Validation of the DLQI questionnaire in assessing the disease burden and principal aspects related to life quality of vitiligo patients.

According to many studies, vitiligo has a negative psychological influence on the patient's life. Multiple factors contribute to the severity of the vitiligo disease burden, among which the most important are self-esteem, stress, and stigma. We aimed to measure the importance of health-related life quality in assessing disease burden in patients with vitiligo. We formulated an HA, which is the principal hypothesis, claiming a single fundamental factor that characterizes the life quality of patients with vitiligo. We also formulated 10 important research questions related to the quality of life that can be generally formulated for patients with dermatological illnesses but particularly suited for vitiligo patients. These research questions capture fundamental aspects of the health-related quality of life of vitiligo patients influenced by symptoms and feelings, daily activities, leisure, job and education, personal relationships, and treatment. These also cover specific aspects related to the quality of life, such as skin-caused sexual difficulties, difficulties in social relationships, and difficulties in performing sports, among others. The Dermatology Life Quality Index (DLQI) questionnaire measures the health-related quality of life of persons suffering from skin diseases. We applied this generic questionnaire to patients with vitiligo. Following a set of inclusion and exclusion criteria, we obtained 114 carefully selected patients who responded to all the questions. This study also validated the DLQI questionnaire on persons who suffer from vitiligo. We investigated whether DLQI has acceptable internal consistency by applying Cronbach's alpha internal consistency indicator (Cα). The obtained Cα = 0.914 indicates excellent internal consistency. We also examined whether all the questions in the questionnaire were mathematically consistent, which we finally proved. It was not necessary to remove any of the questionnaire questions. To prove our HA, a Principal Axis Factoring (PAF) was applied, verifying the assumptions regarding the Average Variance Extracted (AVE) and Convergent Validity (CV). HA proved that applying PAF on DLQI resulted in extracting a single general vitiligo latent factor of life quality, with an initial eigenvalue = 5.671, SS loadings = 5.2, and 52 % of the total cumulative variance explained. Diverse statistical analyses were applied to analyze the 10 formulated research questions. The results of the analysis of the research questions are presented and discussed in the manuscript. One of the conclusions related to the analysis of a research question was that sex had the lowest correlation with the latent life quality factor identified for vitiligo patients.

Multiple verrucous squamous cell carcinomas developing on chronic hidradenitis suppurativa lesions-a rare case report from Romania.

Hidradenitis suppurativa (HS) is an uncommon, recurrent, inflammatory skin illness of the apocrine glands, with a questionable etiology. The disease is associated with a multitude of comorbidities, of which the appearance of malignancy is the most important. Squamous cell carcinoma is considered the most frequent malignancy that can appear in HS. A case report of a 72 years-old male is presented, who suffered over 40 years from persistent, extensive hidradenitis suppurativa in stage Hurley III, on the buttocks and perianal region, who recently presented two verrucous semi-consistent, skin-colored tumors on the right buttock. The biopsy and histopathological exam confirmed a verrucous type of squamous cell carcinoma. There are about 100 reported clinical cases of squamous cell carcinoma complicating hidradenitis suppurativa in the literature, but only a few describe a verrucous carcinoma as a clinical form. The particularity of the case is the rare appearance of multiple verrucous types of squamous cell carcinomas in a male patient, in Hurley Stage III, with a long HS disease duration, appearing on the perianal/gluteal region, being the first case report in our country. We suggest that a tumor screening should be done for all the patients with HS who have these risks.

Embolia cutis Medicamentosa (Nicolau syndrome): case series.

Introduction: Embolia cutis medicamentosa or Nicolau syndrome is a rare drug reaction associated with the administration of various injectable medications. The pathogenesis of the disease is unknown, though intra and periarterial injection of the drug is a possible cause. The aim of this study was to describe and analyze the clinical characteristics of Nicolau syndrome in patients examined in daily dermatological practice. Methods: We performed a retrospective chart review, between January 2011 and December 2020, in patients diagnosed with Nicolau syndrome, from the cases of a private dermatology medical office in Târgu Mureș, Romania. Results: During the 10-year period, 7 patients were diagnosed with Nicolau syndrome. Of these, 4 (57%) patients were males and 3 (43%) were females, The male to female ratio was 1.33. The median age was 64 (interquartile range, IQR, 62-71), with the youngest patient being diagnosed at age 61 and the oldest at age 74. Regarding the drugs classes that caused Nicolau syndrome, these were intravenous antibiotics in 57%, and non-steroidal anti-inflammatory drugs in 43% of cases. Conclusion: All patients healed in a period of 6 to 8 weeks. No complications occurred. In conclusion, Nicolau syndrome is a rare side effect of injectable drug administration.

Exploratory axis factoring for identifying the self-esteem latent factors and their correlation with the life quality of persons suffering from vitiligo.

Objective: Our research aimed to measure the importance of self-esteem in assessing the disease burden in patients with vitiligo, which, according to our knowledge, had not been studied earlier. The purpose of this research study was to expand the state of knowledge regarding the influence of vitiligo on the quality of patients' life, with a particular focus on their self-esteem. We have formulated the following two hypotheses which include H1: two latent factors characterize the self-esteem of patients with vitiligo; H2: the self-esteem of the patients with Vitiligo is correlated with their life quality, by influencing it to a high degree. Methods: We have used two validated questionnaires called Rosenberg (Q1), for the evaluation of self-esteem (for proving H1), and Dermatology Life Quality Index (DLQI) (Q2), to measure the health-related quality of life of patients (for proving H2). Both questionnaires with 10 questions were applied to the same set of 114 carefully selected patients with no missing values to questions. An in-depth statistical and reliability analysis was performed on the outcomes provided by Q1, applying a scale and subscale reliability analysis, using the Cronbach's alpha reliability indicator (Cα). An exploratory analysis called Principal Axis Factoring (PAF) with Oblimin with Kaiser Normalization rotation was applied to prove H1, verifying the assumptions regarding the average variance extracted (AVE) and convergent and discriminant validity (CDV). A scale reliability analysis of outcomes provided by Q2 was performed for proving H2, by calculating Cα. Additionally, a nonparametric correlation analysis was performed, by calculating the Spearman r correlation coefficient between the Rosenberg index and DLQI index, and the 95% confidence interval (CI). Results: Based on the provided data, the value of Cα obtained in Q1 was 0.84. As a result of applying PAF on Q1, H1 has been proven and two latent factors of self-esteem have been extracted. These factors were named competence (eigenvalue = 4.126; 41.258% of total variance explained) and value (eigenvalue = 1.857; 18.57% of total variance explained). For the two subscales determined by the two factors, we have obtained the Cα values of 0.848 and 0.8, all indicating good reliability. For testing H2, on Q2 data we obtained Cα = 0.914. The Spearman correlation coefficient r = -0.734 (p < 0.0001), between the self-esteem questionnaire evaluation result and the life-quality index result indicated the existence of a strong negative correlation, which is significant according to 95% CI [-0.81, -0.63]. Discussion: The study focused on analyzing the self-esteem of patients with vitiligo. In addition, the psychometric properties of the Q1 questionnaire were analyzed and Q1 proved to have good internal consistency. PAF indicated a two-factorial structure, with factors called competence and value, proving H1, with a moderate correlation of 0.427 between the two latent constructs. The competence factor includes motivation, self-efficacy, initiative, and persistence in action. The value factor is much more complex, indicating a feeling, a personal evaluation, or a positive or negative attitude toward one's person, which better captures the entire phenomenology of self-esteem. The statistical analysis of the results provided by the self-esteem questionnaire included questions that proved to be internally consistent. The AVE and CDV assumptions were met. Q2 was proved to have excellent scale reliability. H2 proved a statistically significant strong negative correlation between the Rosenberg score and DLQI score.

Balanitis xerotica obliterans: An observational, descriptive and retrospective clinical study.

Lichen sclerosus is a chronic disease of unknown etiology that can occur in the genital area of both sexes. Balanitis xerotica obliterans (BXO) occurs only in the genital area of men and typically affects the foreskin, penile glans, and/or the meatus. In the present report, an observational, descriptive, and retrospective epidemiological clinical study of available data between January 2006 and December 2020 in patients diagnosed with BXO from the casuistic of CMI DERMAMED (Târgu Mureș, Romania) was performed. During this 15-year period, 164 patients were diagnosed with BXO, of whom 70 (42.8%) were in the 51-60-year-old age group. They presented at the medical consultation at 3-9 months after onset of symptoms, where 124 (75.6%) the patients were found to be with stage III of the disease. The most important comorbidities were found to be diabetes mellitus and obsesity, who were treated with potent steroids (betamethasone and clobetasol) with favorable results, with only nine (5.48%) cases necessitating surgical treatment. In general, BXO is a rare, acquired, non-infectious and chronically inflammatory (autoimmune) skin disease that has an unknown etiology. Although the risk of developing this condition is particularly high in patients in the 40-60-year-old age group, it can occur at any age. In the present report, the majority of the patients presented after a long period of disease development, such that they were already in advanced stages of the condition with clinically subjective symptoms and severe sexual problems. This delay in diagnosis has several causes, including misdiagnosis, psychological issues, and sexual behavior. Diabetes mellitus and overweight/obesity tended to be important comorbidities of BXO since the majority of the patients were also affected by these conditions. These comorbidities can exert an important pathophysiological influence on BXO. The first-line treatment option for this condition is the local application of potent steroids, with favorable effects. Due to the risk of malignant transformation as a result of BXO, it is recommended that these patients should be followed up for a longer period.

Clinicopathological correlation of transient acantholytic dermatosis: A case report.

Transient acantholytic dermatosis (TAD) is a benign, non-familial, non-immune mediated acantholytic disorder of unknown etiology. The presence of polymorphous, unorganized, pruritic lesions on the trunk, associated with focal acantholysis and dyskeratosis, resembles a wide variety of dermatoses. The etiology of TAD (also known as Grover's disease) is unknown, and the success of treatment relies on the correct identification of the disease; however, some cases are refractory to all forms of therapy. For accurate diagnosis, a comprehensive literature review is required. Here, the case of a 55-year-old male with TAD displaying a Darier-like histopathological pattern was reported. The patient was successfully treated with retinoids and acitretin (Neotigason), as well as dapsone, an anti-inflammatory agent, as maintenance therapy. The presence of more than two histological findings, limited to small foci and clinical information, can diagnose Darier disease. The exact pathogenesis has not been elucidated, thus further studies of the pathogenesis of TAD are required.

Keratosis pilaris atrophicans faciei: An observational, descriptive, retrospective clinical study.

Keratosis pilaris atrophicans faciei (KPAF) is a hereditary follicular disorder, an atrophicans subtype of keratosis pilaris (KP) with a highly elusive diagnosis. Clinically, it presents with follicular, horny papules surrounded by an erythematous halo of the cheeks, forehead, chin and eyebrows, and it is followed by a gradual hair loss on the lateral margins of the eyebrows. The onset is as early as a few months after birth, but it is mainly diagnosed in children and adolescents and it can persist through adulthood. At present, the natural progression of the disease is poorly understood, which makes a correct diagnosis highly unlikely. The aim of the present study was to describe the clinical characteristics of KPAF in patients encountered in daily practice, in order to find common characteristics that may aid in the earlier recognition of the disease. An observational, descriptive, retrospective study was performed on 14 patients diagnosed with KPAF between January 2000 and December 2020. The mean age at diagnosis was 17.04 years and the onset of clinical symptoms appeared at a mean age of 4.85 years. The first clinical symptom was KP involving either the upper or lower limbs, or both. Then, erythema of the face appeared at a mean age of 7.21 years, keratotic papules on the face at a mean age of 8.35 years and, finally, loss of hair on the lateral margins of the eyebrows at a mean age of 14 years. The patients also had concomitant xerosis cutis, multiple mole syndrome, acne, contact dermatitis and Laugier-Hunziker syndrome. Evidence of disease progression, associations, as well as efficacious treatment measures are lacking. An earlier diagnosis potentially allows for a more efficacious, targeted treatment option. Either topical emollients, systemic retinoids or laser therapy may prove effective for each patient individually.

Skin endometriosis: A case report and review of the literature.

Skin endometriosis is a rare disease with variable clinical and histopathological characteristics that depend on hormonal stimuli. The skin is not a common location, as most cases of endometriosis involve pelvic sites, such as the ovaries, peritoneum and bowel. However, the most common extrapelvic site affected is the abdominal wall and this location of the disease is frequently associated with obstetric and gynecologic surgery. Here we report a case of skin endometriosis emerged as a painful subcutaneous nodule located near to the left side of an obstetrical surgery procedure scar. The patient affected was a woman in her reproductive age, with a history of right ovary endometriotic cyst laparoscopically removed and histologically confirmed as a primary endometriosis. Dermatologists should be aware of this condition in any woman with a painful lump located in the proximity of a pelvic surgery-induced scar. Its non-specific clinical appearance may confuse the clinician and may delay the diagnosis and management.

Discrepancy in results between dipstick urinalysis and urine sediment microscopy.

With the advancement of urine test automation and the large-scale application of quality management policies, the source of the most crucial errors has become the pre-analytical phase. This study is an attempt to compare the results obtained from the examination of urine strips with those obtained by microscopic examination of urinary sediment, highlighting discordant results. This observational study was conducted between February and August 2019 in a private medical laboratory in Mures County, and 2,600 urine samples were analyzed. We calculated the sensitivity, specificity, positive predictive value, negative predictive value for leukocytes, nitrites and red blood cells, taking as reference the microscopic examination of urine summary screening. Urine samples were collected from patients who presented to the laboratory. The 2,600 urine samples were analyzed using strips with 10 parameters: glucose, protein, bilirubin, urobilinogen, pH, specific density, red blood cells, nitrite, and leukocytes, and then using the microscope to examine the urinary sediment. We identified a small percentage (1.92%) of inconsistencies from the 2,600 samples of urine, between urinalysis and the microscopic examination and we identified the causes. The most common discordant results were: false-negatives for nitrite (72%), followed by false-positives results for red blood cells (22%), false-negative results for leukocytes (16%), false-negative results for red blood cells (4%) and false-positives for leukocytes (4%). The study confirmed that discrepancies appear despite the proper instruction of patients.

Perspectives on skin disorder diagnosis among people living with HIV in southeastern Romania.

The beginnings of the human immunodeficiency virus (HIV) pandemic are closely linked to dermatological conditions. A large part of the population living with HIV (PLWH) has a series of skin conditions that determine at some point, a visit to the dermatologist. The introduction of highly active antiretroviral therapy (HAART) more than 20 years ago has diminished the range of dermatological conditions, with improved immunosuppression of CD4 lymphocytes. The study aimed to describe the prevalence of the diagnosed type of skin changes in PLWH receiving antiretroviral therapy and their stratification according to the degree of immunodeficiency. A prospective study was conducted on 57 PLWH evaluated monthly at an HIV outpatient clinic, from a tertiary hospital in southeastern Romania. Clinical examination and dermoscopy revealed the existence of a wide range of dermatological conditions; all 57 patients (100%) being diagnosed with one or more dermatological conditions. As our study shows, the prevalence of different dermatoses among PLWH varies depending on the geographical region. At the same time, under HAART, the image of dermatoses associated with decreased immunity from HIV infection has changed. The skin changes of PLWH no longer fully follow the classical staging, based on the degree of immunosuppression.

Role of osteodensitometry in osteoporosis and osteopenia in psoriatic arthritis.

Dual-energy X-ray Absorptiometry (DEXA) determines the mineral contents for the spine, the proximal femur and the entire body. A group of 36 patients with psoriatic arthritis were chosen, with different types of arthropathy, from the total 82 patients with psoriatic arthritis in the study group, for which bone mineral density (BMD) was measured, using the DEXA technique. The chosen study group comprised 12 men, 12 premenopausal women and 12 menopausal women, with psoriatic joint damage and a group of 36 healthy individuals, divided based on the same criteria: Men, premenopausal and menopausal women. This study did not emphasize an association between the patient type and the presented bone demineralization type (χ2 (2)=4.473, P=0.107) in men. In premenopausal women, there was a significant association between the patient type and the presented bone demineralization type (χ2 (2)=8.778, P=0.012), as the female patients with psoriatic arthritis presented total and partial demineralization to a larger degree, compared with healthy individuals. In menopausal women, this study did not highlight an association between the patient type and the presented bone demineralization type (χ2 (2)=4.523, P=0.104). Bone demineralization was significant in all three patient groups, both total and partial, in patients with psoriatic arthritis compared with healthy patients. Bone demineralization manifested as osteopenia, with T-scores ranging from -2.5 to -1, and not as osteoporosis. Determining B MD by DEXA technique revealed osteopenia to a higher degree within the group of patients with psoriatic arthritis compared with the healthy patients, as well as the absence of osteoporosis in psoriatic arthritis.

Acyclovir-induced immune thrombocytopenia: Case report and review of the literature.

There are a number of medications which can serve as catalysts for drug-induced immune thrombocytopenia (DIPT). A minimum of six different mechanisms have been put forward as the means by which drug-induced antibodies can encourage platelet destruction, thus emphasising the complexity of the pathogenesis of DITP. Acyclovir, has been widely used because of its highly potent prohibitive properties for infections caused by HSV and VZV. The common adverse effects of this drug are well known, the severe adverse reactions are mostly related to high dose intravenous administrations. The immune thrombocytopenia induced by acyclovir is unusual. The authors present a rare clinical case of acyclovir-induced immune thrombocytopenia in a 72-year-old female patient with typical herpes zoster treated with acyclovir. The clinical and laboratory findings, taken together with the transitory relationship between acycolvir and the start of thrombocytopenia, combined with the elimination of the other know sources of thrombocytopenia, allowed us to reach the diagnosis of acyclovir-induced immune thrombocytopenia. An international database search was employed to complete an extensive review of the current literature. Contemporary information on acyclovir-induced immune thrombocytopenia was collected by the analysis of present day review articles and accessible case reports. The authors found five published cases of acyclovir-induced immune thrombocytopenia. Analyzing these articles it was concluded that immune thrombocytopenia induced by acyclovir is rare, and an unusual side effect, with good prognosis. Prompt diagnosis is vital to appropriate management, therefore clinicians need to be cognisant of this rare potential adverse reaction.

Paraneoplastic pityriasis rubra pilaris in association with prostate carcinoma: A case report and literature review.

Pityriasis rubra pilaris (PRP) is a chronic papulosquamous disorder of unknown etiology, characterized by reddish orange scaly plaques, islands of sparing, palmoplantar keratoderma, and keratotic follicular papules. The disease can be acquired or inherited, being divided into 5 categories: classic adult type, atypical adult type, classic juvenile type, circumscribed juvenile type, and atypical juvenile type. More recently, an HIV-associated type has been added to this classification. The cases of PRP associated with malignancy are unusual. We present a case of a 58-year-old man, with the typical clinical aspect of PRP with a four-month onset of the disease. The histopathological and dermatoscopical findings confirmed the PRP diagnosis. The routine laboratory results were in normal limits, except the number of eosinophils, which was elevated and the number of lymphocytes, which was lower. After a thorough examination within a hematological consultation, the cause of hypereosinophilia remained unknown. An imagistic examination was performed and a prostate hypertrophy was noted. The prostate-specific antigen (PSA) level was found to be increased. The urologic consultation based on clinical, imagistic and microscopic features diagnosed an early stage prostate carcinoma. The conclusion was a paraneoplastic PRP in association with prostate carcinoma. The search in international databases revealed twelve published cases regarding the association of PRP with malignancies. The presented case represents a rare coexistence of PRP with malignancy, particularly with prostate carcinoma, and indicates that PRP can occur as paraneoplastic dermatosis, heralding a malignancy. This case is the first one to present PRP associated with prostate carcinoma. Nonetheless, in the authors' opinion, PRP can be considered a paraneoplastic syndrome; therefore, tumor screening is mandatory in cases presenting this disease.

Cutaneous leukocytoclastic vasculitis associated with erlotinib treatment: A case report and review of the literature.

Erlotinib is a targeted anticancer therapy used for treating epidermal growth factor receptor (EGFR) mutation positive lung cancer in advanced stage as well as for other malignancies. The most common cutaneous side effect of erlotinib, are well documented; however the number of reports regarding cutaneous leukocytoclastic vasculitis (CLCV) are limited. We report a case, a 58-year-old, 60 kg weight, non-smoking woman suffering of lung adenocarcinoma and brain metastases treated with erlotinib monotherapy with 150 mg/day dose, who presents cutaneous leukocytoclastic vasculitis after 8 months of initiating the treatment. The administration of the drug was discontinued and oral prednisolone treatment was introduced at 1 mg/kg body weight dose for two weeks, decreasing the dose with 5 mg, at every 3 days. The treatment was combined with topical potent steroid and antibiotic therapy used once, daily. The lesions cleared within 7 weeks without recurrence. The treatment with erlotinib was restarted after 14 days with a lower dose of 100 mg/day. The skin lesions have not occurred anymore. Unfortunately the evolution was unfavorable, our patient died 3 months after the vasculitis healing, due to the complications of new metastases that occurred. This may indicate the inefficiency of erlotinib. The late onset of 240 days of the vasculitis and the presumed inefficiency of the drug lead to the speculation that the appearance of cutaneous vasculitis could be a worsening clinical marker of the tumor response. This limited number of cases precludes any meaningful interpretation of data about the erlotinib induced cutaneous vasculitis. Further investigations are needed to assess cutaneous vasculitis.

A Case of Generalized, Superinfected Dermatitis and Inguinal Mycobacterium Lymphadenitis - TB or not TB?

Dear Editor, Eczema is an inflammatory dermatitis mediated by cellular immunity, with an etiology in which environmental, immunological, and genetic factors are involved. Skin inflammation through proinflammatory cytokines creates a favorable environment for microbial antigens and optimal conditions for infection (1). In case of underlying immunosuppression, inflammatory features of dermatitis and superimposed infections are more severe. The presence of minor trauma of the skin in the form of fissures can favor both easier inoculation of some bacterial germs, leading to a dermatitis superinfection, and/or the transcutaneous inoculation of atypical mycobacteria, with a possibility of developing localized types of tuberculous lymphadenitis (TLA). TLA, the localized type of systemic tuberculosis (TB) infection, is the most common form of extra-pulmonary TB in developing countries (2), while lymphadenitis due to atypical mycobacteria is a localized disease, more frequently seen in developed countries (3,4). In tuberculosis, the transmission of Mycobacterium tuberculosis is airborne, while in atypical mycobacterium lymphadenitis transmission can be both airborne or by ingestion or inoculation (5). In both forms of TB, lymphadenopathy evolves towards abscess and presents fibrotic scars or calcifications upon healing (6). A positive diagnosis involves a clinical and epidemiological investigation, a purified protein derivative (PPD) skin test, ultrasound, and CT / MRI of lymph node masses. A lymph node biopsy is used to confirm the diagnosis of TB and PCR, while positive culture confirms the etiology of TB lymphadenitis. The differential diagnosis of TLA is difficult: neoplastic, bacterial, or viral and fungal infections, sarcoidosis, Castleman's disease, drug reactions, etc. (5). TB-induced immunosuppression may favor the development of fungal and bacterial infections, sometimes severe and poorly responsive to treatment. On the other hand, immunosuppressive conditions increase the risk of extra-pulmonary TB (2). A 40-year old woman who had experienced recurrent episodes of dermatitis over the previous 7 years was hospitalized with fever, malaise, and a disseminated erythematous and crusted, exudative, and flexural itching rash (Figure 1). There were fetid, purulent secretions at the conjunctival, auricular, genital, and umbilical areas. The clinical exam also revealed lymphadenopathy syndrome (large, painful submandibular, cervical, and axillar bilateral lymph nodes; an indurated, painful, and adherent left inguinal lymph node of 5-6 cm). Microbial cultures isolated multiple multi-drug-resistant bacteria (SAH-MRSA, Acinetobacter baumannii, Enterococcus faecalis, E. coli, Enterobacter) and Candida albicans in the oral cavity and conjunctival, auricular, nasal, umbilical, and genital areas. The skin biopsy confirmed the diagnosis of dermatitis. PPD skin test was 21 mm. Other tests (HIV and syphilis serology, blood culture, chest X-ray) were negative. Systemic treatment with vancomycin, metronidazole, fluconazole, local antiseptic compresses, and topical corticosteroid ointments was initiated. 2 days after starting the treatment with vancomycin, Redman syndrome occurred (headache, dyspnea, colicky pains, myalgia, rush, fever (39 °C), hypotension (80/40 mmHg), and tachycardia (100 bpm)). This syndrome resolved upon discontinuation of Vancomycin. Further treatment with imipenem/cilastatinand linezolid for 14 days lead to a favorable response with amelioration of the symptoms. Biopsy of the submandibular lymph node raised the suspicion of Castleman's disease; however, due to the overall incomplete clinical picture (no night sweats, no weight reduction, lack of hepatosplenomegaly and peripheral neuropathy), we decided to perform a biopsy of an inguinal lymph node. The histopathological aspect suggested TLA (lymphoid hyperplasia predominantly diffuse, reactive, presenting tuberculous follicles with central caseous necrosis) (Figure 2). A combination of specific antituberculous drugs (isoniazid, rifampicin, pyrazinamide, and ethambutol) for 6 months resolved the lymphadenopathy syndrome with no further recurrence of eczema and skin infections. Certain delayed hypersensitivity mechanisms are involved both in dermatitis and in TB. CD4 lymphocytes are the primary mediators of anti-TB immunity, while proinflammatory cytokines mediate the activation of macrophages involved in controlling bacillary growth (1). In cases of superinfected dermatitis, microbial exotoxins penetrate the skin barrier more easily due to inflammation. Released cytokines (IL-1, TNF, and IL12) favor the expression of E-selectin on endothelial vascular growth factor and on skin lymphocyte antigen expression, with amplification of initial skin inflammation and creating favorable conditions for microbial colonization and infection (7). The common denominator in dermatitis and TB are the circulating immune complexes (up to 56% of TB cases), which are formed by the interaction between an antibody and bacterial antigen (8), which was in this case evidenced by increased levels of IgA and IgG. In our case, the frequent recurrences of infected dermatitis with multiple multi-drug-resistant germs that were poorly responsive to treatment and displayed a severe evolution towards generalization as well as the lymphadenopathy and the persistence of a biological inflammatory syndrome indicated that another immunosuppressive cause could be involved. Isolated bacterial and fungal germs changed the immune status of the patient. The risk of mycobacterium infection was increased by the environment they created and the patient's underlying skin inflammation. The diagnosis of TB lymphadenitis was established by the histopathologist, but in the absence of PCR we could not determine whether the TB infection was caused by Mycobacterium tuberculosis or by atypical mycobacteria. Given that there was no evidence of other sites of TB infection, we conjectured that inoculation of mycobacterium took place at the skin lesion and that an atypical mycobacterium might have contributed to the etiology of the TLA. In our case, the anti-tuberculous drugs and skin infection treatment with follow-up of the side-effects led to complete remission of mycobacterium lymphadenitis, dermatitis, and infectious processes, without relapses. In conclusion, in the present case chronic dermatitis alongside infection with multi-drug-resistant germs led to an immunosuppressive status which, when associated with the presence of multiple skin ports of entry, allowed a mycobacterial infection at the inguinal lymph node level. Inguinal TLA induced severe dermatitis and difficulties in diagnosis and treatment.

Multiple nodular cutaneous metastases as the first clinical sign of signet ring cell gastric carcinoma: case report.

Cutaneous metastases from signet ring cell gastric carcinoma are uncommon. A 35-year-old male presented with a three-month history of multiple asymptomatic, indurated, pinky colored nodules of 2.5 to 4 cm in diameter, without any local and general symptoms. Nodule biopsy revealed an infiltrating signet ring cell carcinoma. Gastroscopy and biopsy confirmed the diagnosis of gastric carcinoma with signet ring cells. The present report describes an unusual clinical case of a young patient diagnosed with cutaneous metastasis before detection of his gastric carcinoma.

Steatocystoma multiplex generalisata partially suppurativa--case report.

Steatocystoma multiplex is a rare inherited disorder with an autosomal dominant mode of transmission, but sometimes it may appear sporadically. Usually the onset tends to occur during adolescence or early adult life. A clinical case of a 27-year-old male patient is presented. Since the age of 8, he had been presenting with multiple, asymptomatic, round-to-oval, well-defined, smooth-surfaced, yellow to skin-colored, 5- to 22-mm diameter cysts and nodules initially scattered on the trunk and lately disseminated all over the body with less lesions on the lower extremities. At one of follow-up visits, he presented with high fever, pain with tumefaction of the small and medium size joints of the palms and soles, and deteriorated general status with polymorphous skin lesions. Based on the clinical and paraclinical features, the diagnosis of steatocystoma multiplex generalisata partially suppurativa was made. He was treated with oral isotretinoin (1 mg/kg per day) for 14 weeks, antibiotics and local treatments. The lesions healed slowly, with local disfigurement, hyperpigmentation and unpleasant scars. Isotretinoin usually does not eradicate the condition but could be effective in suppurative abscesses. Steatocystoma multiplex generalisata is considered rare; the true incidence of the disease is unknown. In the disease evolution, the severe inflammatory variant, steatocystoma multiplex suppurativa, may appear at any time.