunt syndrome was significantly correlated with involvement of VII dermatome (OR, 24.68; 95% CI, 2.97~204.75), and showed considerable significant with otalgia (OR, 3.31; 95% CI 0.98~11.22). Postherpetic neuralgia was significantly higher in those over 60 years of age (OR, 2.03; 95% CI, 1.48~2.78), ocular complications (OR, 2.28; 95% CI, 1.57~3.30), and ear involvement (OR 1.94; 95% CI 1.17~3.20). Conclusion: These results demonstrated that facial herpes zoster was associated with ocular complications, Ramsay-Hunt syndrome, and postherpetic neuralgia. The incidence of these complications was related to risk factors such as sex, age, dermatome, underlying disease, Hutchinson's sign and otalgia. To decrease the risk of complications associated with facial herpes zoster, patients should receive appropriate antiviral therapy and interdepartmental consultations immediately.

Ungual Melanoma Disguised by Onychomycosis

Ungual melanoma is known to be frequently misdiagnosed, and the primary misdiagnosis of ungual melanoma includes onychomycosis. We report a very rare case of onychomycosis concealing ungual melanoma in situ. A 52- year-old male patient presented with a yellow to brown thickened left great toenail that had existed for 10 years. In the front view, Hutchinson's sign which refers periungual extension of brown-black pigmentation from melanonychia was also observed on his hyponychium. First, fungal infection of his toenail was confirmed with positive KOH result. Next, a nail biopsy after nail avulsion was done to assess Breslow depth and to determine surgical margin. And ungual melanoma was diagnosed with immunohistochemical stains. Non-amputative wide local excision with 5 mm surgical margin followed by skin grafting was done Unfortunately in three years ungual melanoma in situ has recurred 2 times and then progressed to invasive malignant melanoma, so he was referred to the Department of plastic surgery for further invasive surgical treatment and regularly monitored to check the recurrence. According to a prior retrospective study, 52% of ungual melanomas were clinically misdiagnosed. Thus, proper diagnosis of ungual melanoma is very important for the patients' better prognosis. It would be important for physicians to examine the nail plate as well as the underneath structures for patients with nail disease including onychomycosis.

Clinical features and natural course of pediatric longitudinal melanonychia: A retrospective cohort study in Korea

Large studies on the clinical features and natural course of pediatric longitudinal melanonychia (LM) are lacking. To investigate the clinical features and natural course of pediatric LM. Retrospective cohort analysis of pediatric patients (age ≤ 18years) with LM. We examined 703 LM lesions in 381 children. Single, narrow, and homogeneously pigmented fingernail lesions were most frequently observed. Our results suggested that within 3, 4.5, and 9.5years after onset, approximately 3%, 5%, and 10% of LM lesions, respectively, will completely regress and that single, left-sided, and homogeneously pigmented lesions are more likely to disappear completely. The age of onset, sex, finger/toe position, Hutchinson's sign, and nail dystrophy were not associated with complete regression. During follow-up, most cases demonstrated no change in color or width between the first and last visit, and early darkening/widening before stabilization or lightening/narrowing was common. The lightning of pigmentation was associated with complete regression, whereas change in width was not. Retrospective study at a tertiary center. Our results suggest that clinicians ought to follow pediatric patients with LM without intervention for several years even if lesions grow darker or wider. Single, left-sided, and homogeneously colored lesions are more likely to regress.

Subungual melanoma with blue naevus-like morphological features: a clinicopathological retrospective analysis of nine cases

Melanocytic lesions in the nail apparatus are often challenging. Both subungual melanomas (SUM) and blue naevus of the nail are very rare. Occasionally, melanomas may mimic blue naevus histologically. Benign and malignant blue melanocytic lesions are commonly associated with G protein mutations, a distinct abnormality not associated with conventional subungual melanomas. We describe the clinical, histological and immunohistochemical features of nine cases of SUM with blue naevus-like morphological features. Mutations in exon 4 and 5 of GNAQ and GNA11 were investigated in two cases, which showed no mutations. RNA-seq of one case revealed unknown mutations along with mutations in ATM, METK and ARID1A. Our study delineates a variant of SUM that mimics blue naevus. Awareness of this pitfall is important when evaluating heavily pigmented lesions around the nail in order to avoid misdiagnosis. Appropriate sampling of subungual lesions and clinicopathological correlation are paramount to reach the correct diagnosis.

Dermatoscopic and clinical features of congenital or congenital-type nail matrix nevi: A multicenter prospective cohort study by the International Dermoscopy Society

Congenital nail matrix nevi (NMN) are difficult to diagnose because they feature clinical characteristics suggestive of adult subungual melanoma. Nail matrix biopsy is difficult to perform, especially in children. To describe the initial clinical and dermatoscopic features of NMN appearing at birth (congenital) or after birth but before the age of 5 years (congenital-type). We conducted a prospective, international, and consecutive data collection in 102 hospitals or private medical offices across 30 countries from 2009 to 2019. There were 69 congenital and 161 congenital-type NMNs. Congenital and congenital-type NMN predominantly displayed an irregular pattern of longitudinal microlines (n=146, 64%), reminiscent of subungual melanoma in adults. The distal fibrillar ("brush-like") pattern, present in 63 patients (27.8%), was more frequently encountered in congenital NMN than in congenital-type NMN (P=.012). Moreover, congenital NMN more frequently displayed a periungual pigmentation (P=.029) and Hutchinson's sign (P=.027) than did congenital-type NMN. Lack of systematic biopsy-proven diagnosis and heterogeneity of clinical and dermatoscopic photographs. Congenital and congenital-type NMN showed worrisome clinical and dermatoscopic features similar to those observed in adulthood subungual melanoma. The distal fibrillar ("brush-like") pattern is a suggestive feature of congenital and congenital-type NMN.

Commentary on Hutchinson Sign: Biopsy May Assist in Diagnosis of Subungual Melanoma in Situ.

Commentary on Hutchinson Sign: Biopsy May Assist in Diagnosis of Subungual Melanoma in Situ.

The Trigeminal Herpes Zoster and the Hutchinson Sign Presentation of 5 Cases and Literature Review

Herpes Zoster is an acute disease, with unilateral metameric distribution, which is characterized by the development of vesicles grouped into an inflammatory, erythematous plaque, located on the path of a nerve.

Evaluation of a community education tool for detection of nail melanoma by nail salon technicians

Evaluation of a community education tool for detection of nail melanoma by nail salon technicians

Hutchinson Sign: Biopsy May Assist in Diagnosis of Subungual Melanoma in Situ.

Early and accurate diagnosis of subungual melanoma (SUM) through histopathologic examination is critical, but lack of clinical suspicion leads to delays in diagnosis. Hutchinson sign (HS) can be one of the important clinical indicators for diagnosing SUM. To evaluate the diagnostic value of small biopsies of HS for detecting SUM in situ. We retrospectively evaluated 12 patients who were diagnosed as SUM in situ and underwent punch biopsy at HS areas. Clinical features, dermoscopic findings, and histopathologic findings in HS regions were analyzed. In most cases, HS was seen in hyponychium (11/12, 91.7%) with 1 case found in proximal nail fold, and 1 case in both the hyponychium and proximal nail fold. Dermoscopic features of HS showed irregular diffuse pigmentation (12/12, 100%) and parallel ridge pattern (7/12, 58.3%). Histopathologically, all cases showed irregularly scattered atypical melanocytes with hyperchromatic nuclei. Two cases showed subtle changes in melanocytes with little nuclear atypia, but additional section specimen showed more definitive findings of SUM in situ. We present a supplementary biopsy technique for diagnosing SUM. Biopsy of HS may help in the diagnosis of SUM.

Benefits of telemedicine in diagnosis of herpes zoster ophthalmicus with timely management and follow-up

Sir, Herpes Zoster is caused by the viral reactivation of Varicella Zoster virus, that enters the cutaneous nerve endings during an earlier episode of chicken pox and travels to the Dorsal Root Ganglia and remains latent. It is characterized by the occurrence of vesicular lesions grouped along the Single Dermatome innervated by Dorsal Root of Sensory Ganglion. Herpes Zoster Ophthalmicus (HZO) is involvement of the ophthalmic division of the fifth cranial nerve. It is the second most common type of Herpes Zoster (HZ), after Thoracic Zoster [1]. We present here, a case of Herpes Zoster in a young girl involving Supraorbital, Maxillary and Mandibular of the Trigeminal nerve. Timely diagnosis of HZO was made. The lesion on the tip of the nose (Hutchinson’s sign) alerted the involvement of Nasociliary nerve and to arrange immediate Ophthalmology consultation. Tele-Dermatology helped in reducing waiting time, fast delivery of care and prevention of visual disability [2]. The patient was monitored, motivated and treated, that could happen because of tele- dermatology. Dramatic improvement in the patient was observed in a very short time. The use of tele-dermatology, especially in times of the COVID – 19 pandemic is invaluable. The patient was a girl aged 12-years, presented through telemedicine with 3 days of lesions on the face mimicking acne. On close examination, there were a few Vesicular Lesions among multiple lesions and there was involvement of tip of the nose. Patient also complained of eye pain. This helped us to consider HZO. Prompt immediate treatment with anti-virus was initiated. It was possible to do continuous monitoring with the help of Tele-Medicine and without the patient having to leave the house in COVID era. Patient was advised to consult an Ophthalmologist for further evaluation. As it was essential, for examination of the eye parameters, patient had to attend in person. This one visit was not through Tele-Medicine. Patient was informed on day-1 of treatment that the condition may initially worsen under proper adequate treatment with a graphic representation (Fig. 1) and then decrease later. And this happened in our case, as seen in the six consecutive photographs as indicated below with date and time of the photographs by the patient, which are presented to illustrate the natural progression of disease under proper adequate treatment. This helped in avoiding panic to the patient. The lesions as seen in the pictures became aggressive in two days which means, the eye could have been affected more but for the immediate treatment given. Patient could get treatment from home by consulting online through out, thereby reducing the risk of venturing to a clinic in COVID situation. Except for one visit to the Ophthalmologist which was inevitable. Ocular Manifestations – Ocular manifestations affect about 50% of patients with HZO and can be isolated. This proportion reaches 80% in case of appearance of the Hutchinson Sign. The latter reflects the involvement of the nasociliary branch and is characterized by eruption on the side and on the tip of the nose [3]. Eye examination showed that there was congestion generalized in Conjunctiva. Corneal sensation was reduced, Iris anterior chamber, Pupil, lens, Fundus and extra ocular movements were normal. Immediate treatment was instituted after counselling about the treatment. The patient was advised Valacyclovir 1000 mg, 3 times a day for 7 days along with adequate fluid intake. For relief of pain, patient was given Pregabalin, Tremedol 25 mg and Gabapentin 6%W/W+Lidocaine 5%W/W smooth locally. Eye treatment As per Ophthalmologists advice, Polyethylene glycol 400 0.4% + Propylene glycol 0.3% five times a day and Acyclovir eye ointment a day was prescribed to the patient. All the pictures were taken by the patient and shared with the doctor, during the course of the treatment helping in regular monitoring have been presented (1a – 1f). In this case, Telemedicine gave the scope of reducing waiting time, providing correct diagnosis, enabling faster delivery of care, enabling tele based access to monitor the patient’s condition, counselling, management, monitoring with good end result. Key Takeaways • The importance of (Hutchinson’s sign) involvement of the tip of nose is emphasized. • Counselling the patient with regard to the possibility of worsening of the visible symptoms while under appropriate and adequate treatment, should be given with the help of a graphic representation (Fig. 2). • Prompt referral to Ophthalmologist is necessary. • The consultant and the patient should be conscious of associated potential Vision threatening complications and the need for prompt treatment to protect from visual complications.

Dermoscopic Evaluation of Longitudinal Melanonychia in Children: A Prospective Study.

Background:Longitudinal melanonychia (LM) is a worrisome sign in both children and adults. Nail apparatus melanoma (NAM) can be related to LM, but it is very rare in children. Dermoscopic signs of benign lesions in children can be similar to melanoma; therefore, it is important to review dermoscopy of LM in children to make the best decision in performing biopsy.Aims:Biopsy taking is very challenging in LM in children. Most lesions are benign in children. The aim of this study was to review dermoscopic signs of LM in children and compare them with adults.Materials and Methods:In this prospective study a total of 108 LM (35 children and 73 adults) were undergone dermoscopy of LM. Dermoscopic features were compared in children and adults; both for benign lesions proven by biopsy or follow up and melanomas diagnosed histopathologically.Results:Black background, black band color, band color diversity and pseudo-Hutchinson's sign were more frequent in children in comparison with benign adult melanonychia. Some children's dermoscopic features of LM such as broad band width, Band color diversity, Hutchinson's sign, gray band color, asymmetry of pattern, and regression were similar to melanoma, but we did not find any melanoma by biopsy and/or follow up among children. We also detected the newly described "zigzag" pattern in four children.Conclusion:Dermatologists should consider all dermoscopic features of a lesion, dermoscopic sign changes in follow-up, medical, and familial history of the patient in deciding to perform biopsy of LM in children.

Herpes Zoster Duplex Unilateralis as a manifestation of severe lymphopenia in COVID19

To the editor in chief, SARS-CoV2 (severe acute respiratory syndrome coronavirus-2), a novel coronavirus was first reported in December of 2019 from Wuhan, China as an aetiological agent causing a new infectious respiratory disease (coronavirus disease 2019- COVID-19). The main clinical manifestations of COVID-19 are fever, cough, fatigue, dyspnoea and muscle aches. Herpes zoster is characterized by several groups of painful vesicles on an erythematous base with a distribution in a unilateral dermatome involving the skin and/or mucosa. Herpes zoster is caused by varicella zoster virus which remains dormant in the sensory root ganglion contained by the immune system particularly CD lymphocytes (Wollina, 2017). This characteristic presentation is seen in an immunocompetent host. Severe forms of Herpes zoster not respecting the borders of a dermatome have been described. They are (a) Disseminated Herpes zoster that is, lesions extending over three contiguous dermatomes or lesions going outside the original dermatome. (b) Herpes zoster Duplex—here the lesions involve two non-contiguous dermatomes. If the dermatome involved are unilateral then it is known as Herpes Zoster Duplex Unilateralis and if present bilaterally then—Herpes Zoster Duplex Bilateralis (Jung et al., 2000). The non-contiguous variants are rare in both immunocompetent and immunocompromised host and represent a viraemic spread of VZV due to decrease in lymphocyte count and/or function. Classical Dermatomal Herpes Zoster has been described as a marker of subclinical COVID19 infection (Tartari et al., 2020). We are presenting a case of Herpes Zoster Duplex Unilateralis involving left ophthalmic division of trigeminal nerve (V1) and left Thoracic 10 (T10) dermatome in a patient of COVID19 with severe lymphopenia. A 62-year-old otherwise healthy male presented with highly painful vesicular lesions on an erythematous base involving the left ophthalmic division of trigeminal nerve (Day 6) and left thoracic 10 (T10) (Day 8) dermatome occurring 2 days apart. The vesicles ranged from 0.3 mm to 1 cm in size and had necrotic element at some places. Hutchinson sign was positive. A diagnosis of Herpes Zoster Duplex Unilateralis involving left ophthalmic division of trigeminal nerve and left Thoracic 10 (T10) dermatome was observed. The patient had fever (101–103°F) with malaise for preceding 5 days of appearance of vesicles. His COVID19 RT PCR test was positive (Day 8), however, evaluation for HIV status, diabetes, any immunosuppressive state and malignancy was negative. HRCT thorax showed multiple ground glass opacities in both the lungs with CT severity score being 18/30. His LDH levels were 229 units/L (normal range 135–225 U/L), D-dimer 3,422.26 (0–500 ng/ml), IL-6 levels 23 (normal range 0–7 pg/ml). Troponin-T levels determined by Card test, serum ferritin levels and liver function tests were normal. Total leucocyte count was 7,100 cells/mm3 (4000–11000 cells/mm3 normal range). However differential eucocyte count showed neutrophilia (90%) and relative lymphopenia (2.2%), whereas the normal range is 20%–40%. The patient was treated according to institutional COVID19 protocol and was given piperacillin tazobactam 4.5 mg thrice a day injection, remdesivir 200 mg slow iv infusion and dexamethasone injection 4 mg once daily , low molecular weight heparin 6 mg twice a day subcutaneously for 5 days. For VZV lesions, oral acyclovir was given at a dose of 800mg five times a day for 10 days after which he recovered with mild post herpetic neuralgia. Herpes Zoster Duplex Unilateralis represents a viraemic spread of VZV, probably due to decreased immune protection. In our patient lymphocyte percentage was 2.2% representing a severe lymphopenia. We tried to look into the possible explanations: In COVID 19 patients, the inflammatory cytokine storm is likely a key factor behind the observed lymphopenia. The serum level of pro-inflammatory cytokines, such as TNF-α and IL-6, have been closely correlated with lymphopenia, while recovered patients show close to normal levels of such cytokines (Mazzoni et al., 2020). Autopsy studies on lymphoid organs collected from several patients who succumbed to the disease revealed massive lymphocyte death, which was attributed to high levels of IL-6 as well as Fas–FasL interactions. Our patient also had high IL 6 levels and clinical features suggestive of cytokine storm. COVID-19 infection can result in exhaustion of T cells. A recent study has found both CD4+ and CD8+ T cells from COVID-19 patients had increased cell surface expression of programmed cell death protein 1 (PD-1) and T cell immunoglobulin and mucin domain 3 (Tim-3), the two markers of T cell exhaustion (Diao et al., 2020). The SARS-CoV-2 can directly infect T cells. This infection can interfere with T cell expansion. A report suggests that some genes involved in T cell activation and function, such as MAP2K7 and SOS1 are downregulated in the T cells of severe COVID-19 patients (Ouyang et al., 2020). All these mechanisms may be an explanation to the relative lymphopenia in our patient with an unusual presentation of Herpes Zoster. Nil. None declared.

Longitudinal brush pigmentation on the hyponychium, a dermoscopic feature observed in pediatric nail matrix nevi

Longitudinal brush pigmentation on the hyponychium, a dermoscopic feature observed in pediatric nail matrix nevi

Clinicopathological diversity and outcome of longitudinal melanonychia in children and adolescents: analysis of 35 cases identified by excision specimens.

Longitudinal melanonychia in paediatric patients often represents a difficult diagnostic challenge, and studies emphasising its clinical and histopathological features are limited due to its low incidence in childhood. We retrospectively analysed 35 paediatric cases identified by excision specimens on their clinicopathological features, and performed fluorescence in-situ hybridisation on 13 available cases. Fingernails (77.1%) were more likely to be affected. Total melanonychia and Hutchinson's sign were observed in 10 (28.6%) and 14 (40.0%) cases, respectively. Nail dystrophy at diagnosis was present in five cases. After complete excision of the lesions, four patients relapsed during follow-up (mean=38months). Seventeen cases were diagnosed as lentigines and 18 as naevi, among which 11 cases were categorised as lentigines/naevi with atypical melanocytic hyperplasia. Mild-to-moderate nuclear atypia, confluency of melanocytes, focal pagetoid spread and peri-ungual skin involvement were found in 25.7% (9 of 35), 40.0% (14 of 35), 40.0% (14 of 35) and 40.0% (14 of 35) of cases, respectively. Thirteen cases tested by fluorescence in-situ hybridisation showed no copy number aberration at the probed loci. There was a statistically significant difference in the following features between patients aged less and more than 10years (P<0.05): cytomorphology, mild-to-moderate nuclear atypia, confluency of melanocytes, focal pagetoid spread and melanocyte count. Some concerning clinicopathological characteristics, which are signs indicative of melanoma in adults, are not uncommon in paediatric longitudinal melanonychia, especially in patients aged≤10years. Owing to the extremely low incidence of melanoma in paediatric longitudinal melanonychia, in most circumstances a more conservative clinical management strategy should be adopted.

Clinical features of subungual melanoma according to the extent of Hutchinson’s nail sign: a retrospective single‐centre study

Hutchinson's nail sign (HS) is among the diagnostic criteria for subungual melanoma (SUM). However, there is minimal evidence supporting the overall clinical significance of HS in SUM. To identify clinicopathological features of SUM according to the extent of HS. Retrospective cohort study was performed with consecutive SUM patients at a single centre from January 2006 to December 2017. The extent of HS was defined by the number of affected nail folds (range 0-4). Comparison groups were organized as follows: patients with HS (affecting ≥1 nail folds) vs. without HS; patients with HS affecting ≥2 nail folds vs. HS affecting <2 nail folds; patients with HS affecting ≥3 nail folds vs. HS affecting <3 nail folds. Clinicopathological characteristics of SUM were compared between the groups. Sixty-one SUM patients were included. Forty-six (75.4%) exhibited HS; 22 (47.8%) on a toe and 24 (52.2%) on a finger. In multivariate analysis, nail destruction [hazard ratio (HR), 10.00; 95% confidence interval (CI), 2.61-38.30; P=0.001] was significantly associated with the presence of HS and amputation was significantly associated with HS affecting ≥2 nail folds (HR, 4.75; 95% CI, 1.36-16.61; P=0.015). High T stage (HR, 1.85; 95% CI, 1.20-2.85; P=0.005, Fig. 2) was significantly associated with HS appearing in ≥3 nail folds. Besides its value of detecting SUM, HS provides useful clinical information. The number of nail folds exhibiting HS could be a useful clinical clue for planning therapeutic strategies for SUM.