Emergency department diagnosis and management of skin diseases with real-time teledermatologic expertise.

IMPORTANCE: Skin conditions are a common reason for patients to consult emergency department (ED) physicians. OBJECTIVE: To evaluate real-time teledermatologic expertise with the use of mobile telephones for the diagnosis and management of skin conditions in patients seen in the ED. DESIGN, SETTING, AND PARTICIPANTS: This observational study of adults who consecutively consulted in the ED for a dermatologic condition was conducted under routine conditions in the ED from May 1, 2008, through June 30, 2010. MAIN OUTCOMES AND MEASURES: Diagnosis agreement and management concordance. RESULTS: One hundred eleven patients were enrolled in the study. Eighty-three patients (74.8%) were evaluated using videoconferencing. Dermatologic remote expertise invalidated, enlarged, or clarified ED physicians' diagnosis and management in 75 of 110 cases (68.2%). Videoconferencing improved the diagnostic performance in 57 of 83 cases (68.7%) (P < 10(-4)). Management concordance was moderate between ED physicians and dermatologists for specialist consultation within 24 hours (κ, 0.49; 95% CI, 0.14-0.84) and immediate hospitalization (κ, 0.49; 95% CI, 0.41-0.57). Patients were significantly more often discharged by dermatologists (46.8% vs 39.1%) (P < 10(-4)). CONCLUSIONS AND RELEVANCE: Compared with standard hardware, new-generation mobile devices reduce the cost of videoconferencing, increase the versatility of teledermatology, and decrease general practitioner investment time.

Long-term follow-up of HIV-infected patients once diagnosed with acyclovir-resistant herpes simplex virus infection.

Acyclovir-resistant herpes simplex virus (HSV) infection is common in immunocompromised patients, but the course of such infection is little known. We describe the long-term follow-up of HIV-infected patients diagnosed once with acyclovir-resistant HSV infections. We retrospectively studied all HIV-infected patients between 2000 and 2010 diagnosed with virologically confirmed acyclovir-resistant HSV infection. Patients' socio-demographic and immunovirological characteristics were described. Response to foscarnet or cidofovir and recurrences were reported. Among 5295 HIV-infected patients, 13 (0.2%) were once diagnosed with an acyclovir-resistant HSV infection. Twelve patients were men, nine patients were of African origin. All patients reported previous acyclovir exposure and median CD4 count was 183 cells/mm(3) Ten patients presented exclusively with cutaneous lesions. Initially, 11 patients were treated with foscarnet and two with cidofovir. The median follow-up was 67 months (6-145). All patients recurred, 10 presenting at least one acyclovir-resistant HSV recurrence. The median number of acyclovir-resistant HSV recurrences per patient was 2 (0 - 5). Regarding the first and second recurrences, 7/13 (54%) and 5/11 (45%) HSV clinical isolates exhibited resistance to acyclovir, respectively. Acyclovir-resistant HSV infection prevalence was low in our cohort. The rate of acyclovir-resistant HSV episodes averaged 50% during the two first recurrences.

Molecular characterization of Ancylostoma braziliense larvae in a patient with hookworm-related cutaneous larva migrans.

We report a case of hookworm-related cutaneous larva migrans diagnosed microscopically. Viable hookworm larvae were found by microscopic examination of a skin scraping from follicular lesions. Amplification and sequencing of the internal transcribed spacer 2 allowed the specific identification of the larvae as Ancylostoma braziliense.

Clinical management of rapidly growing mycobacterial cutaneous infections in patients after mesotherapy.

BACKGROUND: Increasing numbers of patients are expressing an interest in mesotherapy as a method of reducing body fat. Cutaneous infections due to rapidly growing mycobacteria are a common complication of such procedures. METHODS: We followed up patients who had developed cutaneous infections after undergoing mesotherapy during the period October 2006-January 2007. RESULTS: Sixteen patients were infected after mesotherapy injections performed by the same physician. All patients presented with painful, erythematous, draining subcutaneous nodules at the injection sites. All patients were treated with surgical drainage. Microbiological examination was performed on specimens that were obtained before and during the surgical procedure. Direct examination of skin smears demonstrated acid-fast bacilli in 25% of the specimens that were obtained before the procedure and 37% of the specimens obtained during the procedure; culture results were positive in 75% of the patients. Mycobacterium chelonae was identified in 11 patients, and Mycobacterium frederiksbergense was identified in 2 patients. Fourteen patients were treated with antibiotics, 6 received triple therapy as first-line treatment (tigecycline, tobramycin, and clarithromycin), and 8 received dual therapy (clarithromycin and ciprofloxacin). The mean duration of treatment was 14 weeks (range, 1-24 weeks). All of the patients except 1 were fully recovered 2 years after the onset of infection, with the mean time to healing estimated at 6.2 months (range, 1-15 months). CONCLUSIONS: This series of rapidly growing mycobacterial cutaneous infections highlights the difficulties in treating such infections and suggests that in vitro susceptibility to antibiotics does not accurately predict their clinical efficacy.

A case-control study of polymorphic eruption of pregnancy.

BACKGROUND: Polymorphic eruption of pregnancy (PEP) is a pruritic disease that usually occurs in primiparous women, most commonly in the last trimester of pregnancy. The origin and pathomechanisms still remain unknown. OBJECTIVES: We attempted to determine the parameters that may be associated with or complicate the course of PEP. METHODS: Data of 200 pregnant women (40 PEP and 160 control) were studied retrospectively and compared statistically using univariable and multivariable analysis. RESULTS: In multivariate analysis, pregnancy with male fetuses (P = .02) and delivery by cesarean section (P = .012) were overrepresented in the PEP group. A tendency toward more multiple gestation pregnancy in PEP was found (P = .07). The risk of PEP was not related to excessive maternal or fetal weight gain. LIMITATIONS: This was a retrospective study. CONCLUSION: This large case-control study confirms the already suspected association of PEP with male fetuses and cesarean deliveries in multivariate analysis. The higher rate of multiple gestation pregnancy was also established.

[Microchimerisme in systemic sclerosis]. / Microchimérisme dans la sclérodermie.

Several studies have shown an association between the presence of systemic sclerosis in females and the presence of fetal cells in peripheral blood. These results have led to the hypothesis that systemic sclerosis (SSc) may indeed be the consequence of an allogeneic fetomaternal reaction. However, certain normal female controls also exhibit microchimerism. In addition, there are several clinical and histological differences between SSc and sclerodermoid graft versus host reaction. If microchimerism plays a role in SSc, it would therefore comprise one step in a multistep process. This review focuses on recent papers targeting microchimerism and its evaluation in SSc.