White Plaques Research Articles

EARLY DETECTION OF VERRUCOUS CARCINOMA USING METHYLENE BLUE STAINING IN SUSPECTED LEUKOPLAKIA LESION: A CASE REPORT

Introduction: Verrucous carcinoma is one of squamous cell carcinoma in the oral cavity which can caused by smoking, alcohol consumption, HPV etc. Verrucous carcinoma can mimick as pre cancer lesion such as leukoplakia, so that early detection is mandatory. Vital staining can be done by toluidine blue, but it reported toxic in organ. Methylene blue had similar chemical structure and exhibited similar physicochemical properties to toluidine blue.The aim of this case report is to report the case of early detection verrucous carcinoma using methylene blue in leukoplakia among smoker and alcoholic patient. Case: A 46-year-old male patient came to RSIGM Sultan Agung Semarang complaint that there was a wound on the left cheek that has not healed for the last 3 years. The wound was not painful but sore when exposed to food. The wound had been treated using Albothyl but there was no change. The patient had been an active smoker since 20 years ago and consume as much as 2-3 packs of cigarettes/day and also consumed alcohol about 4 years ago. Intraoral examination nodular white plaques, unscrappable with pigmentation areas and painless. Clinical diagnosis was nodular leukoplakia. Case Treatment: Early detection using methylene blue 1% was obtained and a positive dark blue indicated a change in malignancy. Patients were given symptomatic therapy of triamcinolone acetonide in orabase 0.1% then an excisional biopsy was performed and a histopathological appearance shows thickening and changes in polarity of the epithelial cells and dysplasia. The final diagnosis is verrucous carcinoma. Conclusion: The persistent white plaque with the risk factors of smoking and alcohol is a suspicion toward malignancy, early detection using methylene blue staining can performed before biopsy.

ORAL VERRUCIFORM XANTHOMA: REPORT OF TWO CASES

Oral verruciform xanthoma (VX) is a benign lesion of unknown etiology, usually found in the gingiva and palate. This study reports on two cases of this uncommon lesion. The first is a nodule in the upper gingiva of an adult man, with the clinical diagnosis of squamous papilloma. The second is a white plaque on the tongue of a 64-year-old man, clinically diagnosed as leukoplakia or reactive hyperkeratosis. After excisional biopsy, both lesions presented a proliferation of squamous epithelium, with elongated rete ridges and numerous foamy macrophages (CD68+) within the connective tissue papillae, classified respectively as flat and verrucous. The first patient died during follow up, but the second showed no signs of recurrence one year after the biopsy. In a 60-year period, we have only 4 cases of VX (0.025%), a lesion that could be clinically misguided as other papillary or verrucous lesions. Oral verruciform xanthoma (VX) is a benign lesion of unknown etiology, usually found in the gingiva and palate. This study reports on two cases of this uncommon lesion. The first is a nodule in the upper gingiva of an adult man, with the clinical diagnosis of squamous papilloma. The second is a white plaque on the tongue of a 64-year-old man, clinically diagnosed as leukoplakia or reactive hyperkeratosis. After excisional biopsy, both lesions presented a proliferation of squamous epithelium, with elongated rete ridges and numerous foamy macrophages (CD68+) within the connective tissue papillae, classified respectively as flat and verrucous. The first patient died during follow up, but the second showed no signs of recurrence one year after the biopsy. In a 60-year period, we have only 4 cases of VX (0.025%), a lesion that could be clinically misguided as other papillary or verrucous lesions.

ORAL MANIFESTATION OF SECONDARY SYPHILIS - A CASE REPORT

This study aims to report a case of secondary syphilis with oral manifestations in a 30-year-old, Caucasian, female patient, with multiple lesions in the mouth that did not heal after 15 days. During anamnesis, the patient reported unprotected sexual intercourse and vaginal discharge. In the intraoral clinical examination, we observed whitish mucous plaques not removed by scraping with a "velvety" appearance located on the lingual edge of the right side and hard palate, with no painful symptoms. With a diagnostic hypothesis of syphilis in the secondary phase, two complementary tests were requested, VDRL and FTA-ABs, which presented a positive result, confirming the diagnosis of syphilis. Three weeks after the antibiotic treatment, the patient returned with no signs of lesions. It is important to highlight the role of the dental surgeon in the diagnosis of systemic diseases with oral manifestations, including cases of sexually transmitted diseases, such as syphilis. This study aims to report a case of secondary syphilis with oral manifestations in a 30-year-old, Caucasian, female patient, with multiple lesions in the mouth that did not heal after 15 days. During anamnesis, the patient reported unprotected sexual intercourse and vaginal discharge. In the intraoral clinical examination, we observed whitish mucous plaques not removed by scraping with a "velvety" appearance located on the lingual edge of the right side and hard palate, with no painful symptoms. With a diagnostic hypothesis of syphilis in the secondary phase, two complementary tests were requested, VDRL and FTA-ABs, which presented a positive result, confirming the diagnosis of syphilis. Three weeks after the antibiotic treatment, the patient returned with no signs of lesions. It is important to highlight the role of the dental surgeon in the diagnosis of systemic diseases with oral manifestations, including cases of sexually transmitted diseases, such as syphilis.

ORAL HAIRY LEUCOPLAKIA IN AN HIV-POSITIVE PATIENT: A CASE REPORT

Our clinic received a 33-year-old male patient, complaining of an oral burning sensation and white lesions on the lateral border of the tongue for 7 months. He also reported weight loss and nausea, and was recently diagnosed with HIV (viral load of 1,260,000 copies/ml and LTCD4 of 86 cells/uL). Intraoral exam showed white, verrucous, and irregular plaques located bilaterally on the tongue. An incisional biopsy was performed and anatomopathological examination showed superficial squamous epithelium with ballooning epithelial cells with bare nuclei, confirming the diagnosis Oral Hairy Leucoplakia (OHL). The in-situ hybridization for Epstein-Barr Virus (EBER) was positive. The patient began antiretroviral treatment, taking dolutegravir, tenofovir, and lamudivine. One month later, he presented undetectable viral load and LTCD4 of 294 cells/uL. After 2 months of follow-up, OHL showed complete clinical regression. AIDS is under control in Brazil, but clinicians must bear in mind the diagnosis of OHL in HIV+ patients. Our clinic received a 33-year-old male patient, complaining of an oral burning sensation and white lesions on the lateral border of the tongue for 7 months. He also reported weight loss and nausea, and was recently diagnosed with HIV (viral load of 1,260,000 copies/ml and LTCD4 of 86 cells/uL). Intraoral exam showed white, verrucous, and irregular plaques located bilaterally on the tongue. An incisional biopsy was performed and anatomopathological examination showed superficial squamous epithelium with ballooning epithelial cells with bare nuclei, confirming the diagnosis Oral Hairy Leucoplakia (OHL). The in-situ hybridization for Epstein-Barr Virus (EBER) was positive. The patient began antiretroviral treatment, taking dolutegravir, tenofovir, and lamudivine. One month later, he presented undetectable viral load and LTCD4 of 294 cells/uL. After 2 months of follow-up, OHL showed complete clinical regression. AIDS is under control in Brazil, but clinicians must bear in mind the diagnosis of OHL in HIV+ patients.

CHRONIC HYPERPLASTIC CANDIDIASIS AS A RARE ADVERSE EVENT OF SECUKINUMAB THERAPY

Secukinumab is an anti-IL-17A monoclonal antibody used for the treatment of psoriasis, a frequent chronic inflammatory skin disease. However, IL-17 is essential in immunity against oral opportunistic fungal pathogens; therefore, oral candidiasis can occur in patients treated with this drug, although adverse oral events are not widely described. A 72-year-old male patient with arthritis psoriasis managed with Secukinumab 300 mg once a month, for 90 days, presented a burning white plaque on the mid dorsal posterior tongue. Fungal culture was performed and a diagnosis of oral candidiasis was established. Systemic and topical antifungal medication led to regression of the lesion and burning sensation resolution. No symptoms or recurrence of the lesion were observed after six months of follow up. This case highlighted the importance of monitoring patients who are under treatment with IL-17 blockers due to the risk of opportunistic infections. Secukinumab is an anti-IL-17A monoclonal antibody used for the treatment of psoriasis, a frequent chronic inflammatory skin disease. However, IL-17 is essential in immunity against oral opportunistic fungal pathogens; therefore, oral candidiasis can occur in patients treated with this drug, although adverse oral events are not widely described. A 72-year-old male patient with arthritis psoriasis managed with Secukinumab 300 mg once a month, for 90 days, presented a burning white plaque on the mid dorsal posterior tongue. Fungal culture was performed and a diagnosis of oral candidiasis was established. Systemic and topical antifungal medication led to regression of the lesion and burning sensation resolution. No symptoms or recurrence of the lesion were observed after six months of follow up. This case highlighted the importance of monitoring patients who are under treatment with IL-17 blockers due to the risk of opportunistic infections.

THE ROLE OF DENTISTRY IN THE EARLY DIAGNOSIS AND FOLLOW-UP OF POTENTIALLY MALIGNANT DISORDERS: A CASE REPORT

In 2017, a 66-year-old male patient, smoker and alcohol-addicted for the last 52 years, presented a white plaque with a diagnosis of epithelial hyperplasia with papillomatosis and mild epithelial dysplasia. The patient did not continue with follow-up care. Later, in May 2021, he returned for further exams, presenting an extensive, hard, ulcerated exophytic erythroleukoplakia, with undefined limits on the edge of the tongue. New biopsies were performed, and the anatomopathological examination showed moderately epithelial dysplasia in the soft palate region. The left tongue was diagnosed with moderately differentiated conventional squamous cell carcinoma staging cT3acN1cM0 tongue squamous cell carcinoma. Treatment consisted of left partial glossectomy, together with radiotherapy (20 fractions x 250cGy/field). These findings are important because they imply that many patients with oral premalignant lesions are not diagnosed in a timely manner. thereby failing to receive the benefits of early detection. In 2017, a 66-year-old male patient, smoker and alcohol-addicted for the last 52 years, presented a white plaque with a diagnosis of epithelial hyperplasia with papillomatosis and mild epithelial dysplasia. The patient did not continue with follow-up care. Later, in May 2021, he returned for further exams, presenting an extensive, hard, ulcerated exophytic erythroleukoplakia, with undefined limits on the edge of the tongue. New biopsies were performed, and the anatomopathological examination showed moderately epithelial dysplasia in the soft palate region. The left tongue was diagnosed with moderately differentiated conventional squamous cell carcinoma staging cT3acN1cM0 tongue squamous cell carcinoma. Treatment consisted of left partial glossectomy, together with radiotherapy (20 fractions x 250cGy/field). These findings are important because they imply that many patients with oral premalignant lesions are not diagnosed in a timely manner. thereby failing to receive the benefits of early detection.

ORAL CARCINOMA IN A PATIENT WITH SYSTEMIC SCLEROSIS

Systemic sclerosis (SSc) is a rare autoimmune connective tissue disorder characterized by fibrosis, vasculopathy, and inflammation. SSc's disease-related characteristics include skin tightness, puffy fingers, open ulcers, and multi-organ involvement. Studies have also identified a higher risk for the development of malignancy in SSc patients. A 56-year-old woman with SSc presented an asymptomatic white plaque of 20 × 25 mm in the right lower lip. Medical history revealed a previous diagnosis of breast cancer and current diagnosis of colorectal cancer. An incisional biopsy was performed, and histological examination showed architectural and cytological atypia of the full epithelial thickness, consistent with those of a severe, in situ dysplasia/carcinoma. The patient was referred to oncology services. Early localized stage diagnosis of in situ carcinoma of the oral cavity brings more favorable prognosis with better overall management, especially in individuals with SSc who presented systemic overlapping complications. Funding: CAPES. Systemic sclerosis (SSc) is a rare autoimmune connective tissue disorder characterized by fibrosis, vasculopathy, and inflammation. SSc's disease-related characteristics include skin tightness, puffy fingers, open ulcers, and multi-organ involvement. Studies have also identified a higher risk for the development of malignancy in SSc patients. A 56-year-old woman with SSc presented an asymptomatic white plaque of 20 × 25 mm in the right lower lip. Medical history revealed a previous diagnosis of breast cancer and current diagnosis of colorectal cancer. An incisional biopsy was performed, and histological examination showed architectural and cytological atypia of the full epithelial thickness, consistent with those of a severe, in situ dysplasia/carcinoma. The patient was referred to oncology services. Early localized stage diagnosis of in situ carcinoma of the oral cavity brings more favorable prognosis with better overall management, especially in individuals with SSc who presented systemic overlapping complications. Funding: CAPES.

PITFALLS IN THE CLINICAL DIAGNOSIS OF ORAL SQUAMOUS CELL CARCINOMA

Oral squamous cell carcinoma (OSCC) may have several clinical manifestations, which can be confused with other more common lesions found in the oral cavity, delaying diagnoses and treatment, consequently worsening prognoses. We present two clinical cases of patients diagnosed with OSCC and no previous history of smoking or alcoholism. A 74-year-old man presented a small, symptomatic white plaque on the right lateral border of the tongue for 3 months. The initial diagnosis was frictional keratosis due to close contact to the lower second molar. The other patient was a 51-year-old man with symptomatic red area on the gingiva with 3 years of evolution. Initial clinical diagnosis was a possible lichen planus. Both patients underwent incisional biopsy, confirming the diagnosis of OSCC. In summary, it is important to recognize the different aspects of OSCC and establish the diagnosis as soon as possible, since clinical stages are directly related to prognoses. Oral squamous cell carcinoma (OSCC) may have several clinical manifestations, which can be confused with other more common lesions found in the oral cavity, delaying diagnoses and treatment, consequently worsening prognoses. We present two clinical cases of patients diagnosed with OSCC and no previous history of smoking or alcoholism. A 74-year-old man presented a small, symptomatic white plaque on the right lateral border of the tongue for 3 months. The initial diagnosis was frictional keratosis due to close contact to the lower second molar. The other patient was a 51-year-old man with symptomatic red area on the gingiva with 3 years of evolution. Initial clinical diagnosis was a possible lichen planus. Both patients underwent incisional biopsy, confirming the diagnosis of OSCC. In summary, it is important to recognize the different aspects of OSCC and establish the diagnosis as soon as possible, since clinical stages are directly related to prognoses.

VAPING IS THE NEW SMOKING: CHANGES IN THE MUCOSA AND SALIVA RELATED TO VAPE

Electronic nicotine delivery systems (e-cigarette, pod, and vape) have become increasingly popular among adolescents and young adults. This report draws attention to the changes observed in the mucosa and saliva of a vaper. Male patient, 26 years old, former smoker, and exclusive vaping for four years. The patient related a history of a white plaque in the posterior region of the hard palate with one-year evolution. Excisional biopsy showed hyperkeratosis without dysplasia. After two weeks, the biopsy region showed a healing aspect. The palate showed the aspect of nicotinic stomatitis. Molecular changes in saliva and vape liquid were analyzed by vibrational spectroscopy. The vape liquid changed color after use despite a lack of compositional changes. The aspect of the saliva was gelatinous in contrast to that of a non-smoker. An increased amount of sugars, glycerol, and formaldehyde, together with a decreasing protein content, was detected. FAPESP (grants #2020/10362-0; #2020/10322-9). Electronic nicotine delivery systems (e-cigarette, pod, and vape) have become increasingly popular among adolescents and young adults. This report draws attention to the changes observed in the mucosa and saliva of a vaper. Male patient, 26 years old, former smoker, and exclusive vaping for four years. The patient related a history of a white plaque in the posterior region of the hard palate with one-year evolution. Excisional biopsy showed hyperkeratosis without dysplasia. After two weeks, the biopsy region showed a healing aspect. The palate showed the aspect of nicotinic stomatitis. Molecular changes in saliva and vape liquid were analyzed by vibrational spectroscopy. The vape liquid changed color after use despite a lack of compositional changes. The aspect of the saliva was gelatinous in contrast to that of a non-smoker. An increased amount of sugars, glycerol, and formaldehyde, together with a decreasing protein content, was detected. FAPESP (grants #2020/10362-0; #2020/10322-9).

STEVENS JOHNSON SYNDROME: A CASE REPORT

A 62-year-old man, in polimiositis treatment for 12 years with immunotherapy, was admitted to hospital to investigate a complaint of high fever for the past three days. Fifteen days before, he suffered a traumatic subdural hematoma surgery removal,after which he started to use antiepileptic drugs. Different cultures were prepared in blood, secretions, and liquor to identify an infectious agent. Despite no positivity, some antibiotics were introduced. On the eleventh day, he presented multiple ulcers in mouth and lips associated to white plaques, suggesting candidosis, dry and erithematous eyes, and exantema on the body. Fever was still present. Stevens Jonhson's Syndrome was diagnosed based on clinical signs. The antiepileptics drugs were changed and antibioticotherapy discontinued; only symptomatic treatment was maintained and corticoids were introduced. The course was favourable ten days later, and the patient was released. Polypharmacy can lead to adverse drug reactions. A 62-year-old man, in polimiositis treatment for 12 years with immunotherapy, was admitted to hospital to investigate a complaint of high fever for the past three days. Fifteen days before, he suffered a traumatic subdural hematoma surgery removal,after which he started to use antiepileptic drugs. Different cultures were prepared in blood, secretions, and liquor to identify an infectious agent. Despite no positivity, some antibiotics were introduced. On the eleventh day, he presented multiple ulcers in mouth and lips associated to white plaques, suggesting candidosis, dry and erithematous eyes, and exantema on the body. Fever was still present. Stevens Jonhson's Syndrome was diagnosed based on clinical signs. The antiepileptics drugs were changed and antibioticotherapy discontinued; only symptomatic treatment was maintained and corticoids were introduced. The course was favourable ten days later, and the patient was released. Polypharmacy can lead to adverse drug reactions.

Oral Manifestations of “COVID-19” Infection

Corona virus disease spreads rapidly throughout the world and created public health emergency. This RNA virus shows different types of stains among which delta (B.1.617.2) stain is more dangerous due to its mutation although omicron (B.1.1.351) spreads more rapidly than other variants. Covid-19 manifest different oral lesions like ulcers, erosion, necrotising periodontal disease, red and white plaque, petechiae, herpetiform lesions, non-specific lesions, HSV-1, acute parotitis etc. This virus also leads to post complications like Mucormycosis, musculoskeletal problems, mental health problems. As this virus spreads through oral and nasal routes so it is important to identify oral lesions as early as possible, so that dentist and paramedical staffs take proper preventive measures.

Evaluation of Efficacy and Side Effects of Impairement Liver Function in Psoriasis Vulgaris Patients Treated with Methotrexate in Dr. Soetomo General Academic Hospital Surabaya: A Retrospective Study

Background: Psoriasis is a chronic inflammatory skin disease that involves several factors, genetic, immunity defects, hormones, and environmental factors. Psoriasis vulgaris is often characterized by a thick, erythematous, well-defined, rough, layered, silvery white plaque. Methotrexate is a first-line systemic therapy in the management of psoriasis vulgaris. This drug effective to reduce the severity of the disease by at least 50% in more than 75% of patients. Unfortunately, methotrexate also has the potential to cause adverse effects, this drug is considered one of the main causes of increased liver enzymes in psoriasis patients for several years so special consideration is needed when prescribing methotrexate to patients. Therefore, periodic evaluation during the use of this drug is needed to find out the side effects that can be caused. Purpose: The aim was to to evaluate PASI, SGOT and SGPT score of psoriasis vulgaris patients who received methotrexate therapy at Dermatology and Venerology Outpatient and Inpatient Clinic Dr. Soetomo General Academic Hospital Surabaya. Methods: This was a observational analytical study with retrospective data through one shot case study pre-experimental study approach, but was conducted pre and post treatment that aimed to evaluate PASI, SGOT and SGPT score of psoriasis vulgaris patients who received methotrexate therapy at Dermatology and Venerology Outpatient and Inpatient Clinic Dr. Soetomo General Academic Hospital Surabaya for the period January 2018-December 2020. Results: The results of this study were 51 psoriasis patients who received methotrexate that include in inclusion criteria. The number of male patients was more than women, 30(58,8%) for men and 21(41.2%) for women. There was a statistically significant difference in the reduction in PASI score of psoriasis vulgaris patients before and after methotrexate therapy (p = 0.001). However, the results of statistical analysis SGOT score of psoriasis vulgaris patients before methotrexate therapy were no different than after receiving methotrexate therapy (p = 0.286). In contrast, the results of statistical analysis SGPT score of psoriasis vulgaris patients after receiving methotrexate therapy increased significantly compared to before receiving methotrexate therapy (p = 0.001). Conclusion: there was significant decrease in PASI scores and significant increase in SGPT scores before and after receiving methorexate therapy. However, for SGOT scores statistically there was no significant difference before and after receiving methorexate therapy.

(126) Development of a Patient Reported Outcome Measure for Lichen Sclerosus

Abstract Introduction Patient-reported outcome measures (PROMs) can provide information that complements the provider-assessed clinical outcome measures of gynecologic and dermatologic diseases. As part of a larger study on lichen sclerosus (LS), genetics and the microbiome, we noted discrepancy between clinical assessment of LS and participant symptoms. Without a PROM, it is impossible to compare our results to those in the literature. Lichen sclerosus is a chronic vulvar dermatosis that affects approximately 1 in 70 women and can cause scarring, sexual dysfunction and malignancy (Krapf, 2020). However, the severity of LS symptoms may not be representative of the current clinical appearance. For example, the patient may report extreme pruritus and general irritation, yet the vulva may not appear erythematous or even consistent with active disease. On the other hand, patients may incidentally be diagnosed w lichen sclerosus after the provider noted classic characteristics including white plaques, erythema, and architectural changes of the labia and clitoral hood and yet the patient may not realize they had a vulvar skin condition with a history of only minimal to no symptoms noted. Objective The aim of our study is to develop patient-reported outcome measures of lichen sclerosus to incorporate patient’s experiences of LS and be able to correlate them to clinical management. Methods Methods: We evaluated 25 initial participants with biopsy proven lichen sclerosus and collected incidence of patient reported outcome measures as the first step of developing a larger PROM based investigation. Results 25 participants enrolled in the study and completed questionnaires on symptoms. Many of these participants were not using topical steroid treatment for symptoms. Most commonly experienced symptoms were: prutitis (52%, n=13, burning (28%, n=7, general irritation (n=12, dryness (48%, n=8), dyspareunia (40% n=10). For many women, the symptoms radiated, woke them up from sleep and caused overall disruption of their quality of life. Conclusions The next step will be to create a prospective survey of women living with LS to collect the most important symptoms according to patients and not just frequency. We hope eventually therapeutic strategies can be targeted at treating these specific symptoms and managing the disease state. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Johnson and Johnson.

Effectiveness of Homoeopathic Medicines in the Treatment of Chronic Urticaria

Background: Chronic urticaria is occurrence of wheals more than twice a week for a period of six weeks or longer. It is a vascular reaction of the skin characterised by the appearance of wheals, which are elevated whitish reddish plaques, generally surrounded by a red halo and associated with severe itching, stinging or burning sensations. Generally the lesions increase in frequency after adolescence, with highest incidence in persons in 3rd decade of their lives. Non- sedating anti-H1 antihistamines are the mainstay of treatment; when ineffective higher dosages are tried, though all are associated with a lot of side effects ranging from arrhythmias to osteoporosis when used for a long period.
 Objectives: The aims and objectives of the present study were to understand the clinical presentation of CU and to assess the effects of constitutional homoeopathic remedies in the treatment of chronic urticaria based on the Urticaria Activity Score (UAS), and to study their effects on the quality of life of the patients before and after treatment, using the Dermatology Life Quality Index (DLQI).
 Materials and Methods: It was a prospective non-randomised uncontrolled observational study; sample size was 30; case taking of all the patients was done based on standard case taking proforma, consent was taken from each patient,a questionnaire of 22 points was used to elicit significant aspects of the nature of urticaria, all the patients were prescribed medicines depending on individual case; follow-up was done every 30 days from first prescription. At each visit, scoring of clinical symptoms was done with the help of UAS. Prognosis was made by comparing the different scores at each visit. Lastly, quality of life assessment was done before and after treatment using DLQI.
 Results: According to severity based on the Urticaria Activity Score, before treatment 10% patients were in mild category, 60% patients in moderate category and 30% in severe category. After treatment, 63.33% patients were in mild category and 36.67% in moderate category. The t-value was 10.56(p=0.001) for UAS. Based on DLQI, 6.67% were in large effect group, 63.33% in moderate effect group, 26.67% in small effect group and 3.33% in no effect group.
 
 KEYWORDS: Chronic Urticaria, Homoeopathic treatment, Urticaria Activity Score (UAS), Dermatology Life Quality Index(DLQI)
 Conflict of interest: None
 

Eosinophilic Oesophagitis in Patients Presenting with Dysphagia: A Retrospective Study from a Single Tertiary Care Centre in Saudi Arabia

Background and Study Aims: Eosinophilic oesophagitis (EoE) is an increasingly common cause of dysphagia in many Western countries, especially in young adults; however, the prevalence of EoE in Middle Eastern countries remains unknown. We aimed to estimate the prevalence of EoE in Saudi patients presenting with dysphagia. Additionally, we aimed to assess the practice pattern of physicians with respect to evaluating these patients.
 Patients and Methods: We performed aretrospective review of all adolescent and adult patients who underwent upper gastrointestinal endoscopy for the assessment of dysphagia. Demographic data and endoscopic and histologic findings were reviewed. The primary outcome was the prevalence of biopsy proven EoE, defined as 15 or more eosinophils per high power field (≥15eos/hpf) in patients presenting with dysphagia. Secondary outcomes included the frequency of endoscopic features suggestive of EoE and the physician’s judgement about the need for oesophageal biopsies to diagnose EoE.
 Results: A total of138 patients were identified and reviewed. The mean age was 50.7 years; 43.5% were males and 56.5% were female. Endoscopy revealed normal oesophageal mucosa in 52.9% of the patients. White plaques were reported in 4.3%, linear furrows in 2.9% and multiple rings (trachealization) in 2.2% of patients. Oesophageal biopsies were obtained from 20.3% of all patients to rule out EoE, this included 7.1% of those with normal appearance of the oesophageal mucosa. Only two patients (1.4%) with biopsy proven EoE were identified from this cohort; both were young adults.
 Conclusions: Failure to perform oesophageal biopsies in patients presenting with dysphagia as per international guidelines could explainthe low prevalence of EoE observed in this population. Alternatively, the prevalence of EoE may be lower than expected in the Middle Eastern countries. Large prospective studies are necessary to accurately assess the prevalence of EoE in Middle Eastern countries.

Comparative Analysis of the Therapeutic Effects of Fresh and Cryopreserved Human Umbilical Cord Derived Mesenchymal Stem Cells in the Treatment of Psoriasis.

Psoriasis, an inflammatory autoimmune skin disease, is characterized by scaly white or erythematous plaques, which severely influence patients' quality of life and social activities. Mesenchymal stem cells derived from the human umbilical cord (UCMSCs) represent a promising therapeutic approach for psoriasis because of its unique superiority in ethical agreeableness, abundant source, high proliferation capacity, and immunosuppression. Although cryopreservation provided multiple benefits to the cell therapy, it also greatly compromised clinical benefits of MSCs due to impaired cell functions. The current study aims to evaluate the therapeutic efficacy of cryopreserved UCMSCs in a mouse model of psoriasis as well as in patients with psoriasis. Our results showed that cryopreserved and fresh UCMSCs have comparable effects on the suppression of psoriasis-like symptoms such as thickening, erythema, and scaling, and serum IL-17A secretion in mice model of psoriasis. Moreover, psoriatic patients injected with cryopreserved UCMSCs had a significant improvement in the Psoriasis Area and Severity Index (PASI), Physician Global Assessment (PGA), and Patient Global Assessments (PtGAs) scores compared to baseline values. Mechanically, cryopreserved UCMSCs markedly inhibit the proliferation of PHA-activated PBMCs, type 1 T helper (Th1) and type 17 T helper (Th17) cell differentiation and secretion of inflammatory cytokines including IFN-γ, TNF-a and IL-17A in PBMCs stimulated by anti-CD3/CD28 beads. Taken together, these data indicated that cryopreserved UCMSCs exhibited great beneficial effect on psoriasis. Thus, cryopreserved UCMSCs can be systemically administered as ''off-the-shelf'' cell product for psoriasis therapy.Trial Registration ChiCTR1800019509. Registered on November 15, 2018-Retrospectively registered, http://www.chictr.org.cn/ .

Disseminated Rasamsonia argillacea infection in a dog

ABSTRACT Case history A 4-year-old, male neutered Borzoi presented for unlocalised pain and frequent episodes of vocalisation. Clinical findings Pain was localised to the lumbar spine and radiographs revealed a L3–L4 lesion consistent with discospondylitis. The dog was treated for presumptive bacterial discospondylitis with surgical debridement, spinal stabilisation, and cephalexin. Samples collected from the affected intervertebral disc at the time of surgery revealed lymphoplasmacytic inflammation with no causative agent identified on histopathology or bacterial culture. After an initial period of improvement, signs recurred despite an 8-week antibiotic course, with the development of inappetence, weight loss, polydipsia, and polyuria. Repeat radiographs revealed a new cervical intervertebral lesion, and concurrent pyelonephritis was diagnosed based on blood and urine results. Fungal culture of urine resulted in growth of Rasamsonia argillacea species complex and disseminated fungal disease was clinically diagnosed. Antifungal treatment was commenced, however the dog deteriorated, and euthanasia was performed. Pathological findings Multifocal white plaques were grossly visualised in the spleen, mesenteric lymph nodes, cervical vertebrae, and kidneys. Periodic acid-Schiff-positive, fine, parallel-walled, occasionally branching, septate hyphae 5–10 μm in diameter, and conidia 5–7 μm in diameter were found on sectioning all organs. R. argillacea species complex was identified by fungal culture of urine and was considered the species of fungal organism seen histologically. The isolate was subsequently confirmed as R. argillacea by DNA sequencing. Diagnosis Disseminated Rasamsonia argillacea infection. Clinical relevance Rasamsonia argillacea species complex is a recognised invasive mycosis in veterinary medicine, with disseminated disease causing significant clinical complications and death. This is believed to be the first report of infection caused by R. argillacea in a dog in Australasia and highlights the importance of awareness of a potential fungal aetiology in dogs with discospondylitis. Abbreviations: CLSI: Clinical and Laboratory Standards Institute; CRI: Constant rate infusion; MEC: Minimum effective concentration; MIC: Minimum inhibitory concentration; PAS: Periodic acid-Schiff

P025 The knee that gave it away: a case report of melioidosis

Abstract Background/Aims Melioidosis, an infectious disease caused by the Burkholderia pseudomallei is very rare within the UK. This gram-negative bacterium is endemic in Southeast Asia predominately Thailand and Northern Australia which is found within the soil and fresh surface water. We present a challenging case of melioidosis who was diagnosed following a culture of a discharging knee swelling. Methods N/A Results 35-year-old, Caucasian gentleman with no previous past medical history presented with a ten week history of diffuse abdominal pain, weight loss, dry cough, fatigue and night sweats. On examination, he appeared pale and initial bloods showed a CRP of 229 mg/L. His other initial observations and baseline blood tests were normal. Abdominal ultrasound detected free peritoneal fluid and a subsequent CT chest and abdominal showed abnormal thickening of his small bowel, mediastinal and retroperitoneal lymphadenopathy along with bilateral pulmonary nodules. A laparoscopy and laparotomy with peritoneal, intraperitoneal and mesenteric lymph node biopsies were inconclusive. Microscopy and culture (MC&S) as well as acid fast bacilli MC&S were both negative. He continued to have systemic symptoms, as well as elevated inflammatory markers. He underwent a bronchoscopy which showed erythematous and a nodular endobronchial mucosa with white plaques seen within the lower trachea and minor narrowing of the lumen. Endobronchial biopsies showed chronic inflammation with no evidence of any malignant cells. Repeated bloods including retroviral screening, anti-nuclear antibody (ANA) and antinuclear cytoplastic antibodies (ANCA) and serum ACE were normal. At this stage, the clinical picture was suggestive of sarcoidosis, however a subsequent rigid bronchoscopy and biopsy did not evidence of granulomas or vasculitis. The patient started to develop increasing right knee swelling with difficulty in walking. The swelling burst open, and the discharging fluid was sent for MC&S. This was positive for Burkholderia pseudomallei. The gentleman completed a 20-week course of antibiotics with clinical resolution. Conclusion Meliodosis can cause a wide range of clinical manifestations varying from asymptomatic to septicemia, osteomyelitis, abscesses, septic arthritis and encephalomyelitis. Our case had travelled to Thailand around 8 months prior to the onset of symptoms. This highlights the possible long latent period between exposure and clinical presentation. Definite diagnosis is through isolation of Burkholderia pseudomallei in cultures. This proved challenging in our case, as multiple biopsies and cultures from different sites did not grow the bacterium. The diagnosis was confirmed following knee fluid culture. Musculoskeletal involvement of melioidosis is a known presentation and its potential to mimic other conditions, may render a diagnostic challenge especially when it occurs outside an endemic area. The case highlights the need for rheumatologists to have a high level of clinical suspicion for early detection, isolation of the organism and proper disease management. Disclosure A. Maksoud: None. L. Sammut: Other; LS has received funding for educational events and activities - from Lilly, Roche/Chugai.

Managing leukoplakia with diode laser: A report of two cases

Oral leukoplakia is the most common precancerous lesion of the oral mucosa. WHO defined it as a lesion which has a white patch or plaque on the oral mucosa that cannot be removed by scraping and cannot be classified clinically or microscopically as another disease process. Management of oral leukoplakia should begin with elimination of predisposing habit. There are currently different approaches in the management of Leukoplakia such as scalpel surgery, systemic carotenoids and antioxidants, electro cauterization, cryotherapy and Lasers. Even though on-surgical options are preferred choice of treatment, it takes time to achieve complete regression of lesion and sometimes may not achieve complete resolution. On the other hand, conventional surgical techniques are invasive and cause trauma to the patient. Excision of precancerous oral lesions using LASER offers comparative advantages over traditional scalpel excision. Laser is an acronym for Light Amplification by stimulated emission of radiation. It is surgical technique which excises the targeted tissue using emission of a monochromatic light of specific wavelength. Because of this property, laser excision of the tissue results in complete bloodless field of surgery, reduced chances of post-surgical inflammation and infections and hence better treatment compliance of the patients towards the surgery. This is one of the important goals for management of oral potentially malignant disorders. We present two case reports of homogeneous leukoplakia treated using diode lasers of wavelength 810nm with follow-up. Both cases did not report any post-operative discomfort or inflammation. The aim of this case report is to highlight the importance of laser excision with minimal complications and better treatment outcomes.

COMPREHENSIVE MANAGEMENT OF ORAL FRAILTY IN MULTIPLE SYSTEMIC DISEASES GERIATRIC PATIENT

ABSTRACTBackground Oral frailty is an important geriatric syndrome characterized by decreases in oral function that coincides with declines in cognitive and physical function. Objective: The aim of this case report is to describe the comprehensive management of oral frailty in a medically compromised geriatric patient prior to cardiovascular surgery. Case: A 64-year-old male patient complained of pain in swallowing and sore mouth since two days before. He had multiple systemic diseases, including infective endocarditis, acute kidney injury, type II diabetes mellitus, thrombocytopenia, and electrolyte-fluid imbalance. Extra-oral examination showed lymphadenitis, icteric sclera, and dry-exfoliative lips. Intra-oral examination revealed tongue depapillation, frothy saliva, and dry mucosa with poor oral hygiene. The scraped-off white plaque leaving erythematous area was found on the dorsal and ventral tongue, buccal mucosa, and hard palate. Irregular multiple major ulcers, surrounded by erythema, well-demarcated with yellowish concave base, and covered by thick yellowish-green sputum at the soft palate to the uvula. The diagnosis was exfoliative cheilitis, aphthous-like ulcer, acute pseudomembranous candidiasis, and moderate xerostomia. A D-E-N-T-A-L questionnaire was used to evaluate oral frailty, and the cumulative result was seven. Case Management: The patient was treated with 100% petroleum jelly, 0.12% chlorhexidine digluconate mouthwash, and chlorine dioxide-zinc mouthwash three times a day. The oral lesions showed significant improvement after one week of treatment. Conclusion: Appropriate therapy for oral lesions and eliminating the infection could be considered to minimize the long-term effect of oral frailty. The comprehensive management of oral frailty could be beneficial for improving the quality of life. Keywords: Geriatric, Oral frailty, Oral lesion, Systemic disease