Superimposed lateralized exanthem of childhood: report of a case related to adenovirus infection.

A 6-year-old boy developed a unilateral itchy rash, which was followed by a less severe bilateral involvement. The lesions resolved spontaneously within 4 weeks. Apparently, the rash was triggered by an adenovirus infection of the respiratory tract. Terms used currently for this disorder include 'unilateral laterothoracic exanthem' or 'asymmetrical periflexural exanthem of childhood'. The recently proposed term 'superimposed lateralized exanthem of childhood' implies the new concept that an early postzygotic mutation has rendered the skin on one side of the body more reactive to infective agents. The subsequent bilateral involvement would reflect a less severe reactivity of the contralateral keratinocytes.

[Unusual faces of syphilis]. / Die ungewöhnlichen Gesichter der Syphilis.

The challenging "great masquerader" is resurgent! For several years syphilis has shown an increasing incidence across Europe and its variable manifestations necessitate its inclusion amongst many differential diagnoses. Using serological tests, it is possible to accurately diagnose syphilis, initiate stage-appropriate therapy and exclude co-infections. In this article, we feature nine unusual presentations of secondary syphilis. In four cases, serology confirmed HIV co-infection.

[Syphilis in the context of HIV-infection--a complex disease]. / Syphilis bei HIV-Infektion--eine komplexe Erkrankung.

HISTORY AND ADMISSION FINDINGS: A 39-year-old man complained about a slightly reddish non-itching rash evolving on his body during the last few weeks without any general symptoms. Physical examination revealed trunk-dominated roseola, papules, a few nodules with haemorrhagic crust on top, and round hyperkeratotic clavus-like lesion on the left plantar foot. In his mouth, he had a few up to 1.5 cm large erosions, and on his capillitium a diffuse alopecia. INVESTIGATIONS: Serologic testing for syphilis was positive with Treponema-pallidum-particle-agglutination test at 1:163840, VDRL 1:64, positive IgG-FTA-ABS and 19S-IgM-FTA-ABS tests, and a pleocytosis of the liquor. In addition, there were a co-infection with mycoplasma hominis and first diagnosis of HIV infection (CDC-stadium A1). TREATMENT AND COURSE: The patient was diagnosed as having secondary syphilis with suspicion of neurologic involvement and was therefore treated with 6x5 Mio. I.E. Penicillin G i.v. per day for 14 days after the initial application of 40 mg methylprednisolone. Under this regimen complete resolution of the skin lesions was noted over a 4 week period as well as slow re-growth of the hair. HIV infection at stadium A1 did not require antiretroviral treatment. CONCLUSION: A non-pruritic rash should always point to the differential diagnosis of syphilis. If syphilis is diagnosed, any other sexually transmitted disease including HIV should be excluded as possible co-infection. In case of HIV, neurosyphilis can develop at an earlier stage of common syphilis.

Autoantibodies against desmocollins in European patients with pemphigus.

BACKGROUND: Autoimmune bullous disorders of the pemphigus group are characterized by autoantibodies targeting desmoglein (Dsg)1, Dsg3 and Dsg4 and occasionally, desmocollin (Dsc)1, Dsc2 and Dsc3. Both Dsg and Dsc are components of desmosomal adhesion complexes. AIM: To investigate the presence of IgG and IgA autoantibodies against Dsc1, Dsc2 and Dsc3 in a cohort of patients with bullous disorders. METHODS: IgG and IgA autoantibodies against Dsc1, Dsc2 and Dsc3 were investigated by ELISA and immunoblotting analysis in a cohort of European patients with pemphigus vulgaris (PV; n = 74), IgA pemphigus (n = 3), paraneoplastic pemphigus (PNP; n = 3) and two cases of atypical pemphigus (n = 2). RESULTS: Of the two cases with atypical pemphigus, one showed IgA reactivity against Dsc1 and Dsc3 and weak reactivity against Dsc2, and the other showed both IgG and IgA reactivity against Dsc1. One patient with IgA pemphigus had IgA autoantibodies against Dsc1, Dsc2 and Dsg1, and one patient with PNP had IgG reactivity against with Dsc3. In contrast, all the PV sera showed IgG reactivity against Dsg3 but not against Dsc1-3. Thus, IgG and IgA reactivity against Dsc was restricted to cases of PNP, IgA pemphigus and atypical pemphigus. CONCLUSIONS: These findings support the concept that desmocollins are not important autoantigens in PV.

[Cutaneous ulcer due to histoplasmosis and HIV infection]. / Hautulkus bei Histoplasmose und HIV-Infektion.

A 33-year-old Brazilian man presented with a painful ulcer on the glabella region. The patient was HIV-positive. Diagnosis of histoplasmosis was established by histopathological examination. In Latin America, disseminated histoplasmosis frequently involves the skin of HIV-positive patients. When affecting the skin, the disease has a wide range of clinical presentations. Our case highlights the importance of including this disease in the differential diagnosis of cutaneous ulcers in HIV patients from areas endemic for histoplasmosis.

Cost utility for penetrating keratoplasty in patients with poor binocular vision.

PURPOSE: Cost-utility and cost-effectiveness analyses are of increasing importance to clinicians and health policy experts. This study determines the costs in Germany and other countries in relation to gain of utility for patients with bilateral poor vision owing to corneal disease undergoing penetrating keratoplasty (PK) in 1 eye. DESIGN: A cost-utility analysis was performed using retrospective clinical data and high-level evidence-based data. PARTICIPANTS: Sixty patients (mean age, 46.3 years) with bilateral poor vision who underwent PK for corneal disease. METHODS: Visual acuity and utility values were obtained before and 1 year after PK and after suture removal. A 10-year graft survival rate of 80% was assumed. Expenses included costs for the corneal transplant and surgery, medication, and optical rehabilitation. A discount rate of 5% was applied for costs and quality-adjusted life years (QALYs). Cost-utility analysis encompassed a 10-year period after surgery. MAIN OUTCOME MEASURES: The number of QALYs was calculated for the study group undergoing PK. This was divided into the cost of the procedure to get the number of euros spent per QALY gained. RESULTS: Median binocular preoperative visual acuity was -log mean angle of resolution (-logMAR) 0.91+/-0.53 (Snellen equivalent 20/160) yielding a utility value of 0.67. After suture removal and optical rehabilitation, binocular visual acuity increased to median -logMAR 0.36+/-0.36 (20/46) with a utility value of 0.79. Over the 10 years after surgery and considering graft survival and discounting, a cost utility of 9551 euros per QALY was gained (equivalent to US11,557 dollars). One-way sensitivity analysis yielded a range from 7706 euros to 12874 euros per QALY, highlighting the robustness of the model. CONCLUSIONS: Although an expensive procedure, PK is cost effective in patients with bilateral poor vision.

[Glucocorticoid-induced osteoporosis. A underestimated sequela of long-term treatment of autoimmune diseases]. / Glukokortikosteroidinduzierte Osteoporose. Eine zu wenig beachtete Folge der langfristigen Behandlung von Autoimmunerkrankungen.

The treatment of autoimmune diseases with systemic glucocorticosteroids remains a therapeutic challenge and requires close collaboration with internists, radiologists and in some cases orthopedic surgeons. Generally, patients initially receive high-dose glucocorticosteroid therapy and are then treated for a longer period of time with moderate to low doses above the level causing symptoms of Cushing's disease. A major cause of complications is glucocorticosteroid-induced osteoporosis with hip fractures, crush fractures of the spine and other low trauma fractures as well as deformities of the skeleton leading to neurological and other systemic problems. Loss of bone mass as a result of high dose or long term systemic glucocorticosteroid treatment is well studied and can be documented in a standardized and reproducible fashion using modern radiological techniques. In recent years several controlled studies of bone loss and therapy of osteoporosis have been published, mostly including patients with rheumatoid arthritis or systemic lupus erythematosus. This review discusses recent publications and provides a brief overview on therapeutic options.