[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.

Invasive Rhinosinusitis Caused by Alternaria infectoria in a Patient with Autosomal Recessive CARD9 Deficiency and a Review of the Literature.

Phaeohyphomycoses comprise a heterogeneous group of fungal infections caused by dematiaceous fungi and have primarily been reported in patients with underlying acquired immunodeficiencies, such as hematological malignancies or solid-organ transplants. Over the past decade, a growing number of patients with phaeohyphomycosis but otherwise healthy were reported with autosomal recessive (AR) CARD9 deficiency. We report a 28-year-old woman who presented with invasive rhinosinusitis caused by Alternaria infectoria. Following a candidate gene sequencing approach, we identified a biallelic loss-of-function mutation of CARD9, thereby further broadening the spectrum of invasive fungal diseases found in patients with inherited CARD9 deficiency. In addition, we reviewed 17 other cases of phaeohyphomycosis associated with AR CARD9 deficiency. Physicians should maintain a high degree of suspicion for inborn errors of immunity, namely CARD9 deficiency, when caring for previously healthy patients with phaeohyphomycosis, regardless of age at first presentation.

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.

Hepatic Metastasis Revealing a Melanoma of the Penis: Case Report.

Melanoma of the penis is a rare tumor with a poor prognosis. We report the case of a 73-year-old patient with no significant medical history, admitted for deterioration of the general condition and bilateral inguinal lymph nodes. An abdominal ultrasound and thoraco-abdomino-pelvic CT (computed tomography) scan revealed metastatic liver nodules, the tumoral nature of which was confirmed by an anatomopathological examination. Further clinical examination revealed papular and ulcerated lesions of the penis located at the urethral meatus and glans penis. These lesions were biopsied and histologically assessed as melanoma. The contribution of imaging in penile tumors is generally not useful for diagnosis as clinical examination is key. However, it has its place in the assessment of locoregional and distant extension. In our case, it was the distant lesions that helped orient the diagnosis. The patient underwent immunotherapical treatment and is still alive 19 months after the diagnosis.

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.

[Polymorphic lucite: about a case]. / La lucite polymorphe: à propos d'un cas.

Polymorphic lucite (PL) is a frequent photodermatosis, but its pathophysiologic mechanism is still poorly elucidated. We report the case of a 54-year old male teacher, with no previous medical-surgical history, presenting with recurrent papular and very pruritic rash lasting for 12 years. Clinical examination showed papular-vesicular excoriated lesions on the face, the neck and the scalp. Eczematiform lesions occurred on the back of the hands. The remainder of the integument as well as the mucous membranes were spared. The suspected diagnoses were lupus, drug-induced photosensitization or contact photosensitivity and polymorphic lucite (PL). During the interview, the patient reported that this eruption had recurred in the same period every year, namely at the beginning of spring and lasted until the end of summer. Photobiological evaluations were not performed. Antinuclear antibody test was negative, and histological examination was non-specific showing dermal dense lymphocytic infiltrate. The diagnosis of LP was suspected and the patient underwent synthetic antimalarial drug-based therapy associated with external photoprotection.

[Sebaceous hamartoma on the face: about a case]. / Hamartome sébacé de la face: à propos d'un cas.

Sebaceous naevus (sebaceous hamartoma) is a congenital lesion mainly localized to the scalp, whose clinical and histologic diagnosis is generally easy. In the vast majority of cases, it is diagnosed at birth, but it can sometimes go unnoticed and give the impression to occur later. This lesion may be complicated by benign tumors or more rare malignancies. We report the case of a 45-year old patient, who had been followed-up for Biermer's anemia (treated with monthly HYDROXOCOBALAMINE injection) and ophiasic alopecia for 15 years, presenting with a 10-year history of bilateral and symmetric pigmented plaques gradually increasing in size. Clinical examination showed temporal and subauricular plaques, with brownish verrucous appearance and smooth surface (A, B). Histological examination objectified acanthosis, papillomatosis and voluminous sebaceous glands located abnormally high within the dermis, suggesting sebaceous hamartoma. CO2 laser treatment was proposed to the patient.

[Basal cell carcinoma: about a historical case]. / Carcinome basocellulaire: à propos d'un cas historique.

We here report the case of an 80 year old man, with clear phototype, villager, residing in one of the most isolated places in our kingdom, located at an altitude above 2400 metres. During humanitarian aid, he presented with ulcero-necrotic tumor infiltrating the nasal root and the right orbit with total destruction of the right eye. The patient reported that the lesion had progressed for two and a half years from a small bleeding papule on the nasal root with orbital spread. Clinical and histological appearance suggested the diagnosis of infiltrating basal cell carcinoma. Staging showed right naso-orbital bone invasion. Mutilating cancer surgery was indicated but the patient refused it. Basal cell carcinoma is reported to have a relatively good prognosis because of its slow and local evolution. However, some cancer types, such as infiltrative tumor occurring in some high-risk areas, including the naso-orbital region, can be rapidly devastating, mutilating and voluminous with aesthetic and functional impairements as well as difficult to manage.

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.

[Elephantiasis of the left lower limb]. / Eléphantiasis du membre inférieur gauche.

We report the case of a 48-year old female patient with a pathological history of chronic venous insufficiency which required a surgical treatment 5 years before, presenting in the Department of Dermatology with increased left lower limb evolved over the past 4 years. Clinical examination showed increased lower limb, compared to the contralateral limb, with surgical scar at the level of the external face of the left leg and some papillomatous lesions involving the entire left foot and covering the five left toes. The diagnosis of post-traumatic lymphedema (post-surgical) was retained. Treatment was based on compression stocking, lymphatic drainage as well as on a preventive treatment including benzathine benzylpenicillin: 1.2 MU every three weeks. Lymphedema is caused by a malfunction of the lymphatic system responsible for lymph stasis in interstitial tissues. This results in an increased limb volume. All the anatomical regions which contain lymphatic fluids can be affected by lymphedema, but it mainly occurs in the limbs. Lymphedema of the lower limbs can be classified as either primary or secondary. End-stage lymphedema is also known as elephantiasis.

Carcinome épidermoïde sur lichen scléro-atrophique vulvaire: Epidermoid carcinoma associated with atrophic vulvar lichen sclerosus.

We here report the case of a 58-year old female patient with no particular past medical history, presenting with a 5-year history of vulvar pruritis, drought and vulvodynia at the Department of Dermatology. Clinical examination showed diffuse porcelaine lesions at the level of the vulva, with a yellowish hemispheric nodular lesion measuring 1 cm in diameter on the whitish plates and some excoriated lesions due to scratching. A skin biopsy was performed at the level of the whitish lesions and at the level of the nodular lesion. Histological examination suggested epidermoid carcinoma for the budding lesion and atrophic vulvar lichen sclerosus for the porcelaine lesions. Surgical treatment was recommended associated with radiation therapy. This study aims to highlight the risk for atrophic vulvar lichen sclerosu degeneration.

Maladie de Bowen du pied droit: Bowen's disease of the right foot.

We here report the case of a16-year old patient, with no particular past medical history, presenting, with skin swelling at the level of the forefoot evolving for 02 years, at the Department of Dermatology. Clinical examination showed hard budding cutaneous mass painless on palpation covering the 2nd, the 3rd and the 4th, right toes, measuring 4 cm in large diameter. The remainder of the clinical examination was normal, without adenopathies. Skin biopsy was performed at the level of the tumor and histological examination showed carcinoma in situ. Surgical treatment was recommended. Bowen's disease is a relatively rare squamous intraepithelial carcinoma in situ. It mainly affects adults at any age, with predominance in women. The diagnosis is suspected on the basis of clinical examination, but it is confirmed by the anatomo-pathological examination.

[Terebrant basal cell carcinoma]. / Carcinome basocellulaire térébrant.

Basal cell carcinoma (BCC) is the most frequent skin cancer. It never affects the mucosa. It is characterized by a local malignancy with an extremely rare risk of developing distant metastasis and the lowest mortality. However in the absence of diagnosis and early surgery, BCC can be locally invasive and result in severe tissue destruction. It can ulcerate and its growth can be extensive and destructive: terebrant tumors affecting the structures of the muscles and the bone. We here report the case of a 80-year old woman living in an isolated rural areas, presenting with ulcerated exudative and smelly burgeoning lesion in the pretragal and the parotid regions. Locoregional examination was unremarkable and histology showed infiltrative BCC. Staging evaluation objectified no bone invasion. The patient was referred to the Division of Plastic Surgery for carcinologic treatment.