Patient Developed Skin Lesions Research Articles

A case report of Steven Johnson’s Syndrome (SJS) /Toxic Epidermal Necrolysis(TEN) overlap caused by Nimesulide

Introduction: Stevens–Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are rare, acute and life-threatening mucocutaneous diseases that are nearly always drug-related. Incidence of SJS and TEN is 0.05 to 2 persons per million populations per year. In India, Nimesulide is easily available as an over the counter drug (OTC), different cutaneous reactions associated with, Nimesulide including angioedema, maculo-papular rash, severe urticaria, pityriasis rosea and worsening of preexisting psoriasis. Patient concern (Case summary): A 17 years old female patient complained about fever and she was prescribed with Tab.Nimesulide twice daily by private practitioner. On the 3rd day of intake of oral Nimesulide, patient developed skin lesions over face, trunk, back and all four limbs. This reaction was diagnosed as Stevens–Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) overlap by Nimesulide based on clinical picture and drug history. Interventions: Tab. Nimesulide was stopped and patient was admitted in dermatology ward. Patient was treated with Inj.Hydrocortisone sodium succinate 100mg iv twice daily, Inj.Cefotaxime 1gm iv thrice a daily, Inj. Metronidazole 500mg once a day and Liquid Cyclosporine 50mg twice a day for 10days. Other treatments included Inj. Albumin 100ml i.v slowly for 3 days given. Patient recovered and was discharged after 10 days. Conclusion: We are presenting a case of SJS-TEN overlap caused by Nimesulide, which is commonly used as an over the counter drug (OTC). Our aims to minimize this type of serious ADR by making alert to physicians and other healthcare professionals, we can avoid hospital admissions because of ADR, reduce economic burden of the patients and health related quality of life of the patient can be improved.

First Reported Case Series of Combined Treatment with CLAG and Venetoclax for Acute Myeloid Leukemia (AML)

Background: Since the 1970s, the standard of care for patients with AML has been a "7+3" induction regimen consisting of 7 days of cytarabine and 3 days of anthracycline. CLAG has been demonstrated to be effective in patients with newly diagnosed, high-risk AML. Venetoclax is a Bcl2 inhibitor FDA approved to treat AML in elderly patients in combination with hypomethylating agents. Here we describe two patients who received both CLAG and venetoclax to treat R/R AML. Both patients were heavily treated (unsuccessfully), and this novel combination therapy was administered near the end of their treatment. Patient #1 was a 54 year old female with AML. Genetic analysis revealed a FLT3-ITD mutation. Patient was treated with cytarabine 3mg/m2 x 5 and mitoxantrone 60 mg/m2 on day 1 of cycle 1. She went into morphologic remission and then received 2 cycles of HIDAC. Unfortunately, patient relapsed 5 months after starting chemotherapy, thus was not a candidate for allo-SCT. At relapse, the patient had mutations of FLT3-ITD, DNMT3A, NPM1, and WT1. The patient was then treated with CLAG -Idarubicin. Venetoclax was added on day 3 of the cycle, in combination to the CLAG regimen, and she received the venetoclax for 7 days (titrated on day 1 at 50 mg, then 100 mg on day 2, and 200 mg for the next 5 days). She also received midostaurin starting day 6 of the CLAG cycle at a dose of 50 mg and received it for 14 days. Patient #2 was a 71 year old female with AML. Patient Karyotype was 45, XX, add(5)(q11), der(6;7)(p10;q10)[20]. Analysis did not detect a targetable mutation, but an NRAS mutation was detected. The patient began cycle 1 of CLAG-Ida, and on day 23 bone marrow biopsy showed myeloid hyperplasia without increased blasts. The patient then received two more cycles of CLAG-Ida at approximate 1 month intervals. 4 months after diagnosis, the patient underwent an allo-SCT. Patient developed skin lesions and on day +96 biopsy revealed leukemia cutis. Bone marrow biopsy showed no morphologic evidence of AML but abnormal karyotype was noted 45,XX,del(5)(q13q33), dic(6;7)(q11;p11.2)[4]/46,XX[16]. On day +103 the patient began decitabine-venetoclax 200 mg. She received 2 more cycles of decitabine-venetoclax. A right axillary lymph node biopsy was done day on day +238 and showed an abnormal immature population expressing CD34, CD117, MPO, CD4, and CD56. Patient then started on GO 4.5mg and then HIDAC. Patient did not respond to these regiments and received CLAG and Venetoclax starting day +307. She completed this cycle but progressed further. She then received hydrea. This was followed by vyxeos on day+357. Patient did not respond and elected to go to hospice; she died day+381 post SCT. Discussion: To our knowledge, this is the first reported case series of concomitant treatment with CLAG and Venetoclax. During the literature review, we looked at FLAG, which is similar to CLAG but uses a different purine analogue fludarabine instead of cladribine. We also saw that FLAG and venetoclax have been combined to treat AML patients as they transition into SCT. When compared to FLAG, CLAG has been shown to be more effective in treating patients with high risk AML. Although in both cases the patients ultimately succumbed to AML, this was a proof of concept, and we suspect the CLAG venetoclax combination will be more efficacious than FLAG-venetoclax in treating high risk patients. This case series is intended to show that these two therapies can be combined, and we propose a further, more complete investigation into the concomitant use of CLAG and venetoclax to treat patients with AML.

Disseminated Pulmonary Kaposi Sarcoma After Lung Transplantation: The Increased Risk Donor

<h3>Introduction</h3> Kaposi sarcoma (KS) is a rare complication after lung transplantation (LTx). It is caused by human herpes virus 8 (HHV-8). We report a case of primary disseminated pulmonary KS after LTx from an increased risk donor. <h3>Case Report</h3> A 66-year-old male with end-stage COPD underwent a bilateral LTx from an increased risk donor with positive HBsAb, HBcAb and Lues Ab, in November 2020. Apart from Valganciclovir (vGCV) and co-trimoxazole, entecavir and benzylpenicillin were given as prophylaxis. Routine immunosuppression included basiliximab, tacrolimus, mycophenolate mofetil (MMF) and prednisolone. vGCV prophylaxis was discontinued at 3 months (CMV-positive donor and recipient). The patient was treated effectively for acute rejection with pulse methylprednisolone in February 2021. Unfortunately, he was readmitted with dyspnea and lung function decline in April 2021. CT-scan showed bilateral consolidations and pleural thickening and the PET-scan showed an intense uptake in both lungs and pleura. Transthoracic needle biopsy showed HHV-8 positive spindle cell lesions. Subsequently, our patient developed skin lesions on his chest and in his mouth compatible with KS (biopsy-proven). In retrospect, the recipient was HHV-8 seronegative before LTx. Therefore, the diagnosis primary HHV-8 infection leading to disseminated pulmonary Kaposi sarcoma was made. Which appeared after cessation of the vGCV prophylaxis. Valganciclovir was initiated and immunosuppression was adjusted: MMF discontinued and tacrolimus switched to sirolimus (target through levels 15 µg/l). Nevertheless, KS was progressive and liposomal doxorubicin 20mg/m2 was started. Our patient deteriorated and was transferred to the ICU for intubation. Bronchoscopy revealed brown endobronchial lesions compatible with KS. The effect of the treatment could not be assessed, because the patient decided to refuse further treatment. He died soon after his decision was made. <h3>Summary</h3> Scarcity of donor organs led to the acceptance of an increased risk donor. Prophylaxis against hepatitis B and Lues was given, but after discontinuation of vGCV our patient developed a primary HHV-8 infection leading to disseminated KS and ultimately the death of our patient. HHV-8 testing of donor serum and lifelong prophylaxis might have prevented this clinical course and should be considered in recipients of increased risk donors.

A Study of Sexually Transmitted Diseases and Dermatological Manifestations in Human Immunodeficiency Virus-Infected Patients

Background: The majority of human immunodeficiency virus (HIV)-infected patients develop skin lesions at some point during the course of the disease. The occurrence of sexually transmitted diseases (STDs) may increase the transmission and progression of HIV. Hence, it is essential to study the various infectious and noninfectious dermatoses. Objectives: (1) To study the various STDs and to familiarize with the atypical presentation of various STDs in HIV infected individuals. (2) To study clinical and epidemiological aspects of various dermatological manifestations in HIV infected individuals. (3) To identify dermatological manifestations as indicators (markers) of HIV/acquired immunodeficiency disease syndrome progression. Materials and Methods: A cross sectional descriptive study was conducted on known HIV-positive individuals attending the outpatient department of Dermatology in Siddhartha Medical College, Vijayawada, with symptoms suggestive of skin disease or sexually transmitted infections. A detailed clinical history and physical examination were done in all cases. Wherever necessary, relevant investigations were done to confirm the diagnosis in patients. Statistical analysis used: Results were tabulated and analyzed using simple statistical methods. Results: A total of 500 patients were recruited in the study among whom 363 (72.6%) had only dermatological manifestations, 127 (25.4%) had sexually transmitted infections (STIs) and 10 (2%) had overlap manifestations. The majority of them were in the age group of 28–37 years. The most common STI observed was herpes genitalis, followed by genital warts and genital molluscum contagiosum. Pruritic Papular Dermatoses were found to be the most common noninfectious dermatosis. Conclusions: There is a need to know the atypical manifestations of various dermatoses in HIV patients, as these conditions may pose a diagnostic dilemma to the treating dermatologist. This ensures correct diagnosis and the necessary treatment.

Dermatological Manifestation in Coronavirus Disease 2019 Patients in Iraq

Background: Coronavirus disease-19 (COVID-19) is a growing pandemic around the globe that was initially discovered in Wuhan in December 2019. Despite the relatively high incidence of cutaneous manifestations in COVID-19, their role in early recognition and disease progression has not been fully investigated.&#x0D; Aim of this study: To report the possible incidence of the cutaneous lesion in COVID 19 patients and to describe various cutaneous manifestations and their correlation with other clinical features in Covid-19 positive patients to facilitate diagnosis and prognostications toward this virus.&#x0D; Methods: This research was conducted as a cross-sectional study. Skin lesions photography and their analysis were collected by dermatologists from 18 cities in Iraq between September 2020 to January 2021. The data were processed using statistical package SPSS version 23.&#x0D; Results: A total of 3117 confirmed COVID-19 cases were included in this study. Around 268 patients developed skin lesions with age ranged between 8 to 84 years. Of these skin lesions, 46.2% developed during the illness with minority erupting during the prodromal phase, whilst 38.8% appeared after hospitalization. The most common skin lesion was in the form of urticarial 36.74% followed by herpetic lesions 28.4%, maculopapular rash 11.74% and the remainder being candidiasis, oral thrush, chilblains, and other skin conditions. The most affected area was the torso (46%) followed by limbs, face, fingers, and toes.&#x0D; Conclusion: This study demonstrated the high incidence rate of dermatological lesions in different phases of COVID-19 with urticarial rash being the most frequent clinical pattern.&#x0D;

Optic Neuropathy and Scleritis as the Presenting Feature of Lepra Reaction

A major problem in the management of leprosy patients is the occurrence of "reactions". These reactions are the consequences of the dynamic nature of the immune response to <i>Mycobacterium leprae</i> (<i>M. leprae</i>) that may occur before, during, or following the completion of multi-drug therapy (MDT). They can be of two types- Type 1 lepra reaction and Type 2 lepra reaction also known as Erythema Nodosum Leprosum (ENL). We report an unusual case of a 35 year old male patient who initially presented with complaints of a central scotoma. He neither had visible skin lesion suggestive of leprosy nor a history of either completion or concurrent anti leprosy drug treatment. He was diagnosed to be a case of anterior ischemic optic neuropathy for which he was treated with intravenous injections of methylprednisolone to which he significantly responded. Two months later, he complained of diminution of vision, redness and pain in the left eye which was diagnosed as scleritis. He was managed with topical prednisolone acetate eye drops. Within a week, the patient developed skin lesions over the cheekbones, ear lobules and the back of his hands. He was referred to a rheumatologist and a dermatologist for the same. The dermatologist suspected the lesions to be a manifestation of a Lepra Reaction. The presence of lepra bacilli was confirmed after taking a biopsy from the raised lesions and he turned out to be a case of undiagnosed lepromatous leprosy. He was subsequently treated with anti-leprosy drugs according to the WHO-MDT-MB along with a cover of steroids. After three months of initiation of this treatment, his ocular and dermatological lesions completely resolved. This is a unique case in which anterior ischemic optic neuropathy and scleritis preceded the symptom of leprosy, manifested as skin lesions.

Clinical and pathological features of myeloid leukemia cutis

BackgroundMyeloid leukemia cutis is the terminology used for cutaneous manifestations of myeloid leukemia. ObjectiveThe purpose of this study was to study the clinical, histopathological and immunohistochemical features of myeloid leukemia cutis. MethodsThis was a retrospective study of clinical and pathological features of 10 patients with myeloid leukemia cutis. ResultsOne patient developed skin lesions before the onset of leukemia, seven patients developed skin infiltration within 4-72 months after the onset of leukemia, and two patients developed skin lesions and systemic leukemia simultaneously. Of these patients, five presented with generalized papules or nodules, and five with localized masses. The biopsy of skin lesions showed a large number of tumor cells within the dermis and subcutaneous fat layer. Immunohistochemical analysis showed strong reactivity to myeloperoxidase (MPO), CD15, CD43 and CD45 (LCA) in most cases. NPM1 (nucleophosmin I) and FLT3-ITD (Fms-like tyrosine kinase 3-internal tandem duplication) mutations were identified in one case. Five patients with acute myelogenous leukemia and one patient with chronic myelomonocytic leukemia died within two months to one year after the onset of skin lesions. Study limitationsThis was a retrospective and small sample study. ConclusionsIn patients with myelogenous leukemia, skin infiltration usually occurs after, but occasionally before, the appearance of hemogram and myelogram abnormalities, and the presence of skin infiltration is often associated with a poor prognosis and short survival time. myeloid leukemia cutis often presents as generalized or localized nodules or masses with characteristic pathological and histochemical findings.

Dermatological Manifestations In Human Immunodeficiency Virus Infected Patients: Histopathology And CD4 Cell Count Correlation

Background:More than 90% of the Human immunodeficiency virus (HIV) infected patients develop skin lesions at some point throughout the course of the disease. Although these conditions may be seen in general healthy population, their occurrence in patients with acquired immunodeficiency syndrome is often atypical, more severe and explosive. Histopathology study of skin biopsies from these lesions is very useful for the final diagnosis of these lesions. Methods :Total 60cases were studied. Punch biopsies from the skin lesions were studied with routine histopathology examination and special stains were used as and when required. The results were divided into infectious and non-infectious categories. Results were correlated with the CD4 counts of the patients Results :Out of that 22 (36.66%) patients had infectious lesions and 38 (63.33%) patients had non-infectious lesions. The spectrum of various non-infectious and infectious lesions such as viral, bacterial, fungal, protozoa, dermatitis, popular lesions and their association with CD4 counts is discussed. Conclusion: In present study mean CD4 cell count was found to be low ( 350) CD4 cell counts. DOI: 10.21276/APALM.1538

Skin Manifestation among HIV Patients and Its Correlation with CD4 Count and WHO Clinical Staging in Jimma University Specialized Hospital, Southwest Ethiopia

Background: More than 90% of human immunodeficiency virus (HIV+) infected patients develop skin lesions at some time throughout the course of the disease. Several skin diseases have proved to be sensitive and useful indicators of progression of HIV+ infection. Although these conditions may be seen in general healthy population, their occurrence in patients with acquired immunodeficiency syndrome is often atypical, more severe and explosive. Objective: The aim of the study was to assess the magnitude and prevalence of skin manifestation among HIV patients in JUSH ART Clinic. Methods: A retrospective study was conducted among HIV patients in JUSH ART Clinic using a structured data collection format and the data was collected from patient’s record (card) and was analyzed by using SPSS version 20. The result was presented using numbers, ratios and tables. Results: Of 268 HIV/AIDS, patients who have follow-up in Jimma University Specialized Hospital (JUSH) Antiretroviral therapy (ART) clinic 137 (51.1%) were having skin manifestations. The commonest type of skin lesion identified was Herpes Zoster, 74 (54%). This study showed that HIV positive (HIV+) patients with advanced stages of skin disorders had relatively lower CD4+ cell counts. Skin manifestation was significantly associated with WHO clinical stage with P=0.019 and CD4+ cell count with a P-value 0.0001. Conclusion: Skin diseases are highly prevalent among HIV- Positive patients and the frequency and number of these manifestations are well correlated to the patient’s immune status and World Health Organization (WHO) staging. Therefore, examination of skin disorders, as early diagnosis and management of skin problems will improve the quality of life in HIV positive patients.

Skin Lesions Associated with Dietary Management of Maple Syrup Urine Disease: a Case Report

Abstract Leucinosis (maple syrup urine disease - MSUD) is an inherited aminoacidopathy and organic aciduria caused by severe enzyme defect in the metabolic pathway of amino acids: leucine, isoleucine, and valine. The classical variant of the disease is characterized by accumulation of both amino and α-keto acids, particulary the most toxic rapid elevation of circulating leucine and its ketoacid, α-ketoisocaproate, which cause encephalopathy and life-threatening brain swelling. However, patients with the most severe form, classical maple syrup urine disease, may appear normal at birth, but develop acute metabolic decompensation within the first weeks of life with typical symptoms: poor feeding, vomiting, poor weight gain, somnolence and burnt sugar-smelling urine, reminiscent of maple syrup. Early diagnosis and dietary intervention improve the patient’s condition, prevent severe complications, and may allow normal intellectual development. We present a 4-month old infant with leucinosis dignosed 3 months earlier, due to elevated levels of amino acids: leucine, isoleucine and valine. The patient was full-term neonate with an uncomplecated delivery, without any family history of metabolic disorder or consanguinity. The infant was referred to a dermatologist, because of maculopapular exanthema on the scalp, trunk, upper and lower extremities, and exfoliative dermatitis of the perioral, particularly anogenital regions, associated with diarrhea. Skin involvement was associated with poor general condition of the infant exhibiting severe hypotension, anemic syndrome, dyspepsia and neurological symptoms. Exanthema developed a few days after the initiation of nutritional therapy for MSUD: isoleucine-, leucine-, and valine-free powdered medical food (MSUD-2) supplemented with iron. Zink levels were within normal ranges. Rapid skin improvement occurred after adequate branched-chain amino acids supplementation was commenced under regular laboratory control (normal zinc serum level with deficiencies of leucine and valine), skin hygiene with antiseptics, emollients and low potent topical corticosteroids. Treatment of acute metabolic decompensation and dietary restriction of branched-chain amino acids are the main aspects in the management of maple syrup urine disease. Common findings in patients with MSUD include: plasma amino acid imbalance, particularly of essential amino acids, failure to thrive attributed to restriction of particular precursor amino acids and natural proteins, micronutrient deficiencies or higher energy requirement due to chronic illness or inflammation. Due to low intake of branched-chain amino acids, some patients develop skin lesions known as acrodermatitis enteropathica-like syndrome. Here we report a case of an infant who developed acrodermatitis enteropathica-like skin eruptions due to branched-chain amino acid deficiency during treatment of maple syrup urine disease. According to available world literature, this is the first report of acrodermatitis enteropathica-like syndrome in an infant with maple syrup urine disease (leucinosis) in the Republic of Bulgaria.

Nifurtimox therapy for Chagas disease does not cause hypersensitivity reactions in patients with such previous adverse reactions during benznidazole treatment

Currently, only two drugs are approved for treating Trypanosoma cruzi infection: benznidazole and nifurtimox. Adverse reactions are frequent with both drugs: they have chemical similarities and common metabolic pathways making cross reactions a possibility. Our objective was to describe the safety/tolerability profile of nifurtimox in patients who had previously discontinued benznidazole due to hypersensitivity reactions. We performed a prospective observational study from September 2009 to December 2011. Patients who discontinued benznidazole therapy due to hypersensitivity reactions (HR) and were later treated with nifurtimox were included. HR to benznidazole were defined as presence of a rash with or without mucosal involvement, fever or laboratory abnormalities (such as eosinophilia, leucopaenia or impaired liver function tests). The drugs were prescribed for 60 days (benznidazole) or 60–90 days (nifurtimox). The National Cancer Institute criteria (CTCAE, 2006, Version 3.0) were used for grading and reporting of adverse reactions (AR). Eighteen patients (16 females, two males, median age 35.5 years, range 15–50 years) with asymptomatic late chronic infection, were included. Median time between benznidazole interruption and start of therapy with nifurtimox was 121.5 days (IQR 72–223 days). Fifteen patients (83.3%) developed an AR to nifurtimox, gastrointestinal complaints and anorexia being the most common, and 13 patients (72%) completed the treatment schedule. Five patients interrupted therapy (27.8%) mainly because of gastrointestinal intolerance and/or nervous system toxicity. Only one patient developed skin lesions, a mild maculopapular rash not requiring specific therapy or treatment withdrawal. There was no severe AR. Nifurtimox as second line therapy in patients who discontinued benznidazole specifically due to HR appears to be safe and does not seem to be associated with a higher incidence of AR.

Atopic dermatitis–like presentation of graft-versus-host disease: A novel form of chronic cutaneous graft-versus-host disease

Graft-versus-host disease (GVHD) is a systemic disease, and skin is often one of the target organs. An atopic dermatitis (AD)-like presentation has never to our knowledge been reported. We sought to describe an AD-like presentation of cutaneous GVHD. Data on 11 patients with an AD-like presentation of GVHD were collected. The clinical and laboratory findings were retrospectively studied. All 11 patients developed skin lesions after hematopoietic stem-cell transplantation. The skin lesions occurred between 2 to 12 months after transplantation. Eight patients received their transplant from a first-degree family member; 3 received their transplant from an unrelated donor. The skin lesions were pruritic and suggestive of AD, whereas the histology showed features of AD and GVHD. The lesions responded to topical and systemic anti-inflammatory and immunosuppressive therapy and phototherapy. The number of patients is small and the study is retrospective. AD-like GVHD might represent a novel form of chronic cutaneous GVHD and responds well to treatment.

Dermatological manifestations in human immunodeficiency virus infected patients: Morphological spectrum with CD4 correlation

Background:More than 90% of human immunodeficiency virus (HIV) infected patients develop skin lesions at some time throughout the course of the disease. Several skin diseases have proved to be sensitive and useful indicators of progression of HIV infection. Although these conditions may be seen in general healthy population, their occurrence in patients with acquired immunodeficiency syndrome is often atypical, more severe and explosive.Aims:The present study was carried out to categorize the skin lesions by histopathology using punch biopsy or cytology when feasible in HIV infected patients and to see the correlation for various skin lesions with CD4 counts.Materials and Methods:In total 110 known HIV positive patients with the symptomatic skin lesions, cytology and punch biopsy was correlated with CD4 counts.Results:Maximum patients were between 31 and 40 years. 53 (48.18%) patients had infectious and 37 (34.55%) patients had non-infectious lesions. Out of 110 patients, CD4 counts were available in 70 patients. The spectrum of various non-infectious and infectious lesions such as viral, bacterial, fungal, protozoa and their association with CD4 counts is discussed.Conclusions:CD4 counts below 200 were associated with the maximum infectious lesions, whereas CD4 counts more than 350 showed more of the non-infectious lesions. Most common infectious lesion was Molluscum contagiosum. The most common non-infectious lesion was pruritic papular eruptions.

Dermatological manifestations in human immunodeficiency virus infected patients: Morphological spectrum with CD4 correlation

More than 90% of human immunodeficiency virus (HIV) infected patients develop skin lesions at some time throughout the course of the disease. Several skin diseases have proved to be sensitive and useful indicators of progression of HIV infection. Although these conditions may be seen in general healthy population, their occurrence in patients with acquired immunodeficiency syndrome is often atypical, more severe and explosive. The present study was carried out to categorize the skin lesions by histopathology using punch biopsy or cytology when feasible in HIV infected patients and to see the correlation for various skin lesions with CD4 counts. In total 110 known HIV positive patients with the symptomatic skin lesions, cytology and punch biopsy was correlated with CD4 counts. Maximum patients were between 31 and 40 years. 53 (48.18%) patients had infectious and 37 (34.55%) patients had non-infectious lesions. Out of 110 patients, CD4 counts were available in 70 patients. The spectrum of various non-infectious and infectious lesions such as viral, bacterial, fungal, protozoa and their association with CD4 counts is discussed. CD4 counts below 200 were associated with the maximum infectious lesions, whereas CD4 counts more than 350 showed more of the non-infectious lesions. Most common infectious lesion was Molluscum contagiosum. The most common non-infectious lesion was pruritic papular eruptions.

Fatal Strongyloides stercoralis hyper-infection in a patient with multiple myeloma

Strongyloides stercoralis (S.S.) is a human intestinal parasite, which may lead to complicated strongyloidiasis. We report a case of disseminated strongyloidiasis following the treatment of myeloma. The patient developed skin lesions, respiratory distress, aseptic meningitis and bacterial and fungal sepsis. The diagnosis of strongyloidiasis was established through endotracheal tube secretions. Despite the treatment with Ivermectin and Albendazole, the outcome was fatal. The value of screening for strongyloidiasis is unclear but may be of benefit in patients with hematological malignancies from high endemic areas

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Circulating Endothelial Progenitor Cells Decreased in Patients with Sclerodermatous Chronic Graft-versus-Host Disease

Chronic graft-versus-host disease (cGVHD) is a common late complication of allogeneic stem cell transplantation (allo-SCT). Some cGVHD patients develop skin lesions, and the skin lesions in sclerodermatous cGVHD (s-cGVHD) patients resemble those in progressive systemic sclerosis (PSS), which is characterized by impaired production of circulating endothelial progenitor cells (EPCs). We investigated, retrospectively, whether low EPC production may promote the development of sclerodermatous lesions in cGVHD. Peripheral blood (PB) was obtained from 14 healthy volunteers and 27 allo-SCT patients. Five patients developed s-cGVHD. CD34 + cells were purified by using the magnetic cell-sorting separation system, and the CD34 +/CD133 +/vascular endothelial growth factor (VEGF) receptor-2 + EPCs were quantified. The endothelial cell colony-formation potential was evaluated. Serum VEGF and basic fibroblast growth factor (b-FGF) concentrations were measured by ELISA. The s-cGVHD patients had significantly lower median circulating EPCs frequencies than non-s-cGVHD patients or control (145 of 20 mL [interquartial range—IQR 107-193] versus 1083.5 [IQR 669.3-2151]; P = .0023, and versus 1530.5 [IQR 961.3-2158]; P = .0012, respectively). They also had impaired median endothelial-forming ability compared to non-s-cGVHD patients or controls (3.8 [IQR 1.0-4.3] versus 12.8 [IQR 8.8-28.8], and versus 26.4 [IQR 23.6-30.6], respectively; P = .0012). Their VEGF and b-FGF serum levels were also higher than in controls. In conclusion, s-cGVHD patients show findings consistent with those seen in PSS with impaired vasculogenesis that may limit blood perfusion and may contribute to the development of sclerodermatous lesions.

Granulocytic sarcoma masquerading as Ewing′s sarcoma: A diagnostic dilemma

An eleven-year-old boy presented with a swelling in his left elbow. Radiologically the features were that of an Ewing's sarcoma involving the ulna. Histopathology showed small round cell tumor strongly positive for Monoclonal Imperial Cancer research fund 2 (MIC2) antigen. Similar cells in the bone marrow were involved with MIC2 positivity. The patient developed skin lesions, which on biopsy were found to be chloromas. The initial biopsies were reevaluated with special stains revealing granulocytic sarcomas in acute myeloid leukemia masquerading as Ewing's due to its MIC2 positivity. The possibility of myeloid neoplasms should be considered routinely with known MIC2 positive round cell tumors.

Allergic to all medicines and red coloured urine

Dermatitis artefacta is a disorder in which the skin is the target of self-inflicted injury. We report a case of dermatitis artefacta, in which the patient developed skin lesions, after taking each and every medication. Additionally he also had red coloured urine after taking certain group of medications, which, on further investigations, was found to be associated with glucose 6-phosphate dehydrogenase (G6PD) deficiency. This case illustrates the presence of factitious dermatitis and physical co-morbidity simultaneously, which was missed before psychiatric referral. Every symptom in a patient with a factitious disorder should not be labelled as feigned without a proper workup.

Kinetics of Circulating Endothelial Progenitors in Patients with Sclerodermatous Chronic Graft-Versus-Host Disease.

Chronic graft-versus-host disease (cGVHD) is a common late complications of allogeneic stem cell transplantation (allo-SCT). Some cGVHD patients develop skin lesions. This may be partly because cytotoxic T cells injure skin endothelial cells in GVHD patients. Since the skin lesions in sclerodermatous cGVHD (s-cGVHD) patients resemble those in progressive systemic sclerosis, which is characterized by impaired production of circulating endothelial progenitor cells (EPCs). We investigated whether low EPC production may help to promote the development of skin lesions in s-cGVHD patients. Peripheral blood (PB) was obtained from 14 healthy volunteers and 27 allo-SCT patients. Five patients developed s-cGVHD. In accordance with the Declaration of Helsinki recommendations, all procedures were approved by the institutional review board, and written informed consent was obtained from every participant. First, we assesed the absolute number of CD34+ cells by using a flow cytometric gating strategy on the basis of the International Society of Hematotherapy and Graft Engineering guidelines. The median CD34+ cell frequencies of the healthy volunteers, the 14 non-s-cGVHD, and the s-cGVHD patients were 1.74 /μL PB [IQR 1.34–2.01], 0.85 [0.73–1.62], and 0.41 [0.17–0.42], respectively. The non-s-cGVHD patients had significantly lower frequencies than control (p=0.018) while the s-cGVHD patients had significantly lower frequencies when compared to either the healthy volunteers (p=0.0012) or non-s-cGVHD (p=0.014) groups. Next, the CD34+/CD133+/vascular endothelial growth factor (VEGF) receptor-2+ EPCs were quantified after CD34+ cells were purified by using the magnetic cell sorting separation system. The s-cGVHD patients had significantly lower median circulating EPCs frequencies than non-s-cGVHD patients or control (median 145/20 mL [107–193] vs 1083.5 [669.3–2151]; p=0.0023, and vs 1530.5 [IQR 961.3–2158]; p=0.0012, respectively, Figure 1). We next assessed the ability of endothelial colony in PBMNCs of each group by using the standard CFU-EC assay. The s-cGVHD patients also had impaired median endothelial-forming ability compared to non-s-cGVHD patients or controls (3.8 [IQR 1.0–4.3] vs 12.8 [IQR 8.8–28.8], and vs 26.4 [IQR 23.6–30.6] respectively; p=0.0012, Figure 2). Lastly, the endothelial cell colony-formation potential was evaluated. Serum VEGF and basic fibroblastic factor (b-FGF) concentrations were measured by ELISA. Their VEGF and b-FGF serum levels were also higher than in controls. In conclusion, s-cGVHD patients show impaired vasculogenesis that may limit blood perfusion and could be responsible for the development of sclerodermatous lesions. Administration of EPCs to the skin lesions of s-cGVHD patients may be a novel therapy. [Display omitted]