Metastatic Adenocarcinoma of the Lung Presenting as a Presternal Cutaneous Mass: Case Report and Brief Literature Review.

BACKGROUND: Cutaneous metastases from lung cancer are uncommon; they can be the presenting sign of an unknown malignancy. CASE REPORT: We present a 53-year-old man with a presternal mass that proved to be a cutaneous metastasis revealing an underlying lung adenocarcinoma. We searched the relevant literature and present a review of the main clinical and pathological features of this type of cutaneous metastasis. CONCLUSION: Skin metastases are a rare manifestation of an underlying lung cancer, of which they can be the initial manifestation. Recognition of these metastases is important to promptly introduce an appropriate treatment.

[Cost and factors associated with the prescription of non-antiretroviral drugs among HIV-infected patients under antiretroviral therapy in a reference hospital in Morocco]. / Coût et facteurs associés à la prescription des médicaments non antirétroviraux chez les patients infectés par le VIH sous thérapie antirétrovirale dans un hÔpital de référence au Maroc.

Objective: To determine the costs of non-antiretroviral drugs and to identify the factors associated with their prescription in HIV-1 patients on antiretroviral therapy in Morocco. Methods: Retrospective study of a cohort of 264 patients living with HIV-1 who were given antiretroviral therapy in the Venerology Dermatology Department at the Mohamed V Military Training Hospital of Rabat during the period from January 1st, 2014, December 31st, 2018. The costs retained were those of the hospital pharmacy for essential drugs, otherwise they were the costs in the private pharmacies. The logistic regression model was used to analyze the factors associated with prescription. Results: Of the 264 patients included, the male predominance was 75%. The median age of patients was 49 [41-57]. At the onset, 21.2% of patients were already in the AIDS stage. After a mean duration of 11.1 ± 6.8 months of antiretroviral therapy, 71.6% of patients received at least one prescription for a non-antiretroviral drug. Over the entire follow-up period, the mean cost per patient was 24.2 €, and the mean cost supported per patient was 22.1 €. After cotrimoxazole (30.7% of patients), the most frequently prescribed drugs were iron (29.2% of patients), antibiotics (20.8% of patients), hypolipemics (20.1% of patients) and general antimycosics (16.3% of patients). Age (RR: 1.01; 95% CI: 1.00-1.07), AIDS stage (RR: 2.15; 95% CI: 1.61-4.19), anemia (RR: 2.02; 95% CI: 2.10-5.41) and number of comorbidities (RR: 2.45; 95% CI: 2.10-5.41) were significantly associated with the prescription of non-antiretroviral drugs. Conclusion: Our work highlights the high frequency of prescription of non-antiretroviral drugs in patients living with HIV in Morocco; especially those who are older, anemic at the onset and those who are already at the AIDS stage.

Mortality and prognostic factors of Bullous Pemphigoid in a Moroccan population.

BACKGROUND: Bullous pemphigoid is a common autoimmune blistering skin disease that is significantly associated with a high rate of morbidity and mortality. OBJECTIVE: Our aim was to determine the 1-, 2- and 3-year mortality rate and standardized mortality ratio of BP in Moroccan patients, as well as to identify risk factors that influence survival both in the 1st and 3rd year of follow-up. METHODS: All patients with BP diagnosed between January 2008 and December 2017 in a tertiary referral centre at the Mohammed V Military Hospital in Morocco were included retrospectively. RESULTS: The 1-year, 2-year and 3-year mortality rates of the cases were 25.8%, 32.3% and 43%, respectively. The median age of onset was 72 years (range, 64 ∼ 80 years), and 51 (54.8%) patients were men. The standardized mortality ratio of patients with BP was 2.6 times higher than that of age- and sex-matched members of the general Moroccan population. Besides advanced age, the presence of diabetes mellitus at the time of diagnosis was associated with increased 3-year mortality in multivariate analysis. CONCLUSION: This is the first study analysing the mortality rate of bullous pemphigoid in Morocco. Our findings confirm a high mortality rate for BP patients compared with the expected mortality rate for age- and sex-adjusted general Moroccan population. Risk factors for increased 3-year mortality include advanced age at the time of diagnosis and diabetes mellitus.

Multimorbidity among persons living with human immunodeficiency virus in a moroccan referral hospital.

Background: Multimorbidity is the co-existing of two or more chronic health conditions in addition to human immunodeficiency virus (HIV). In Morocco, the prevalence of and factors associated with multimorbidity in HIV-infected patients have not been well-documented. Methods: This cross-sectional analysis was conducted in 2018 and included 269 HIV-infected patients. Medical records were reviewed to identify chronic health conditions and to rate multimorbidity using the Cumulative Illness Rating Scale (CIRS). Associations between a higher CIRS score and risk factors were assessed using linear regression. Results: The mean age was 48.9 ± 10.7 years with a male predominance (75.5%). One in 5 (20,8%) had ever been diagnosed with acquired immunodeficiency syndrome. More than a 3rd (34.8%) of the patients had two or more chronic health conditions in addition to HIV. The most frequently documented comorbidities were metabolic complications followed by vascular disease. In multivariate analysis, older age, male gender, duration of receiving antiretroviral therapy, taking indinavir-containing antiretroviral regimen, having ever been stage Centers for Disease Control and Prevention B or C, and current viral load ≥50 copies mL-1 were associated with a higher CIRS score. Conclusion: The prevalence of comorbidities is substantially high. Care models for people living with HIV should include assessing and managing multimorbidity, particularly in patients who present with these associated factors.

The association between bullous pemphigoid and comorbidities: a case-control study in Moroccan patients.

BACKGROUND: Comorbidities of bullous pemphigoid (BP) have not been thoroughly described in Morocco. This study investigates clinical features, comorbidities, and medications in a cohort of Moroccan patients with confirmed BP to help decrease morbidity and mortality. MATERIAL AND METHODS: This cross-sectional study involved 81 cases of BP diagnosed in 2015-2018 and 162 age- and sex-matched controls with complete follow-up at the Department of Dermatology in a university hospital setting. RESULTS: Eighty-one individuals were included in the study; the mean age at diagnosis was 71.3 years, and 53% were men. The most common comorbidities were hypertension (58%), type 2 diabetes (43%), and dyslipidemia (31%). Almost a quarter of the cohort (28%) had been diagnosed with at least one neurological disease before the onset of BP. BP was significantly associated with the presence of malignancies (14%; p = 0.017) and stroke (16%; p = 0.009) compared to an age-matched control group. The most common standard medications were beta-blockers, diuretics, and statins. In total, 86% of the patients with type 2 diabetes were taking antidiabetic drugs, especially metformin (82%) and gliptins (51%). CONCLUSION: This study showed that BP is associated with stroke and the presence of malignancy compared to the age-matched general population. This study also calls for investigation into the specific role of some drugs as inducing factors for BP.

Pseudo-Hyperchloremia: Think about Analytical Interference with Bromides.

BACKGROUND: We report a case of pseudo-hyperchloremia in a patient hospitalized in the dermatology department at the Mohammed V Military Hospital of Instruction in Rabat. The examination revealed self-medication with calcium bromo-galactogluconate, allowing the suspicion of an analytical interference on chloremia by bromides. METHODS: The determination of chloremia was done by indirect potentiometry on an Architect ci8200®. RESULTS: A biological assessment was carried out on admission, showed isolated hyperchloremia at 137 mmol/L (95 - 110 mmol/L), while the other electrolytes, the anion gap, and kidney function were normal. A follow-up electrolytes test one week after stopping calcium bromo-galactogluconate showed normalization of chloremia to 109 mmol/L. CONCLUSIONS: The analytical interference of bromides on the chloride assay causes pseudo-hyperchloremia, an analytical anomaly not very well-known by clinicians.

Pemphigus Vulgaris: A Clinical Study of 31 Cases (2004-2014) in Morocco.

BACKGROUND: Pemphigus vulgaris is a rare bullous autoimmune dermatosis whose evolution and prognosis are unpredictable. AIM: The objective was to analyze long-term outcomes in patients with pemphigus vulgaris by identifying the factors that are able to influence prognosis, in particular the phenotype of pemphigus vulgaris, age at onset, multiplicity of mucosal involvement, relapse and remission rates, and survival functions. METHODS: A retrospective analysis of a cohort of 31 patients followed for pemphigus vulgaris during the period from January 2004 to January 2014. Inclusion criteria were a diagnosis of pemphigus vulgaris confirmed by histopathology and direct immunofluorescence (DIF) and a period of follow-up of at least five years from the diagnosis. The following information was collected by a single investigator. RESULTS: In total, 67.7% of patients presented a mucocutaneous pemphigus vulgaris. Male-female sex ratio was 2.4. The median duration of patient's follow-up was estimated at 7 (6-9) years. Multiple mucosal involvement in the oral cavity and at other mucosal sites was significantly associated with severe mucocutaneous pemphigus vulgaris (p=0.01). Multiple relapses were significantly associated with the disease severity (p=0.04). CONCLUSION: Poor prognosis factors were severe mucocutaneous type of pemphigus vulgaris and multiple mucosal involvement in the oral cavity and at other mucosal sites.

The dilemma of treating pyoderma gangrenosum associated with monoclonal gammopathy of undetermined significance.

Pyoderma gangrenosum (PG) is a rare ulcerative skin condition. It can be associated with a number of systemic diseases. Association with monoclonal gammopathy of undetermined significance (MGUS) is uncommon, but prognosis may be different depending upon the type of MGUS. Cases of MGUS- related PG reported in the literature with data concerning evolution and treatment were identified through a PubMed search. A patient with recurrent PG in the setting of a MGUS-IgA-? in our department was also included. In total, 10 cases were identified. Only the two cases with Ig populations other than IgA improved without recurrence after treatment of the PG. All the patients with MGUS-IgA showed recurrences. Early multiple myeloma was proposed for three patients with MGUS-IgA-related PG. Second or third line treatments were necessary in some cases.

Predictive factors for relapse in adults with dermatomyositis.

INTRODUCTION: Dermatomyositis (DM) is a severe disease that can be chronic with relapses and severe morbidity. The objective of this study was to analyze clinical features at presentation that predict non-paraneoplastic DM relapse in adult patients. METHODS: A multicenter retrospective study focused on 33 patients diagnosed with DM and treated using corticosteroids from 2000 to 2015. This study also aimed to compare patients with and without relapse based on some predictive factors such as demographic characteristics and clinical symptoms. A Cox model was used to estimate hazard ratios (HRs). RESULTS: We identified 33 patients with an average age of 41.8 ± 12 years (range 18-68 years). The sex ratio of females to males was 2:1. During the 13.5-month follow-up period, two (6%) patients died and 21 (63.6%) suffered from a relapse. In univariate analysis, skin ulceration in the initial presentation of disease (HR = 3.1, range 1.1 to 15.1) was significantly associated with a relapsing course. CONCLUSIONS: This study demonstrates that in the initial presentation of the disease skin ulceration is significant in allowing prediction of the occurrence of DM relapse.

Leflunomide-Induced Hidradenitis Suppurativa.

Hidradenitis suppurativa is an inflammatory disease of the pilosebaceous unit with a chronic intermittent course and a devastating effect on quality of life. Rare reports of drug-induced hidradenitis suppurativa exist. We report on 2 women on follow-up for rheumatoid arthritis, who presented hidradenitis suppurativa after different periods of treatment with leflunomide and who improved few weeks after discontinuation of the medication.

[Allopurinol-induced DRESS syndrome: Drug Reaction with Eosynophilia and Systemic Symptoms (DRESS)]. / Dress syndrome secondaire à l'allopurinol.

We report the case of a 60-year old patient with a 1-month history of hyperuricemia treated with allopurinol. The patient presented to the Department of Dermatology with acute rash on the face and the lower limbs associated with fever, arthralgias and myalgias. Clinical examination showed symmetric macular erythema on the face at the level of the cheeks with discreet edema (A), erythematous plaques at the level of both legs with healthy skin areas extending progressively from the bottom-up. Lesions were very itchy with burning sensation (B). The examination of the oral cavity showed very painful erosive lesions at the level of the internal face of the cheeks. Lymph nodes were free. Paraclinical tests showed leukocyte counts at 20000, elevated transaminases > 100 IU, eosinophil counts at 1500, HHV6 serology was negative. The diagnosis of DRESS syndrome was retained. The patient underwent corticosteroid therapy at a dose of 1 mg/kg/day associated with symptomatic treatment. Treatment evolution was marked by spectacular improvement after 06 days (C and D) with regression of skin lesions and gradual normalization of laboratory results.

[Acquired facial angiokeratoma]. / Angiokératome acquis de la face.

Angiokeratomas are vascular dilations (telangiectasic papules) with keratotic surface caused by capillary dilation in the dermal papilla due to venous hyperpression, vascular malformation or a capillary fragility. They most commonly are benign and just unsightly and they may sometimes reveal a dreaded overload disease known as Fabry Disease. Here we report the case of a 56-year old patient, with no notable medical history, presenting with nontraumatic, nonpruritic, bleeding on contact, grouped cluster erythematous papules without extracutaneous manifestations on the left malar region, that had occurred 4 months before. Diascopy revealed partially emptied papules with keratotic surface. Kaposi syndrome, melanoma, carcinoma or angiokeratoma were suspected. Histological examination revealed angiokeratoma. Treatment based on electrocoagulation was proposed to the patient.

[Keratoacanthoma of the left forearm]. / Kératoacanthome de l'avant-bras gauche.

We here report the case of a 54-year old woman presenting with a swelling in the left forearm occurred eight weeks before and rapidly increasing in volume. Clinical examination showed ulcero-budding painless purplish skin lesion measuring 2 cm along its longer axis (A). The patient underwent simple biopsy. Histological examination showed dyskeratosic, disorganized, hyperplastic epithelium with cytonuclear abnormalities, suggesting malignant transformation. Given the absence of infiltration in the chorion and the presence of hyperkeratosis, the diagnosis of keratoacanthoma was made. Resection of the tumor was indicated to confirm or deny this diagnosis. Histological examination revealed a protruding epithelial tumor-like lesion circumscribed by two species of lateral "bird beaks" delineating a crater filled with many layers of keratin. The crater was bordered by hyperplastic epithelium. The crater base was characterized by irregular papillomatous projections as well as by few cellular strands which seemed to shred in the underlying dermis. These were basophilic made up of cells displaying a certain degree of cytonuclear abnormalites arranged in one or two peripheral areas and, in their center, some eosinophilic, keratin, homogeneous cells, few mitoses as well as many horny globes, most often completely keratinized (B). The diagnosis of keratoacanthoma was retained. Keratoacanthoma is a well defined anatomo-clinical entity which can be very difficult to distinguish from squamous cell carcinoma, whose incidence is three times higher. A distinction between these two lesions is necessary due to their different management.

Tuberculous gummas: Epidemiological, clinical, bacteriological, immunological, and therapeutic features.

Tuberculous gummas are an unusual form of tuberculosis (TB) accounting for 1%-2% of all cutaneous TB cases. The aim of this article was to describe the epidemiological, clinical, bacteriological, immunological, and therapeutic features of this form upon a case report and a literature review. Forty-eight case reports were identified through a PubMed and Google Scholar search using the following keywords: "tuberculous gumma" and "metastatic tuberculous abscesse." Tuberculous gumma can occur at any age. Immunodepression is not a sine qua non condition to the development of the disease. Limbs are the most frequent site for gummas. Tuberculous gummas are associated to another location in only 73% of cases. The most frequent associated locations are lung, nodes, and musculoskeletal apparatus. Mantoux test is negative in 38% of cases. Skin stain is positive in 45% of cases and culture in 85% of cases. Giant epithelioid cell granuloma is present in 82.4% of cases. There is no universally accepted chemotherapy regimen for metastatic tuberculous abscesses. The classic 2RHZE/4RH is highly effective.

[Tuberous sclerosis complex: the role of patient's history and clinical examination]. / Sclérose tubéreuse de Bourneville: importance de l'anamnèse et de la clinique.

Tuberous sclerosis complex (TSC) is a neurocutaneous multisystemic syndrome most commonly affecting the skin, the brain, the kidneys, the lungs and the eyes. The diagnosis is based on clinical characteristics; 90% of patients have skin lesions and seizures are the initial symptom in 80% of patients. Patients with STB often show a high incidence of neuropsychiatric symptoms, including mental retardation, autism and learning difficulties. Epilepsy and brain and renal tumors are treated with aggressive therapeutic and surgical approaches. We report the case of a 13-year old girl, presenting with a 1-year history of acne resistant to therapy. Clinical examination showed symmetric grouped red papules with smooth surface on the central face and the chin (A). The objective clinical examination also showed frontal fibrous plaques (A), achromic macules on the upper limbs and grayish tumors in the periungual folds of the toes (B). During a new interview, patient's mother reported that these lesions had their onset when the patient was 5 years old, manifesting as seizures at the age of 2 years and disappearing at the age of 6 years, with good psychomotor development. The girl had a history of consanguinity but she had no other family history. Based on these major criteria, the diagnosis of Tuberous sclerosis complex was made. The patient underwent MRI of the brain showing intensely enhanced multiple bilateral subependymal and intraventricular nodules as well as signal abnormalities in the subcortical white matter at the level of the frontal, parietal and temporal area and linear abnormalities in the subcortical white matter. Thoracoabdominopelvic CT scan showed liver and renal lesions suggesting angiomyolipomas. Ophthalmologic examination, electrocardiogram and cardiac ultrasound were normal. Vascular laser treatment of angiofibromas, annual clinical monitoring and paraclinical monitoring every 3 years were proposed to the patient.

[A rare and atypical cause of scrotal ulcerations]. / Une cause rare et atypique des ulcérations scrotales.

Salmonelloses are bacterial infections of the faecal peril; they are endemic in some regions of the world. They can colonize almost any organ hematogenously, hence, severe forms may be observed. We report a case of typhoid fever in a 16-year old young adolescent with no medical history, sexually transmitted diseases or sexual intercourses, presenting with necrotic scrotal ulcerations evolving over the past 3 weeks in a context of fever, diarrhoea, weight loss and alteration of the general state. Paraclinical assessment showed 7g/dl hypochromic microcyticanemia with target cells in blood smear and normal hemoglobin electrophoresis, biologic inflammatory syndrome, malabsorption syndrome, cytolysis and hepatic cholestasis 20 times above the normal, hepatosplenomegaly, normal viral serologic testing (HBV, HCV, HIV, EBV and CMV) and positive testing for salmonella. The patient underwent 3 weeks of therapy with fluoroquinolones with favorable evolution. Dermatologic manifestations are frequent and polymorphic in typhoid fever; however cutaneous and, in particular, scrotal ulcerations are rarely reported. Differential diagnosis may be based on sexually transmitted diseases, inflammatory bowel diseases or hematologic disorders. More often diarrhoea is reduced or absent and patient's outcome depends on antibiotic. Diagnostic confirmation in patients with an atypical clinical picture, as in the case of our patient, is based on serology. Treatment is based on proper and prolonged antibiotic therapy and on prophylaxis measures to neighbouring.

[Atypical and revelatory livedo reticularis!?] / Livédo atypique et révélateur!?

Atherosclerosis is a frequent and life-threatening complication in elderly patients with multimorbidity as well as with one or multiple cardiovascular risk factors. It can affect all the arterial trunks of the lower limbs and can cause obliterative arterial disease of the lower limbs. We here report the case of an elderly patient with ecchymotic livedo reticularis of the right thigh revealing ipsilateral obliterative arterial disease of the lower limb with septic loosening of total hip prosthesis. The study involved a 70-year old man with favorable atheromatous condition complicated 6 months before by ischemic heart disease revascularized with double prostheses (stent) and with right total hip prosthesis implanted 10 years before. He presented with large mesh and incomplete livedo reticularis associated with ecchymoses on the right thigh (A). Clinical examination showed reduced distal pulses in the right lower limb. Laboratory tests showed discrete inflammatory syndrome and normal haemostatic and immunological tests . Standard radiographic evaluation of the right hip showed a loosening of the distal end of the prosthesis (C). Echo-doppler of the lower limbs and angio-scanner showed occlusion of the right external iliac axis, right double primitive iliac stenosis and a lesion due to septic dislocation of the right femoral prosthesis with abscess collection measuring 48 mm/30 mm ( B). The patient was referred to the Division of Vascular Surgery for revascularization. Vascular imaging by echo-doppler and/or angio-scanner should be performed, in particular in elderly patients with livedo reticularis or venous collateral circulation and with cardiovascular risk factors.