Uncommon Presentation of Leprosy: A Report of Two Cases.

Lazarine leprosy is an unusual expression of usually borderline tuberculoid (BT) form characterized by spontaneous ulceration of skin lesions. This is presumably the result of an exaggerated type 1 reaction. It commonly occurs in the BT, borderline lepromatous forms and rarely in the lepromatous forms of leprosy. We report two cases of lazarine leprosy in the BT and BT downgrading to borderline lepromatous spectrum in healthy and immunocompetent males.

Histoid hansen's with transepidermal elimination: Five cases.

Histoid leprosy is an expression of multibacillary leprosy with unique histopathology and characteristic bacterial morphology. It is characterized by the occurrence of asymptomatic firm, dome-shaped succulent papulonodules on apparently normal skin, or subcutaneous tissues. There are very few reports of the detection of Mycobacterium leprae in the epidermis in leprosy, which may have a possible role in transmission. We report five de novo cases of histoid leprosy with transepidermal elimination.

The 'Why and How' of Cervical Cancers and Genital HPV Infection.

Knowing about the virology of human papillomavirus (HPV) including its structure, functions and mechanism of infection, helps in understanding the disease process and morphology of precancerous lesions for cervical cancer. Two types of HPV, low- and high-risk type, adopt different mechanisms of infection which cannot be differentiated on morphological basis. In addition to HPV infection, many other factors such as genetic predisposition, hormonal factors, host immune response, and multiple sexual partners can modify the course and progression of the disease. The viral genome comprises early and late proteins. These early and late genes are expressed in particular course of time after initial infection. Various products of early genes (E1-E7) coordinate for completion of viral life cycle in maturing squamous epithelium by utilizing replication factors and DNA polymerase enzyme of the host cell nucleus. The late genes are mainly concerned with packaging of the viral particles and their release through mature squamous cells. The episomal form of infection seen in the low-risk group of viruses results in productive infection whereas the integrated form seen in high-risk group of viruses is the basis of disruption of host cell growth cycle by inactivating two important tumor suppressor genes p53 and Rb gene by products of E6 and E7 genes. Cervical precancerous lesions and cancer are the resultant effect of the accumulation of mutations. This article discusses the virology of HPV, pathogenesis of HPV infection, and various other factors modifying the disease course.

Clinical Spectrum of Cutaneous Tuberculosis in Central India: A Retrospective Study.

INTRODUCTION: Extrapulmonary tuberculosis (EPTB) is a significant health problem in both developing and developed countries. In India, cutaneous TB constitutes about 0.1% to 2% of the total skin diseases attending outpatients. AIM AND OBJECTIVES: To study the clinical spectrum and therapeutic outcome in cutaneous TB. MATERIAL AND METHODS: Medical records of diagnosed cases of cutaneous TB from June 2015 to June 2018 were analyzed retrospectively with respect to epidemiology, clinical features, investigations, and treatment outcome. Statistical analysis was done using mean, median, and proportion. RESULTS: Fifty-two patients with cutaneous TB were recruited. Females (61.53%) outnumbered males. The most common age group affected was 21-30 years (32.69%) followed by 41-50 years (30%). Lupus vulgaris was the most common clinical type with head and neck being the most common site of involvement. Mantoux positivity was reported in 67.30% of patients while raised ESR in 71.15% of patients. Two patients had serology positive for HIV. Conclusive evidence of TB on histopathology was reported in 86.53%. Excellent response was observed in cases of lupus vulgaris, scrofuloderma, and tuberculosis verrucosa cutis. CONCLUSION: This retrospective analysis emphasizes the importance of clinicopathological correlation and therapeutic response in cutaneous TB. Although positive results of ESR, Mantoux reactivity, and TB cultures facilitate the clinical diagnosis, negative results should not exclude the diagnosis of cutaneous TB. This prominent case detection in the era of the Revised National TB Control Programme, in short period of time signifies health burden of cutaneous TB in this part of Maharashtra.

Clinical Spectrum of Cutaneous Malignancies in Central India: A Retrospective Study.

INTRODUCTION: Cutaneous malignancies account for 1%-2% of all the diagnosed cancers in India. Nonmelanoma skin cancers (NMSCs) include basal cell carcinomas (BCC) and squamous cell carcinomas (SCC). Others include melanoma, cutaneous lymphomas, and sarcomas. Exposure to ultraviolet (UV) rays is the most important risk factor associated with skin malignancies, although various other factors are also implicated. AIMS AND OBJECTIVES: The aims of this work were to study clinical spectrum with age and sex distribution of cutaneous malignancies and metastasis; to study clinicopathological variants of each type of cutaneous malignancies; and to study the risk factors associated with cutaneous malignancies. PATIENTS AND METHODS: It was a retrospective analysis of clinically and biopsy proven cases of cutaneous malignancies from January 1, 2016 to January 31, 2018. Medical records of patients were assessed with respect to demographic information, clinical examination, dermoscopy, and histopathology. Statistical analysis was done using mean, proportion, and percentage. RESULTS: Sixty-six cases with cutaneous malignancies were recruited. There was female preponderance. The most common age group affected was 60-70 years. BCC was the most common malignancy (41%) followed by SCC (30%), malignant melanoma (9%), and cutaneous T-cell lymphoma (1.5%). Head and neck was the most common site involved. The most common clinical type of both BCC and SCC was the nodular type. Acral lentiginous was the most frequent subtype of melanoma reported. The most common predisposing for NMSCs was prolonged sun exposure (46%). CONCLUSION: This study highlights an increasing trend of NMSCs with female preponderance. Head and neck is the most common site involved. Increased risk of NMSCs is seen with increased sun exposure and predisposed genetic conditions. T-cell lymphoma was common than B-cell type. The most common internal malignancy to cause cutaneous metastasis was breast carcinoma.

Multiple Erythematous Nodules: An Intriguing Entity.

Pyogenic granuloma (PG), also called a lobular capillary hemangioma, is a benign vascular proliferation of skin or mucous membrane. It classically presents as a solitary friable nodule over the face or distal extremities. Multiple disseminated PG is a rare form generally reported after trauma such as burn injury. We report two cases of spontaneous development of multiple localized PGs in immunocompetent individuals.

Lazarine leprosy: A unique phenomenon of leprosy.

Leprosy, a chronic granulomatous disease, has been known since ages but even today continues to baffle the clinicians with a wide spectrum of clinical, histopathological, and immunological characteristics. Leprosy reactions are mainly of two types, namely, Type 1 and Type 2. In Type 1 leprosy reaction, the preexisting lesions become erythematous, edematous, and rarely ulcerate. Ulcerating Type 1 reaction is called lazarine leprosy. Ulcerations may occur in borderline tuberculoid (BT) pole or borderline lepromatous pole but more common in BT pole. In this postelimination era of leprosy, we report an interesting case report of BT Hansen's disease with Type 1 lepra reaction with ulceration, namely, lazarine leprosy.

Klippel-Trenaunay Syndrome with Arterio-veno-lymphatic Malformation: A Rare Presentation.

Klippel-Trenaunay syndrome (KTS) is a rare disorder characterized by triad of vascular malformations, varicose veins, and bony or soft tissue hypertrophy involving an extremity. Port wine stain is the most common vascular malformation associated with this syndrome. Various other rare vascular malformations described are angiokeratomas, angiokeratoma circumscriptum naeviformae, angiodermatitis, etc. This is the first instance, to the best of our knowledge, describing the capillary, venous, and lymphatic malformations in a same case of KTS.

Mycetoma: A Common Yet Unrecognized Health Burden in Central India.

CONTEXT: Mycetoma is a chronic suppurative infective disorder of skin, subcutaneous tissue, fascia, and bones caused by the traumatic inoculation of either fungal (eumycotic) or bacterial (actinomycotic) organisms present in the soil. Triad of tumefaction, discharging sinuses, and grains characterizes the disease. AIMS: This study was undertaken to study the clinical spectrum and treatment response of mycetoma in central India. SETTINGS AND DESIGN: It was a retrospective study of clinical and/or biopsy-proven and treated cases of mycetoma from November 2015 to October 2016. SUBJECTS AND METHODS: Medical records of diagnosed and treated mycetoma patients were enrolled retrospectively during November 2015 and October 2016. Case records of patients were evaluated with respect to demographic, clinical, microbiological details, bone involvement, and treatment. Type of therapies and outcome, wherever available, were also assessed. STATISTICAL ANALYSIS: Statistical analysis was done using proportion, mean, and percentages. RESULTS: Eleven cases (male = 8) were seen during the study period (seven actinomycetoma and four eumycetoma). Foot and lower extremity was the most common site (9/11), whereas upper extremity and forehead were involved in one case each. On culture, the organisms isolated were Phialophora and Fusarium. Modified Welsch regimen was started in six of seven patients with actinomycetoma, whereas one was started on sulfamethoxazole-trimethoprim and a combination of amoxicillin and clavulanic acid therapy. All four cases of eumycetoma were treated with itraconazole. On follow-up, six cases of actinomycetoma cases showed significant improvement. Two cases of eumycetoma showed mild to moderate improvement and one case required surgical intervention. One case each of actinomycetoma and eumycetoma were lost to follow-up. CONCLUSION: Mycetoma has been recognized as a neglected tropical disease by the World Health Organization, recently. There are very few case reports from the central part of India. Prominent case detection in our study emphasizes the need of larger studies to know the extent of disease in this part of India.

A retrospective study of the severe and uncommon variants of erythema nodosum leprosum at a tertiary health center in central India.

BACKGROUND: Erythema nodosum leprosum (ENL) classically presents with tender, coppery, evanescent nodules along with constitutional features and visceral involvement. However, uncommon morphological variants of ENL-like erythema nodosum necroticans, erythema multiforme (EM)-like ENL, Sweet's syndrome (SS)-like ENL, Lucio phenomenon, and reactive perforating type of ENL have also been described in the literature. The primary objective of this study was to describe the clinical features of the severe and uncommon morphological variants of ENL. METHODS: This was an observational case series with retrospective review of records of all ENL patients with ulceronecrotic lesions admitted in the Department of Dermato-venereo-leprology of a tertiary health center of central India over a period of 2 years. RESULTS: Eighteen patients were included, all of whom had ulceronecrotic lesions. Four out of them had EM like ENL, two had SS-like presentation, and one of them had annular bullous lesions over old infiltrated plaques of leprosy. CONCLUSIONS: Uncommon variants of ENL can be very commonly misdiagnosed in patients, especially in those who have not been previously diagnosed with leprosy. Hence, a high index of suspicion is required in such cases to avoid delay in the diagnosis and resulting morbidity.

Dermatological manifestations in human immunodeficiency virus infected patients: Morphological spectrum with CD4 correlation.

BACKGROUND: More than 90% of human immunodeficiency virus (HIV) infected patients develop skin lesions at some time throughout the course of the disease. Several skin diseases have proved to be sensitive and useful indicators of progression of HIV infection. Although these conditions may be seen in general healthy population, their occurrence in patients with acquired immunodeficiency syndrome is often atypical, more severe and explosive. AIMS: The present study was carried out to categorize the skin lesions by histopathology using punch biopsy or cytology when feasible in HIV infected patients and to see the correlation for various skin lesions with CD4 counts. MATERIALS AND METHODS: In total 110 known HIV positive patients with the symptomatic skin lesions, cytology and punch biopsy was correlated with CD4 counts. RESULTS: Maximum patients were between 31 and 40 years. 53 (48.18%) patients had infectious and 37 (34.55%) patients had non-infectious lesions. Out of 110 patients, CD4 counts were available in 70 patients. The spectrum of various non-infectious and infectious lesions such as viral, bacterial, fungal, protozoa and their association with CD4 counts is discussed. CONCLUSIONS: CD4 counts below 200 were associated with the maximum infectious lesions, whereas CD4 counts more than 350 showed more of the non-infectious lesions. Most common infectious lesion was Molluscum contagiosum. The most common non-infectious lesion was pruritic papular eruptions.

Interobserver agreement in the reporting of cervical biopsy specimens obtained from women screened by visual inspection with acetic acid and hybrid capture 2.

Visual inspection with acetic acid (VIA) and human papillomavirus detection have sensitivity higher than cytology but lower specificity. The high false-positive rate of either test poses a challenge to the colposcopists who obtain biopsies from the innocuous changes and to the pathologists who have to interpret large numbers of specimens that are either normal or have low-grade abnormalities. Interobserver variation in histopathologic interpretations of cervical punch biopsy specimens is high, specially for the lower-grade abnormalities. Use of the modified Bethesda system to report histology in place of the cervical intraepithelial neoplasia (CIN) system has the potential to reduce such variability as there are fewer categories. The present study aimed to assess the interobserver agreement to interpret cervical punch biopsies when both pathologists followed the modified Bethesda classification system and also when one pathologist followed the modified Bethesda classification system and the other followed the CIN classification system. Colposcopy-directed punch biopsies were obtained from VIA and/or Hybrid Capture 2-positive women. The Institute pathologist interpreted the slides using the CIN system. Blinded review was done by 2 external pathologists who independently interpreted cervical punch biopsies using the Bethesda system. The Institute pathologist's diagnoses based on CIN system were converted post hoc into categories belonging to the Bethesda system for comparison. The overall agreement was poor (κ=0.36). The lowest agreement was observed in the low-grade squamous intraepithelial lesion category (κ=0.23) and the highest in the squamous cell carcinoma category (κ=0.76). The agreement between the reviewers, both of whom used the Bethesda system, was substantial.