Diagnostic Pearls of Vulvar Epidermolytic Acanthoma: Case Report.

Epidermolytic acanthomas (EA) are uncommon benign tumors clinically presenting as single to multiple papules. Histologically, EA display hyperkeratosis, hypergranulosis, acanthosis, and epidermal degeneration-also known as epidermolytic hyperkeratosis (EH). EA may be misdiagnosed as condyloma both clinically and histopathologically when located on the genitalia. Thus, this diagnosis carries a significant psychological burden and must remain in the differential when initially considering genital warts. We utilize the case of a 62-year old female referred to dermatology for a 5-year history of multiple pruritic and hypopigmented vulvar papules-misdiagnosed as genital warts-to highlight the impact of differentiating EA from genital warts. This patient was initially misdiagnosed with common genital warts at her gynecologist's office and treated unsuccessfully for years. A shave biopsy was performed and histology revealed EH, consistent with EA.

Melanocytic marker Melan-A detects molluscum contagiosum bodies.

Melan-A is one of the most commonly used immunohistochemical assays (IHC) in dermatopathology laboratories to detect the presence and outline the distribution of melanocytes. It is a cytoplasmic stain that detects a melanocyte-specific cytoplasmic protein involved in the formation of stage II melanosomes. Clinically, Melan-A is primarily used to detect and confirm melanocytic tumors although it is also positively expressed in adrenal cortical tumors and sex cord stromal tumors. We found that Melan-A also detected and highlighted Henderson-Patterson bodies of molluscum poxvirus. To determine if other melanocytic markers detect molluscum contagiosum bodies, S-100, HMB-45, MITF, and SOX-10 were also tested. In 15 tested molluscum cases, Melan-A stains were positive in all cases, whereas the other tested melanocytic markers were negative. Our results confirm that Melan-A is very sensitive in detecting molluscum contagiosum bodies and could be clinically useful to supplement the hematoxylin and eosin (H&E) in cases that are very inflamed or only have limited biopsy material.

A Rare Case of Transient Acantholytic Dermatosis (AKA. Grover's Disease) with Concomitant Pediculosis Pubis: An Atypical Presentation and First Documented Case Report.

A 66-year-old male presented with a one-month history of persistent pruritic eruptions distributed mainly on the trunk. A punch biopsy from the left upper abdomen revealed focal acantholytic dyskeratosis with mixed inflammatory infiltrate in the dermis composed of numerous eosinophils. Grover's disease was diagnosed based on the clinical and histopathological findings. Appropriate treatment was initiated but failed to relieve symptoms of itchiness. A further investigation of the hair follicles under mineral oil preparation revealed an infestation of pediculosis pubis. Subsequent treatment with Ivermectin and permethrin cream led to the complete resolution of his symptoms. This case report highlights an unusual and first documented case of Grover's disease with a concomitant infestation of pediculosis pubis. To date, no reported cases in the literature have associated Grover's disease with pubic lice infestation. However, there are three reported cases of concurrent scabies and Grover's disease in the literature. This rare case underscores the clinical value in further investigating treatable underlying conditions in patients with suspected transient acantholytic dermatosis.

Erythema ab igne with features resembling keratosis lichenoides chronica.

Erythema ab igne (EAI) is an asymptomatic dermatosis that develops in response to chronic exposure to low-grade heat. Characteristic findings on histopathology include epidermal atrophy, dermal elastosis, atypical histiocytes, and melanin and hemosiderin deposition. Reactive endothelial changes and prominent vascular proliferation are variable. Keratosis lichenoides chronica (KLC) is a rare lichenoid hyperkeratotic dermatosis. Acanthosis with parakeratosis and a lichenoid interface dermatitis with lymphocytes, histiocytes, and plasma cells are characteristic findings of KLC. Although its etiology remains unclear, KLC has been reported to occur in response to heat. Herein, we report a case of EAI with features resembling KLC.

Adult Patients with Respiratory Distress: Current Evidence-based Recommendations for Prehospital Care.

INTRODUCTION: We developed evidence-based recommendations for prehospital evaluation and treatment of adult patients with respiratory distress. These recommendations are compared with current protocols used by the 33 local emergency medical services agencies (LEMSA) in California. METHODS: We performed a review of the evidence in the prehospital treatment of adult patients with respiratory distress. The quality of evidence was rated and used to form guidelines. We then compared the respiratory distress protocols of each of the 33 LEMSAs for consistency with these recommendations. RESULTS: PICO (population/problem, intervention, control group, outcome) questions investigated were treatment with oxygen, albuterol, ipratropium, steroids, nitroglycerin, furosemide, and non-invasive ventilation. Literature review revealed that oxygen titration to no more than 94-96% for most acutely ill medical patients and to 88-92% in patients with acute chronic obstructive pulmonary disease (COPD) exacerbation is associated with decreased mortality. In patients with bronchospastic disease, the data shows improved symptoms and peak flow rates after the administration of albuterol. There is limited data regarding prehospital use of ipratropium, and the benefit is less clear. The literature supports the use of systemic steroids in those with asthma and COPD to improve symptoms and decrease hospital admissions. There is weak evidence to support the use of nitrates in critically ill, hypertensive patients with acute pulmonary edema (APE) and moderate evidence that furosemide may be harmful if administered prehospital to patients with suspected APE. Non-invasive positive pressure ventilation (NIPPV) is shown in the literature to be safe and effective in the treatment of respiratory distress due to acute pulmonary edema, bronchospasm, and other conditions. It decreases both mortality and the need for intubation. Albuterol, nitroglycerin, and NIPPV were found in the protocols of every LEMSA. Ipratropium, furosemide, and oxygen titration were found in a proportion of the protocols, and steroids were not prescribed in any LEMSA protocol. CONCLUSION: Prehospital treatment of adult patients with respiratory distress varies widely across California. We present evidence-based recommendations for the prehospital treatment of undifferentiated adult patients with respiratory distress that will assist with standardizing management and may be useful for EMS medical directors when creating and revising protocols.

Pemphigus vegetans with paronychia-like changes resistant to rituximab therapy.

Pemphigus vegetans (PVeg) is a clinical variant of pemphigus vulgaris (PV) that makes up about 2% of all cases. It is distinguished from PV by the presence of vegetative plaques that are usually found in the oral mucosa or intertriginous areas. PVeg can present as one of two clinical subtypes: Hallopeau type and Neumann type. The Hallopeau type is a milder form of the disease, often sparing the oral mucosa. The Neumann type is a more severe form that often includes oral mucosal involvement. Nail unit disease of PVeg is rare, lending to limited recommendations for management. Herein, we present a case of PVeg with paronychia-like changes following rituximab therapy, along with a brief review of PVeg nail unit disease management. Previously reported treatments include prednisone, azathioprine, dapsone, and cyclosporine. In this patient with nail disease, despite rituximab therapy, intralesional triamcinolone acetonide was effective, thereby avoiding the need for additional immunosuppression.

Scar sarcoidosis following rituximab therapy.

Drug-induced sarcoidosis has been rarely described but it constitutes a potential side effect of immunomodulatory medications. We report a case of rituximab-induced scar sarcoidosis and review similar published cases. Although there is evidence of B-cell dysregulation in the pathogenesis of sarcoidosis, the use of rituximab for this disease needs to be carefully evaluated based on reports of worsening and de novo development of sarcoidosis after rituximab therapy.

Altered Mental Status: Current Evidence-based Recommendations for Prehospital Care.

INTRODUCTION: In the United States emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of a patient with an acute change in mental status and to compare these recommendations against the current protocols used by the 33 EMS agencies in the State of California. METHODS: We performed a literature review of the current evidence in the prehospital treatment of a patient with altered mental status (AMS) and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the AMS protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were patient assessment, point-of-care tests, supplemental oxygen, use of standardized scoring, evaluating for causes of AMS, blood glucose evaluation, toxicological treatment, and pediatric evaluation and management. RESULTS: Protocols across 33 EMS agencies in California varied widely. All protocols call for a blood glucose check, 21 (64%) suggest treating adults at <60mg/dL, and half allow for the use of dextrose 10%. All the protocols recommend naloxone for signs of opioid overdose, but only 13 (39%) give specific parameters. Half the agencies (52%) recommend considering other toxicological causes of AMS, often by using the mnemonic AEIOU TIPS. Eight (24%) recommend a 12-lead electrocardiogram; others simply suggest cardiac monitoring. Fourteen (42%) advise supplemental oxygen as needed; only seven (21%) give specific parameters. In terms of considering various etiologies of AMS, 25 (76%) give instructions to consider trauma, 20 (61%) to consider stroke, and 18 (55%) to consider seizure. Twenty-three (70%) of the agencies have separate pediatric AMS protocols; others include pediatric considerations within the adult protocol. CONCLUSION: Protocols for patients with AMS vary widely across the State of California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols.