Herpes zoster ophthalmicus.

Herpes zoster ophthalmicus (HZO) occurs when latent varicella zoster virus reactivates in the ophthalmic division of the fifth cranial nerve (CNV1). HZO commonly affects older and immunocompromised patients. This disease is considered an ophthalmic emergency due to the wide range of associated ocular symptoms, including severe chronic pain and vision loss. HZO is typically a clinical diagnosis due to its classic presentation of a unilateral vesicular eruption in the dermatomes corresponding to CNV1. Timely treatment is imperative to minimize ocular morbidity in HZO, given that ocular involvement is present in 50% of affected patients.

Sarcoidosis With Skeletal Involvement Masquerading as Metastatic Malignancy.

Sarcoidosis is a systemic disorder characterized by noncaseating granuloma formation, which can affect any organ in the body; however, skeletal involvement is relatively uncommon. This case report presents a rare case of sarcoidosis primarily affecting the skeletal system in a 39-year-old man with a history of neurosarcoidosis. The patient presented with symptoms of nausea, vomiting, fatigue, weight loss, and lower back and pelvic pain, which were initially suspicious for malignancy. Computed tomography scans revealed lytic bone lesions and lymphadenopathy. However, a biopsy of a left inguinal lymph node confirmed necrotizing granulomatous lymphadenitis, which was consistent with necrotizing sarcoid granulomatosis - a rare variant of sarcoidosis. The patient was treated with systemic corticosteroids, which led to clinical improvement. The prognosis of sarcoidosis is generally good, with spontaneous remission occurring in up to two-thirds of patients; however, some patients may develop chronic and/or progressive disease. In particular, patients with a history of neurosarcoidosis may be at an increased risk for chronic or recurrent disease. This case highlights the importance of considering sarcoidosis in the differential diagnosis of patients presenting with nonspecific symptoms and lymphadenopathy, even in the absence of pulmonary involvement.

Cutaneous Manifestations of Lightning Injury: A Review of the Literature.

Lightning is a rare but potentially devastating cause of injury and mortality. The cutaneous burns associated with lightning strikes demonstrate peculiar pathognomonic signs and patterns. In this review of the literature, we discuss the epidemiology and etiology of lightning injuries, lightning compared to other forms of high voltage electrical injury, the clinical features of lightning injuries, the most common cutaneous manifestations associated with lightning strikes, and the treatment and prevention of lightning injuries. Some of the cutaneous manifestations include feathering lesions, linear burns, punctate burns, and thermal injuries. While not considered true burns, Lichtenburg figures display a unique ferning pattern. Although lightning injuries are typically superficial, transient, and resolve relatively quickly compared to other electrical burns, the ability to recognize their cutaneous manifestations may improve emergent care and life-saving measures for these victims. Additionally, superficial surface burns secondary to lightning injury do not preclude systemic injury and significant pathology may be underlying.

Atrial Myxoma Presenting With Hemorrhage and Multifocal Infarcts in the Brain of a 59-Year-Old Man: An Uncommon Outcome for the Most Common Primary Heart Neoplasm.

Atrial myxomas are the most common primary neoplasm of the heart. Due to their mass effect, they may lead to dysfunction of the heart or mitral valve. Rarely, neoplastic fragments may embolize or a thrombus secondary to stasis may form, which can infarct downstream structures (e.g., the brain). We report the case of a 59-year-old man presenting with headaches, visual changes, and word-finding difficulty secondary to multifocal brain lesions that were identified on computed tomography and magnetic resonance imaging. After an extensive workup, the etiology of the patient's neurological symptoms was determined to be embolization from a large atrial myxoma (2.3x3.5 cm). Histologic and immunohistochemical examination of the atrial myxoma and largest brain lesion yielded similarities, including the presence of spindle-shaped and stellate cells, myxoid regions, Alcian blue pH 2.5 positivity, calretinin positivity, cluster of differentiation 34 (CD34) positivity, and cluster of differentiation 68 (CD68) negativity. This case was remarkable due to the patient's late presentation, the large size of the atrial myxoma, the presence of abundant cerebral hemisphere and cerebellar lesions, and the histologic comparison of the heart and brain lesions. Atrial myxomas have been reported from childhood to late adulthood and when symptoms typically present clinically due to the mass effect. However, neurologic manifestations from embolization or thrombus formation can occur, as in the present case. Therefore, considering the presence of atrial myxomas is important in patients with neurologic manifestations and heart murmurs.

Ethics training in dermatology residency programs: A survey of dermatology residency program directors and assistant/associate program directors.

Professionalism, defined as a demonstrated adherence to professional and ethical principles, is one of the six core competencies of dermatology graduate medical education. We sought to assess the current educational landscape for ethics training in dermatology residency programs by surveying dermatology residency program directors and assistant/associate program directors. A sixteen-question survey was designed and distributed to dermatology program directors and assistant/associate program directors via an email list. The estimated response rate was 43.17%. Most (54.55%) dermatology residency programs did not have an ethics curriculum. Among programs with an ethics curriculum, about three-fourths were implemented in the past ten years. The most common settings for teaching ethics were "formal didactics" (31.91%) and "ad hoc during clinical encounters and other clinical settings" (27.66%). Cited barriers to implementing and/or maintaining an ethics curriculum were "lack of time" (30.10%), "lack of faculty with expertise in ethics" (24.27%), and "lack of useful resources" (20.39%). Despite requirements for ethics training, most dermatology residency programs did not report having an ethics curriculum. This study's results highlight the need for an increased emphasis on ethics training in US dermatology residency programs.

Dupilumab-Associated Head and Neck Dermatitis With Ocular Involvement in a Ten-Year-Old With Atopic Dermatitis: A Case Report and Review of the Literature.

Facial and neck erythema secondary to dupilumab use is a side effect not reported in clinical trials; however, it has been reported aftermarket initially in adults and most recently in adolescents. We report the youngest known case of head and neck dermatitis (HND) secondary to Malassezia furfur accompanied by ocular involvement. Treatment with oral fluconazole 150 mg weekly was initiated with subsequent cutaneous improvement. Additionally, his conjunctivitis improved with fluorometholone 0.1% eye drops. As dupilumab becomes more accessible to children, understanding the pathophysiology of HND, characterizing the clinical course, and developing diagnostic and treatment guidelines for this age group will be imperative.

Changes to Drug-Coated Balloon Reimbursement Affect Peripheral Arterial Disease Patient Care: A Single-Center Experience.

INTRODUCTION: Balloon angioplasty (BA) and stenting have long been the mainstays of endovascular therapy in peripheral arterial disease (PAD). However, the rise of drug-coated balloons (DCBs) has revolutionized care in recent years, with multiple clinical trials showing superiority over BA in maintaining primary patency and freedom from target lesion revascularization (TLR). With the recent drop of the add-on payment for DCBs, a barrier for their use and consequently reduced therapy adoption in PAD might arise. We assessed if this affected physicians' behavior and hospital administration towards stocking and using DCBs. METHODS: This single-center, retrospective study evaluated DCB utilization in 2017 versus 2018. Data were collected in two groups: 1) July 1, 2017, to December 31, 2017 - with pass-through code (PTC) - prior medical billing reimbursement - and 2) January 1, 2018, to June 30, 2018 - without PTC - markedly reduced reimbursement. Patients treated for superficial femoral artery (SFA) or popliteal artery (POP) disease were included. The study aimed to determine changes in DCB utilization between the years with and without PTC, and we investigated the treatments that have replaced DCBs. Additionally, we aimed to collect data on readmissions and procedure costs compared to national data. RESULTS: From July through December 2017, 350 DCBs were used in 209 patients (1.675 DCBs per patient), while from January through June 2018, 256 DCBs were used in 180 patients (1.422 DCBs per patient) - a 15.07% reduction in DCBs per patient. The detailed numbers of DCB-treated patients were presented as fractions of total interventions in the groups with and without PTC. CONCLUSION: The findings of this study show a statistically significant reduction in DCB usage following PTC withdrawal. There are several ethical implications to these findings, primarily highlighting patient beneficence and justice. Moving forward, it will be important to determine if this shift in treatment is owed to other treatment strategies such as BA, BA and atherectomy, BA and bare-metal stents (BMS), or BA and drug-eluting-stents (DES). The next steps should also include determining procedure costs and comparing readmission rates.

A Case of Metastatic Basal Cell Carcinoma (BCC) With Spinal and Pulmonary Metastases Treated With Vismodegib, Sonedigib, and Radiotherapy.

Basal cell carcinoma (BCC) is the most common malignancy worldwide and has one of the most favorable prognoses due to its tendency to remain local. Clinical presentation with rare distant metastases significantly increases morbidity and mortality. Historically, no effective therapies have existed for locally advanced or metastatic BCC. Recent research highlights the possibility of treating patients with advanced and metastatic BCC with hedgehog pathway inhibitors, such as vismodegib or sonedigib. We present the case of a 62-year-old male with a history of a large left shoulder lesion, which was diagnosed as a nodulocystic BCC following biopsy and histopathologic examination. The primary lesion was managed with surgical excision, and his ensuing metastatic disease was treated with vismodegib, sonedigib, tumor debulking, and radiation therapy. Magnetic resonance imaging and computed tomography of the chest revealed probable metastases to the apical segment of the left upper lobe and thoracic spine, leading to spinal stenosis and probable cause of the patient's ataxia and paresthesias. Due to the ability of BCCs to transform during metastasis, it is impossible to identify the nature of metastatic lesions (i.e., basaloid, squamous, or hybrid) without biopsy. In this case report, we review the etiologies, typical demographics, presentation patterns, and treatment regimens for metastatic BCC and the possibility of metastatic disease transforming to squamous or hybrid variants.

Seasonal Variation in the Diagnosis of Skin Cancers From 1983 to 2017 in Greenville, North Carolina.

Background Seasonality of diagnosis occurs in many types of cancer and is well-established in non-melanoma (NMSC) and melanoma (MSC) skin cancers. Benign skin conditions have also been shown to demonstrate a similar seasonality pattern. Investigations into the seasonality of NMSC and MSC diagnoses are less common than benign skin conditions despite the high healthcare burden of the disease. In this study, we investigated if seasonality and monthly patterns of NMSC and MSC diagnoses are present in Eastern North Carolina. Methodology We observed and analyzed incident cancer diagnoses for patients visiting the Physicians East Dermatology clinic in Greenville, North Carolina, from 1983 to 2017 (n = 8,021 basal cell carcinomas (BCCs), n = 5,660 squamous cell carcinomas (SCCs), n = 451 MSCs, n = 14,132 total). Results Chi-square tests showed the highest rates of diagnosis for BCCs in August (9.85%), September (9.62%), and October (10.0%). For SCCs, the diagnosis rates were the highest in July (8.62%), August (9.63%), and October (9.58%). For MSCs, the diagnosis rates were the highest in May (9.98%), June (10.2%), and July (10.4%). Analysis of the differences between observed skin cancer diagnoses by month and equal distribution across all months in the event of no seasonality revealed peaks of skin cancer diagnoses corresponding to July through October for BCCs; July, August, and October for SCCs; and May through September for MSCs. Analysis of the patterns of diagnosis of this data over 34 years illustrated a continuously increasing pattern of diagnosis for all three cancer subtypes from 1983 to 2017. Conclusions This study identified a statistically significant pattern of seasonality in both NMSCs and MSCs, which was consistent with the findings of previous studies. Moving forward, further research should investigate the roles of temperature, quantified ultraviolet exposure, and geographic location and their relationships to seasonality.

Intraneural Synovial Sarcoma of the Median Nerve in a 15-Year-Old Male: A Case Report and Review of Literature.

There have been 8 synovial sarcomas of the median nerve reported. We report a case of a 15-year-old male with synovial sarcoma of the right-hand median nerve. Patient presented with a 2-month history of enlarging mass at the base of the right thenar eminence associated with numbness in the median nerve distribution. Physical examination revealed a soft mass over the thenar eminence and paresthesia in the median nerve distribution. He underwent excision of the tumor, which revealed a well-encapsulated lesion encompassing the median nerve, involving the first, second, and radial aspect of the third web space as well as recurrent branches of the median nerve. Following excision of the tumor, a thorough metastatic workup was negative for metastatic disease. He was staged as III, T2b, N0, M0-poorly differentiated monophasic synovial sarcoma of the right median nerve. Postoperatively the patient was started on chemotherapy and radiation. Intraneural synovial sarcoma is extremely rare. Our case is the youngest with the longest follow-up. He is currently at a status of 3 years posttreatment with no signs of recurrence and excellent use of his right hand. This case is of particular interest due to the rarity of the disease along with this being the best outcome reported in the literature to-date.

Reduction of Opioid Prescriptions in Maxillofacial Trauma Following North Carolina STOP Act.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: On January 1, 2018, the Strengthen Opioid Misuse Prevention (STOP) Act was implemented to increase oversight over opioid prescriptions in North Carolina. The aim of this study is to evaluate the legislation's efficacy in reducing opioid prescriptions following facial fracture repair. METHODS: A retrospective chart review of patients who sustained maxillofacial fractures and underwent repair from January 1, 2015 through December 31, 2019 at a level 1 trauma center was performed. The North Carolina Controlled Substance Database was used to quantify perioperative opioid prescriptions in morphine milligram equivalents (MME). Average MME per patient was compared between 2 groups, patients who underwent surgery before the NC STOP Act came into effect and patients who underwent treatment after. This comparison was also performed on case type subgroups including surgically treated fractures of the orbit, mandible, midface, and multiple regions. A student's t-test was used to compare before and after groups in all analyses. RESULTS: Of the 253 patients who met inclusion criteria, 146 were in the before group, and 107 were in the after group. There was a statistically significant, 30.9% decrease in overall average MME prescribed after the NC STOP Act was enacted. A statistically significant decrease was noted in patients who had facial fractures of multiple regions. CONCLUSION: Since the implementation of the NC STOP Act in 2018, there have been statistically and clinically significant decreases in the amount of opioids prescribed following surgical management of facial fractures.

Morbihan disease: A diagnostic dilemma: two cases with successful resolution.

Morbihan syndrome is a rare entity characterized by persistent erythema and solid edema of upper two-thirds of the face. Although its etiology is poorly understood, it is known to have a wide differential diagnosis and is frequently under-recognized.1-3 We report two such cases of Morbihan syndrome in patients that responded well to treatment with a combination of 2.5% hydrocortisone cream, brimonidine 0.33% topical gel, metronidazole gel and 100 mg doxycycline twice daily. This report emphasizes the necessity of biopsy for clinical correlation in cases of chronic facial edema. It also serves to highlight a potential association of Morbihan syndrome to diabetes mellitus through recently discovered pathophysiology of diabetes on the lymphatic system. It underscores the effectiveness of our therapeutic regimen in the context of other treatment regimen effectiveness. Finally, it highlights novel advances into the diagnosis and treatment of the disease.

A Case Study and Review of Literature of Eruptive Syringoma in a Six-Year-Old.

Syringomas are benign tumors originating from the intraepidermal portion of eccrine sweat ducts. A six-year-old African American female presented with multiple 2-3 mm hyperpigmented papules over the neck, upper chest, and axillae bilaterally. The lesions were non-tender, non-pruritic, and did not bleed when lightly scraped. A café-au-lait macule was incidentally found in the mid-back of the patient. Histopathologically, multiple small ducts displaying a tadpole-shaped/paisley-tie pattern with fibrotic stroma were identified on hematoxylin and eosin staining. Epithelium showing nests of cells with basaloid appearance and dilated glands filled with eosinophilic material were also identified. These histopathologic findings were consistent with a diagnosis of eruptive syringoma. The patient was treated conservatively, and the lesions subsided without intervention. In most patients requesting treatment, isotretinoin is used; however, this may be an unnecessary measure in many patients. Overall, this case was significant due to the patient's young age, ethnicity, and clinical improvement in the absence of treatment.

Subacute Combined Degeneration Secondary to Nitrous Oxide Abuse: Quantification of Use With Patient Follow-up.

Subacute combined degeneration (SCD) is caused by demyelination of spinal cord white matter secondary to vitamin B12 (cobalamin) deficiency leading to core symptoms of spastic paresis and vibratory and proprioceptive deficits. Most common causes of B12 deficiency revolve around malabsorption and pernicious anemia; however, nitrous oxide (N2O) can also indirectly cause B12 deficiency by inactivating its biologically active form. We report a case of a patient who took advantage of the unregulated N2O market and presented with signs and symptoms of SCD secondary to N2O abuse. Prior to symptom onset, the patient reported approximately 3,000g of N2O inhalation within five days prior to symptom onset in addition to daily use three weeks prior. Work up revealed laboratory and imaging abnormalities consistent with SCD, although B12 levels were normal intrinsic-factor-blocking (IFB) antibodies were present. Appropriate treatment was undertaken, and the patient was followed up at one week and one month with noticeable clinical improvements. Similarities of this patient to literature include the classic presenting symptoms of SCD and the gradual symptomatic improvement with B12 injections and N2O abstinence. This case is remarkable due to SCD occurrence after recreational N2O abuse, objective quantification of N2O intake over a specified time period to induce SCD, occurrence secondary to N2O inhalation, positive IFB antibodies, and symptomatic presentation with B12 values within normal limits. This report highlights the dangers associated with N2O abuse and moving forward awareness of this case can be referenced to aid in educating members of our communities at risk for substance abuse.