Tuberculoid Leprosy Masquerading as Erythema Induratum.

Introduction: Erythema Induratum (EI) is a relatively rare dermatologic disorder affecting subcutaneous fat tissue, which is often associated with Mycobacterium tuberculosis. This report details the presentation, diagnosis and management in a 70-year-old female who presented with a painful erythematous annular rash at the clinic. The rash was later diagnosed as EI associated with Mycobacterium leprae, one rarely seen in literature. Discussion: EI is a rare form of panniculitis that typically presents as a recurrent grouping of tender nodules and plaques on the posterior aspect of the lower legs. Although EI is considered idiopathic in most cases, it can be associated with M. leprae. Given the atypical presentation of a rash, a biopsy was done. It showed epithelioid granulomatous dermatitis with lobar panniculitis. A DNA polymerase chain reaction (PCR) was also sent and revealed the presence of M. leprae. Treatment of EI without association with M. leprae includes potassium iodide, non-steroidal anti-inflammatory drugs (NSAIDs), rest, elevation, compression and, in severe cases, systemic immunosupressives. If tuberculoid leprosy is confirmed, the attending physician is encouraged to consult the infectious disease department as treatment varies with presentation. Conclusions: This case details the diagnosis and management involved in a case of tuberculoid leprosy masquerading as EI. Management of the EI involved NSAIDs and potassium iodide. The leprosy was treated with dapsone and rifampin in conjunction with an infectious disease consultation. Our case highlights the importance of relying on a strong clinical suspicion based on a patient's social history in order to diagnose rare entities accurately.

Laser skin resurfacing, chemical peels, and other cutaneous treatments of the brow and upper lid.

The focus of this article is treatments of the brow and upper lid, in the context of appreciating their relationship to the forehead and periorbital complex to best evaluate and treat. This material is focused on treatments designed to stimulate collagen synthesis, as well as improve fine lines, wrinkles, and overall appearance of the skin, by mechanical dermabrasion, application of chemical peels, laser surgery, and treatment with energy devices including radiofrequency and focused ultrasound.

Eruptive vellus hair cysts.

Eruptive vellus hair cyst (EVHC), described initially in 1977, is a benign dermatologic condition that is characterized by the sudden appearance of monomorphic, follicular, asymptomatic, small papules in children and young adults. The diagnosis is based on the histopathologic findings of stratified-squamous epithelium with a granular layer that surrounds a cystic space filled with laminated keratin and a variable number of vellus hair cysts. EVHC can be associated with steatocystoma multiplex. A current hypothesis suggests that EVHC originates from a cystic change at the insertion of the pilosebaceous duct. EVHC is primarily treated for cosmesis with retinoids, surgery, and lasers.

Subcutaneous dematiaceous fungal infection.

Subcutaneous dematiaceous fungal infections, which include chromoblastomycosis and phaeohyphomycosis, are a heterogeneous group of clinical entities that are caused by dematiaceous or pigmented fungi found in soil. These infections have a wide spectrum of clinical presentations that depend largely on the specific causative organism and on the integrity of the host's immune response. Treatment is challenging and involves a highly individualized plan that often combines both surgical and long-term medical treatment.

Erythrodermic lichen planus.

Lichen planus (LP) is a relatively common papulosquamous disorder that is characterized by pruritic, polygonal papules in a characteristic distribution. We present a case of a 71-year-old man with erythroderma, who was ultimately diagnosed with severe, generalized LP. Treatment of severe LP is challenging, and there are few, robust, clinical trials in the literature to guide the selection of appropriate treatment. We discuss the treatment options for generalized LP and the evidence in support of these agents.

Chemical leukoderma.

Chemical leukoderma is defined as an acquired, hypopigmented dermatosis that results from repeated cutaneous application of an agent that destroys epidermal melanocytes in genetically susceptible patients. Chemical leukoderma may develop both at the site of contact with the chemical as well as remotely from the exposure. Avoidance of the causative agent may lead to spontaneous repigmentation, but treatments commonly used in vitiligo, such as narrow-band ultraviolet B phototherapy, PUVA photchemotherapy, or topical immunosuppressants, often are necessary. We present a case of chemical leukoderma secondary to pyrethroid insecticides that has progressed despite avoidance of the agent for over ten years.

Standing and exercise Doppler echocardiography in obstructive hypertrophic cardiomyopathy: the range of gradients with upright activity.

BACKGROUND: The ideal provocative maneuver in patients with hypertrophic cardiomyopathy (HCM) is a subject of ongoing investigation. Standing is a fundamental activity of daily life. This study examined acquisition of standing, Valsalva, and post-exercise left ventricular outflow tract gradients in HCM. METHODS: Rest supine, standing, and post-Valsalva gradients were measured in 98 consecutive patients with HCM who were referred for outpatient echocardiography. In 53 (54%) of the 98 patients, symptom-limited treadmill exercise was also performed, with gradients measured immediately after in the supine position. RESULTS: Fifty-six (57%) of the 98 patients had resting gradient<30 mm Hg and would thus be characterized as nonobstructive at rest. In the 98 patients, median gradients were 25 mm Hg at rest (range 0-205 mm Hg), increasing to 44 mm Hg after standing (range 0-309 mm Hg), an increase of 76%, and were again higher after Valsalva, 64 mm Hg (range 0-256 mm Hg) (P<.001). In the 53 patients who had gradient assessed after exercise, they were higher still, 100 mm Hg (range 0-256 mm Hg) (P<.001). In 29 patients (30%), standing provoked a higher gradient than Valsalva. CONCLUSION: Although standing increased gradients by 76%, it is not as potent a provocative maneuver as Valsalva or treadmill exercise. Nevertheless, standing is recommended as a physiologic provocative maneuver. In some patients standing may guide therapy; in others, the standing and exercise gradient provide a correct appreciation of the range of physiologically experienced gradients during daily upright activity.

Glomangioma.

A 22-year-old man presented with a 9-year history of multiple blue nodules on the medial aspect of his right arm. A biopsy specimen showed a cystic space with a cuboidal cellular lining that stained positive for α-smooth-muscle actin; these findings were consistent with multiple glomangiomas. We review the clinical and histopathologic characteristics of this rare entity.

Necrolytic acral erythema.

Necrolytic acral erythema (NAE) is a recently recognized dermatosis almost exclusively associated with hepatitis C virus (HCV) infection and closely related to a group of necrolytic erythemas and metabolic syndromes. NAE is characterized by pruritic, symmetric, well-demarcated, hyperkeratotic, erythematous-to-violaceous, lichenified plaques with a rim of dusky erythema on the dorsal aspects of the feet and extending to the toes. Based on morphology and histopathologic features, NAE can be difficult to distinguish from certain groups of necrolytic erythemas, which include necrolytic migratory erythema, acrodermatitis enteropathica, biotin deficiency, niacin deficiency, and essential fatty acid deficiencies. The condition is particularly important for clinicians to diagnose because the majority of the patients present to dermatologists without a known history of HCV infection. Thus, NAE can serve as a cutaneous marker for underlying HCV infection. Resolution of NAE can be achieved by treatment of the underlying HCV infection and the use of oral zinc therapy.

Facial shaping: beyond lines and folds with fillers.

Facial attractiveness is the most important determinant of physical attractiveness, and an important factor in social and interpersonal interactions. The field of facial rejuvenation using minimally invasive procedures has expanded exponentially over the last decade. Historically, aging and the resulting changes were primarily attributed to changes in the skin and the underlying musculoskeletal system. However, more recent understanding of the changes associated with facial aging has shifted the focus to changes in the distribution of subcutaneous fat. With the introduction of seemingly endless varieties of fillers over the last decade, restoration of volume loss by subcutaneous fat, and to some extent bone, has never been easier. Here, the authors review the basic principles that govern facial beauty, facial anatomy, the aging process, and the wide variety of fillers available on the market today that enable a dermatologic surgeon to revitalize the face.

Enhancing the eyes: use of minimally invasive techniques for periorbital rejuvenation.

Facial beauty, specifically of the periorbital complex, is an important component of physical attractiveness and non-verbal communication, and is reflective of chronological age. In fact, eye contact is often the first, and some say the most important, form of interaction between individuals. These properties have made rejuvenation of the periorbital complex highly desirable. In the past, rejuvenating the eye meant the need for invasive surgical treatments. Although these may be necessary in advanced cases, minimally or noninvasive procedures have increasingly become first line treatment options since the advent of topical therapies and minimally invasive procedures, which include botulinum toxin, dermal filler injections, laser and chemical peels, laser skin resurfacing, microdermabrasion and intense pulsed light photorejuvenation. Here, the authors review the anatomy of the periorbital complex, the characteristics of an attractive eye, and a variety of techniques that may be used alone or in combination to achieve "the beautiful eye.

Acute respiratory failure due to refeeding syndrome and hypophosphatemia induced by hypocaloric enteral nutrition.

We report a case of acute respiratory failure due to refeeding syndrome caused by hypocaloric enteral tube feeds. A 60-y-old obese man, with a diagnosis of esophageal carcinoma with local metastases, underwent feeding jejunostomy tube insertion. Enteral tube feeding was initiated at small volumes providing 4.4 kcal x kg(-1) x d(-1) and gradually increased over 48 h to 29 kcal x kg(-1) x d(-1) (based on adjusted body weight). The patient then developed acute respiratory distress requiring intubation and ventilatory support. Serum phosphorus (P) level was extremely low at <0.7 mg/dL. Serum potassium (K) and magnesium (Mg) levels were also low. It took >4 d to adequately correct the electrolyte derangements. Successful liberation from mechanical ventilation was then possible. In chronically malnourished patients undergoing nutritional support, even hypocaloric feeding should be considered a risk factor for developing refeeding syndrome leading to severe and acute electrolyte fluid-balance and metabolic abnormalities.

Autonomically induced conversion of pulmonary vein focal firing into atrial fibrillation.

OBJECTIVES: This study was designed to determine the mechanism(s) whereby focal firing from pulmonary veins (PVs) is converted into atrial fibrillation (AF). BACKGROUND: The mechanism(s) whereby PV focal firing or even a single PV depolarization is converted into AF is unknown. METHODS: In 14 anesthetized dogs a right thoracotomy was performed to expose the right superior pulmonary vein (RSPV). An octapolar electrode catheter was sutured alongside the RSPV so that the distal electrode pair was adjacent to the fat pad containing autonomic ganglia (AG) at the veno-left atrial (LA) junction. An acrylic plaque electrode on the fat pad allowed AG stimulation at voltages ranging from 0.6 to 4.0 V. Multi-electrode catheters were sutured to the atria with their distal electrode pairs at the fat pad-atrial junctions. Right superior pulmonary vein focal firing consisted of S(1)-S(1) = 330 ms followed by as many as 11 atrial premature depolarizations (APDs) (A(2)-A(12)) whose coupling interval just exceeded RSPV refractoriness. RESULTS: Autonomic ganglia stimulation, without atrial excitation, caused a reduction in heart rate (HR): control 142 +/- 15/min, 4.0 V; 75 +/- 30/min, p /=9.3 V. CONCLUSIONS: The effects of AG stimulation at the base of the RSPV can provide a substrate for the conversion of PV firing into AF.