An observational study of severe cutaneous adverse reactions at a tertiary care teaching hospital.

Background: The term severe cutaneous adverse reactions to drugs (SCAR) comprises of acute generalized exanthematous pustulosis (AGEP), drug reaction with eosinophilia and systemic symptoms complex (DRESS), Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS-TEN) and drug-induced erythroderma or exfoliative dermatitis (ED). The present study aims at describing the epidemiological and clinical profile, probable cause and the extent of morbidity and mortality in patients with severe cutaneous adverse drug reactions. Methods: An observational study of all cases of SCAR presenting to our centre during the period from Jun 2018 to July 2019 was carried out. Results: A total of 24 SCAR patients were studied. Most of the patients were in the age group of 11-20 years. The commonest reactions observed were SJS-TEN (54.2%) followed by DRESS (42%). Antibiotics are the most common cause of SJS-TEN, whereas almost all the drug groups were implicated equally in DRESS. No causative drug could be found in two of the SJS-TEN patients. These patients had raised atypical targetoid lesions as well as evidence of viral reactivation which could have been the probable trigger for the SCAR. A total of five patients (20.8%) died during treatment in hospital, and the percentage mortality was highest in SJS-TEN. Conclusion: Nondrug aetiologies for SJS-TEN are on the rise, and this was observed in this study too. Viral reactivation may be the commonest aetiology in such cases, and the morphology of the rash can give a clue to such cases.

DRESS, the maverick among SCARS: A case series-based review of literature.

DRESS is a potentially life-threatening severe cutaneous adverse reaction (SCAR). Historically, it was most frequently linked with phenytoin and was initially described as phenytoin hypersensitivity syndrome; however, it was later found to be caused by various other medications, with the commonest been aromatic anticonvulsants, allopurinol and sulfonamides. The severity of this entity is related to systemic involvement, which can result in multiorgan failure and death. The diagnosis of DRESS, especially in the early stages, remains challenging and elusive due to its heterogeneous clinical presentation and the complex course of the disease with different patterns depending on the causal drug. The most important step in the management of DRESS is early diagnosis and immediate cessation of the suspected offending drug along with oral steroids or immunosuppressants to control the disease. We describe the varying presentation and management of six adults with DRESS from a tertiary care hospital, observed over a two-year period with a brief review of the literature.

Randomized control trial to study the efficacy and safety of platelet-rich plasma as intraoperative holding solution in hair restoration surgery: A pilot study.

Background: Hair restoration surgery is a definitive surgical procedure undertaken for androgenetic alopecia (AGA). Platelet-rich plasma (PRP) therapy has gained importance in recent times as a valuable adjunct to therapy in hair restoration. However, the various beneficial effects of PRP as intraoperative holding solution hair restoration surgery remain to be objectively defined. Methods: Twenty cases of AGA were allocated into two groups (PRP and non-PRP). The follicular grafts harvested were stored in platelet-rich plasma/chilled ringers lactate solution depending on subject/control and were implanted in receding hairline using hair implanters. Patients were reviewed at the end of 2 weeks, 4 weeks, 8 weeks, 3 months, and 6 months using clinical and folliculoscopic images. The analysis was performed using SPSS version 20.0. Results: Follicular growth as assessed using the percentage of grafts in actively growing phase posttransplant showed faster recovery from 'shock effluvium' in the PRP group when compared with the non-PRP group from Week 4, through Week 8 and 3 months with the 'lead' increases of percentage growth difference being statistically significant(P = 0.02) between the two groups. At the end of 6 months, 100% of patients recorded a hair shaft length of >10 mm in the PRP group, whereas only 20% achieved >10 mm length. The difference in hair densities between PRP and the non-PRP group from 4 weeks up to 6 months in the non PRP group remained significant (P < 0.05). Conclusion: Intraoperative PRP as a holding solution improves outcome in hair restoration surgery by a significant improvement in the mean density of the implanted follicular unit grafts at 6 months.

Cutaneous manifestations leading to a diagnosis of a case of severe disseminated histoplasmosis in a human immunodeficiency virus-positive child.

This 9-year-old boy who was human immunodeficiency virus positive since birth presented with raised skin lesions, breathlessness, and cough and was treated as a case of disseminated tuberculosis. When no improvement was seen, he was referred to the dermatologist whose examination revealed papulonodular lesions with crusting over the face and extremities. Based on clinical suspicion of histoplasmosis, investigations done revealed a CD4 count of 3 cells/µL and histopathological features of histoplasmosis along with the disseminated disease. Cutaneous manifestations thus led to an early diagnosis of the case and a good prognostic outcome.

Cytomorphological Patterns of Nerve Aspirates in Pure Neuritic Leprosy-A Single Centre Cross-Sectional Observational Study.

BACKGROUND: Pure neuritic leprosy (PNL) poses a diagnostic challenge because of absence of skin patches, inconclusive skin biopsies and nerve conduction studies. Nerve biopsy though the diagnostic gold standard, is invasive, requires expertise, and may not be feasible in all cases. Fine needle aspiration cytology (FNAC) of accessible thickened nerves can be utilized as a minimally invasive diagnostic modality in PNL. This study was carried out to describe cytomorphological patterns of nerve aspirates in patients of PNL for diagnosis and classification of leprosy and study its advantage, if any, over skin biopsy. METHODS: Twenty-seven treatment naive clinically diagnosed patients of PNL were included in this cross-sectional study carried out from January 2017 to December 2018 at a tertiary care centre in Western India. FNAC was done from a clinically involved nerve and aspirates were evaluated for cytomorphological characteristics and the presence of Acid-Fast Lepra bacilli. RESULTS: Nerve aspirates were diagnostic in 10 (37%) patients while 17 (63%) aspirates showed non-specific or no inflammation. Of the diagnostic aspirates, six (22.2%) were classified as tuberculoid leprosy, three (11.1%) as lepromatous and one (3.7%) as borderline leprosy. Mycobacterium leprae were demonstrated among three (11.1%) of these aspirates. In comparison, only three (11.1%) skin biopsies were diagnostic of leprosy with features of indeterminate spectrum. Remaining 24 skin biopsies showed normal histology in 20 (74.1%) cases to perivascular lymphocytic infiltrate in four (14.8%) cases. CONCLUSION: Our study demonstrates that FNAC of clinically thickened nerves has a better diagnostic yield than skin biopsy in PNL and shows all spectrums of leprosy. It also offers the advantage of sampling major nerve trunks without the fear of residual neurological deficit. However, most of the smears were paucicellular and a negative aspirate does not rule out leprosy.

Effects of Mass Shootings on the Mental Health of Children and Adolescents.

PURPOSE OF REVIEW: To examine mass shootings in youth including mass shooting trends, risk and protective factors for emotional sequelae, mental health, prevention of mass shootings, and the assessment and treatment of survivors. RECENT FINDINGS: Many youth are exposed to gun violence, with a smaller subset exposed to mass shootings. While youth have varying responses to mass shootings, possibly due to risk and protective factors as well as level of exposure, the mental health outcomes are significant and include posttraumatic stress, suicide, depression, substance abuse, and anxiety. Efforts at developing effective prevention and treatment programs are still underway but generally take a tiered public health approach. Mass shootings have significant mental health outcomes for youth survivors, particularly those with direct exposure or risk factors. Continued efforts are needed to better understand the effects of mass shootings and how to prevent them from occurring as well as how to best address the needs of survivors.

Cutaneous Phaeohyphomycosis Presenting as a Progressive Disfiguring Lesion of the Face in an Immunocompetent Individual; A Rare Occurrence.

Phaeohyphomycosis encompasses many clinical syndromes occurring due to a wide variety of dematiaceous fungi. It can manifest as superficial, cutaneous, subcutaneous, or systemic forms involving the skin, subcutis, paranasal sinuses, or the central nervous system. Subcutaneous phaeohyphomycosis is the most common subtype and occurs due to wound contamination or traumatic inoculation of the saprophytic fungus from soil and vegetation. Multiple cases of subcutaneous phaeohyphomycosis involving the extremities in the form of cystic lesions and abscesses have been reported. However, involvement of the face in the form of a progressive ulcerative and disfiguring lesion in an immunocompetent person is extremely rare. We report a rare case of subcutaneous phaeohyphomycosis presenting as a slowly progressive disfiguring lesion of face.

A Case Report of Early Disseminated Lyme Disease.

Lyme disease is a multi-organ infectious disease caused by the spirochete "Borrelia burgdorferi," and transmitted by the "Ixodes" tick. Early disseminated Lyme disease can have varied central nervous system manifestations ranging from meningitis to radiculopathy and cranial neuropathy. If not suspected, misdiagnosis or delayed diagnosis can prove to be fatal. Erythema migrans is the most common clinical presentation, thereby, making dermatological examination extremely crucial in early diagnosis and treatment.

Nail Changes Induced by Chemotherapeutic Agents.

INTRODUCTION: Nail toxicity is a relatively uncommon cutaneous adverse effect of chemotherapeutic agents. Rapidly dividing cells of the nail matrix are perturbed by the antimitotic activity of these agents. Although most of these changes are cosmetic and regress once the therapy is completed, a few of these adverse effects are challenging to manage and require temporary or permanent suspension of chemotherapeutic agents. MATERIALS AND METHODS: A total of 205 patients with various malignancies and under chemotherapy in oncology ward of the hospital over a period of 3 months were screened for nail involvement postchemotherapy. Relevant details, protocol of chemotherapeutic agents were assessed. Nail examination was carried out in daylight and the changes were analyzed. RESULTS: A total of 124 (60.4%) patients had nail changes due to chemotherapeutic agents. The most common change was diffuse hyperpigmentation in 101 (81.4%) patients commonly due to a combination of cyclophosphamide and adriamycin in 43 (42.5%) patients. Longitudinal melanonychia was seen in 36 (29%), Beau's lines in 31 (25%), onychomadesis in 17 (13.7%), Mees' lines in 15 (12%), paronychia in 12 (9.6%), subungual hyperkeratosis in 10 (8%), and Muehrcke's lines in 4 (3.2%) patients. All the patients who developed Muehrcke's lines were on a combination of cyclophosphamide/doxorubicin/5 FU. Exudative onycholysis was observed in 2 (1.6%) patients; both these patients were on paclitaxel therapy. A total 2 (1.6%) patients who developed exudative onycholysis were advised discontinuation and another substitute chemotherapy was advised. Therapy for 2 (1.6%) patients who developed acute paronychia due to gefitinib was temporarily suspended. Unfortunately, most of the patients were on multiple chemotherapeutic agents hence, we could not pinpoint one drug as a cause. Therefore, a combination of agents was implicated in most cases. CONCLUSION: Nail toxicities are common with chemotherapeutic agents, however less importance is given to nail involvement. Apart from being cosmetically significant, a few adverse effects may warrant modification of the chemotherapy.

A Rare Case of Lichenoid Sarcoidosis Mimicking Papular Amyloidosis.

Cutaneous lesions in sarcoidosis are seen in nearly 20-30% and include lesions like papules, nodules, plaques, infiltrated scars, and erythema nodosum. Lichenoid variants of cutaneous sarcoidosis, a type of papular variant is quite rare. Herein we report a case of lichenoid sarcoidosis in a 40-year-old male who presented with raised itchy lesions over his legs and lower back of 8 years duration.

Adverse Childhood Experiences, Maternal/Fetal Attachment, and Maternal Mental Health.

Background: This pilot study investigated the potential impact of exposure to childhood adversity on variables known to be related to posttraumatic stress (including attachment, mental health, and perceived stress) in a clinic sample of pregnant women. Materials and Methods: Participants consisted of 101 pregnant women recruited from the Virginia Commonwealth University Health System in Richmond, VA. All participants completed the Adverse Childhood Experience (ACE) questionnaire, Parental Bonding Instrument, Maternal Fetal Attachment Scale, Posttraumatic Stress Disorder (PTSD) Checklist, Symptom Checklist, and the Perceived Stress Scale. Results: Increased exposure to ACEs was negatively associated with retrospective report of viewing one's mother and father as caring and involved. ACE exposure was a statistically significant predictor of viewing one's mother and father as intrusive and controlling. ACEs were positively associated with self-reported PTSD symptoms, depressive and anxious symptomatology, and perceived stress. No direct effect of adverse childhood events on maternal/fetal attachment was found. Conclusions: ACE associations are discussed in terms of study methodology and needs for future research. Providers may consider incorporating the ACE questionnaire to identify exposure to childhood adversity and events that may increase an individual's risk for toxic stress and negative health outcomes.

Pseudoxanthomatous or xanthelasmoid mastocytosis: Reporting a rare entity.

Mastocytosis is a disease characterized by abnormal and pathologic increase in mast cells in the cutaneous tissue and extracutaneous organs such as the bone marrow, liver, spleen, lymph node and gastrointestinal tract. Cutaneous mastocytosis comprises of four major clinical variants: solitary and multiple mastocytomas, urticaria pigmentosa, diffuse cutaneous mastocytosis and telangiectasia macularis eruptiva perstans. Cutaneous mastocytosis of the xanthelasmoid type is a rare variant of diffuse mastocytosis. It is clinically characterized by the typical yellowish hue and is accompanied histologically by mast cells infiltrating far into the lower dermis. Here we report one such rare case.

A Descriptive Study to Analyze Chemotherapy-Induced Hair Loss and its Psychosocial Impact in Adults: Our Experience from a Tertiary Care Hospital.

BACKGROUND: Hair loss is one of the most commonly reported and psychologically distressing adverse effects of chemotherapeutic agents. Studies on its impact on psychosocial aspect of cancer patients are lacking at present. OBJECTIVE: To study the chemotherapeutic agents causing hair loss and its psychosocial implications in adults. MATERIALS AND METHODS: Observational study was done for a period of 1 year, wherein all cancer patients, more than 18 years of age who developed hair loss while on chemotherapy were assessed for type of malignancy, details of chemotherapy protocol, their knowledge about chemotherapeutic agents induced hair loss, and its impact on their social life and patterns of adjustment to deal with it. A prevalidated closed-ended questionnaire was used as a data collection tool. RESULTS: Out of 179 patients, 96 (53.6%) were males as against 80 (44.6%) females, and 49 (27.3%) patients were between 18 and 30 years of age. Carcinoma lung was the most common malignancy seen in 46 (25.6%) patients followed by rectosigmoid carcinoma in 41 (22.9%) patients. Combination of cyclophosphamide and doxorubicin was the most common combination resulting in hair loss in 49 (27.3%) cancer patients. A total of 101 (56.4%) patients felt that hair loss was the worst side effect of chemotherapy, while 29 (16.2%) had to continue because it was life-saving. A total of 129 (72%) patients said hair loss is affecting their social life; 37 (20.6%) patients were using hair accessories while 69 (38.5%) did not even attempt to hide hair loss as they were too occupied with fear of disease. CONCLUSION: Chemotherapy-induced hair loss is a common adverse effect in cancer patients undergoing treatment. A thorough counseling about it and methods to deal with it should be a part of management of the patients.

Immune-mediated tuberculous uveitis - A rare association with papulonecrotic tuberculid.

The tuberculids are a group of distinct clinicopathological form of skin lesions representing hypersensitivity reaction to hematogenous dissemination of Mycobacterium tuberculosis or its antigen from an underlying active or a silent focus of tuberculosis elsewhere in the body in an individual with a strong antituberculous cell-mediated immunity and by definition do not show bacilli on special stains and are culture-negative. Ocular involvement can occur in tuberculosis, both due to direct invasion by the bacilli as well as an immune-mediated reaction; however, immune-mediated tuberculous uveitis occurring as a hypersensitivity response in association with PNT has hardly been reported in the literature. Here we report one such rare case.

Clinical Profile of Cutaneous Adverse Effects of Epidermal Growth Factor Receptor Inhibitors: A Prospective Observational Study of 76 Cases.

BACKGROUND: Epidermal growth factor receptor (EGFR) inhibitors are an extensively utilized class of chemotherapeutic agents which form an integral component of treatment in solid organ malignancies such as non-small-cell lung carcinoma, pancreatic carcinoma, colorectal carcinoma, and head and neck carcinoma. It has two subclasses: epidermal growth factor inhibitors (erlotinib) and monoclonal antibody (cetuximab). A wide array of cutaneous adverse effects has been attributed to this class of drugs, such as papulopustular eruptions, paronychia, xerosis, and changes in hair and nails. MATERIALS AND METHODS: A total of 76 cases of various malignancies on EGFR inhibitors who developed cutaneous side effects while on therapy and reported or referred to us by oncologists from January 2017 to January 2018 were included in the study. All the patients who were on other associated medications or radiotherapy were excluded. RESULT: In all, 45 (59.2%) were males and 31 (40.7%) were females. Non-small-cell lung carcinoma was the most common carcinoma in 32 (42.1%) patients, and cetuximab was the most common drug in 29 (38.1%) cases. Papulopustular eruptions were seen in 61 (80.2%) patients, xerosis in 31 (40.7%), mucositis in 6 (7.8%), hair growth problems in 4 (5.6%), and paronychia and pyogenic granuloma in 2 (2.6%) patients each. CONCLUSION: Although most of the skin toxicities associated with EGFR inhibitors can be managed conservatively, a critical analysis of the cases that are significantly affected due to these side effects is required in cohesion with the treating oncologist to improve the therapeutic compliance of the drug.