Fatal misdiagnosis of progressive disseminated histoplasmosis.

Disseminated histoplasmosis is the form of a mycosis caused by the fungus Histoplasma capsulatum that mainly occurs in immunosuppressed hosts, usually with non-specific symptoms. In non-endemic areas, where the disease is rarely involved in the differential diagnosis, a delay in treatment may lead to severe medical complications. Due to the rising prevalence of disseminated histoplasmosis in these areas, a thorough medical history is regarded as the decisive factor in prompt diagnosis of the disease. We, herein, report the case of an immunocompetent Greek farmer with disseminated histoplasmosis whose condition was initially misdiagnosed, and the consequential inadequate treatment led to his death.

Necrolytic migratory erythema caused by pancreatic hyperglycemia with emphasis on therapeutic and prognosis: A case report.

BACKGROUND: With the incidence of pancreatic diseases increasing year by year, pancreatic hyperglycemia, as one of the common complications, is gradually gaining attention for its impact on the skin health of patients. CASE SUMMARY: This was the case of an elderly female with clinical manifestations of necrolytic migratory erythema, "three more and one less," diabetes mellitus, hypertension, anemia, hypoproteinemia, and other syndromes, which had been misdiagnosed as eczema. Abdominal computed tomography showed a pancreatic caudal space-occupying lesion, and the magnetic resonance scanning of the epigastric region with dynamic enhancement and diffusion-weighted imaging suggested a tumor of the pancreatic tail, which was considered to be a neuroendocrine tumor or cystadenoma. The patient was referred to a more equipped hospital for laparoscopic pancreatic tail resection. Post-surgery diagnosis revealed a neuroendocrine tumor in the tail of the pancreas. To date, the patient's general condition is good, and she is still under close follow-up. CONCLUSION: Necrolytic migratory erythema can be induced by endocrine system tumors or endocrine metabolic abnormalities, with complex clinical manifestations, difficult diagnosis, and easy misdiagnosis by dermatologists. The initial treatment principles in dermatology include symptomatic supportive therapy and effective drugs to relieve skin lesions. After clarifying the etiology of glucagonoma, comprehensive treatment in collaboration with endocrinologists, general surgeons, and oncologists can help provide individualized treatment for patients and improve their prognosis.

Allergy Wheal and Erythema Segmentation Using Attention U-Net.

The skin prick test (SPT) is a key tool for identifying sensitized allergens associated with immunoglobulin E-mediated allergic diseases such as asthma, allergic rhinitis, atopic dermatitis, urticaria, angioedema, and anaphylaxis. However, the SPT is labor-intensive and time-consuming due to the necessity of measuring the sizes of the erythema and wheals induced by allergens on the skin. In this study, we used an image preprocessing method and a deep learning model to segment wheals and erythema in SPT images captured by a smartphone camera. Subsequently, we assessed the deep learning model's performance by comparing the results with ground-truth data. Using contrast-limited adaptive histogram equalization (CLAHE), an image preprocessing technique designed to enhance image contrast, we augmented the chromatic contrast in 46 SPT images from 33 participants. We established a deep learning model for wheal and erythema segmentation using 144 and 150 training datasets, respectively. The wheal segmentation model achieved an accuracy of 0.9985, a sensitivity of 0.5621, a specificity of 0.9995, and a Dice similarity coefficient of 0.7079, whereas the erythema segmentation model achieved an accuracy of 0.9660, a sensitivity of 0.5787, a specificity of 0.97977, and a Dice similarity coefficient of 0.6636. The use of image preprocessing and deep learning technology in SPT is expected to have a significant positive impact on medical practice by ensuring the accurate segmentation of wheals and erythema, producing consistent evaluation results, and simplifying diagnostic processes.

Comparative host transcriptomics as a tool to identify candidate biomarkers for immune reactions in leprosy using meta-analysis.

Background Leprosy is no longer considered an imprecation, as an effective multidrug therapy regimen is available worldwide for its cure. However, its diverse clinical manifestations sometimes involve acute inflammatory reactions. These complications result in irreversible nerve damage, neuritis and anatomical deformities that emerge before, during the treatment or after the completion of treatment. Reversal reaction (Type-I) and erythema nodosum leprosum (Type-II) are the leprosy reactions generally seen in patients with lepromatous and borderline forms of leprosy. At present, there is no accurate diagnostic test available to detect these leprosy reactions. Objectives To identify potential biomarkers indicative of Type-I and Type-II leprosy reactions that could help in their early diagnosis. Methods and Results Host-transcriptomics investigations have been utilised in this study to decipher a correlation between host-gene expression-based biomarkers and exacerbation of leprosy reactions. We present a comparative analysis of publicly available host transcriptomics datasets (from Gene Expression Omnibus) related to leprosy reactions. Individual datasets were analysed and integration of results was carried out using meta-analysis. Common differentially expressed genes (DEGs) were identified using the frequentist and Bayesian ratio association test methods. We have identified several genes - ADAMTS5, ADAMTS9, IFITM2, IFITM3, KIRREL, ANK3, CD1E, CTSF, DOCK9 and KRT73 to name a few - which can serve as potential biomarkers for Type-II reaction. Similarly, ACP5, APOC1, CCL17, S100B, SLC11A1 among others may likely serve as biomarkers for Type-I reaction. Limitations The number of datasets related to leprosy reactions found after the systematic search is less (n = 4) and may limit the accuracy of identified biomarker genes. This could be resolved by including more studies in the data analysis. Conclusion We provide a comprehensive list of gene candidates which could be prioritised further in research focusing on immune reactions in leprosy, as they are likely important in understanding its complexities and could be useful in its early diagnosis.

Interventional human ocular safety experiments for 222-nm far-ultraviolet-C lamp irradiation.

The study aimed to directly assess the ocular safety of 222-nm far-ultraviolet-C (UVC) irradiation in humans, given the limited clinical trials in this area. This wavelength offers the potential for safe and effective microbial inactivation in occupied spaces, but its safety profile for human eyes requires thorough investigation. This prospective, interventional study involved five subjects aged 29-47 years, who were exposed to 222-nm UVC at doses of 22, 50, and 75 mJ/cm2. The subjects were monitored using custom-made glasses with a UV-cut filter on one eye to serve as a control. UVC irradiation was conducted using a KrCl excimer lamp, and ocular examinations were performed prior to exposure, 24 h post-exposure, and at 1, 3, and 6 months. Parameters assessed included visual acuity, refractive error, corneal endothelial density, corneal erosion scores, and conjunctival hyperemia scores. The study found no clinically significant photokeratitis or long-term eye damage across the five subjects, even at the highest dose of 75 mJ/cm2. Temporary ocular discomfort, including sensations of dryness and epiphora, was reported, but these symptoms subsided within hours after irradiation. The findings indicate that 222-nm far-UVC irradiation up to 75 mJ/cm2 does not cause "clinically significant photokeratitis" or long-term ocular damage, though it may induce temporary discomfort. This supports the safe use of 222-nm UVC for germicidal applications in occupied environments, providing a basis for revised safety guidelines.

Epidermal and dermal hydration in relation to skin color parameters.

BACKGROUND: Our goal was to investigate linkages between skin color parameters and skin hydration. Since most prior studies focused on stratum corneum hydration, we focused on epidermal and dermal hydration in relation to skin color parameters in both sexes. MATERIALS AND METHODS: Thirty adults (16 female) with an age ± SD of 24.3 ± 0.6 years participated. Three sites on both volar forearms were evaluated for melanin index (MI), erythema index (EI), Individual Typology Angle (ITA), tissue dielectric constant (TDC) values to depths of 0.5 mm (TDC0.5) and 2.5 mm (TDC2.5), and Fitzpatrick skin type (FST). RESULTS: MI and EI were highly correlated (r = 0.800, p < 0.001) with maximum differences in MI and ITA along the arm of 3% and 6.3% with no difference between arms. Male MI was greater than females (p < 0.01). Male TDC2.5 was 36.1 ± 5.4 and correlated with EI (r = 0.231, p = 0.035). Contrastingly, female TDC25 was 28.5 ± 3.6 with no correlation with EI but was correlated with MI (r = -0.301, p = 0.003). These differential patterns held true for TDC0.5. For both sexes, FST and ITA were highly correlated (r = -0.756, p < 0.001). CONCLUSIONS: The findings revealed several correlations between skin color parameters and hydration that differed between males in females in some cases. The observed correlations may indicate that melanin may differentially impact water-holding capacity between sexes and provides a future research target. Further, these initial findings also may hold significance for dermatological assessments and the customization of skincare treatments tailored to individual skin types and demographics.

Dermatoscope for the diagnosis of erythema with purpura induced by lidocaine/prilocaine cream: A case report.

BACKGROUND: Lidocaine/prilocaine (EMLA) cream is a local anesthetic that is applied to the skin or mucosa during painful therapeutic procedures with few reported side effects. CASE SUMMARY: Here, we report the use of dermatoscopy to identify a case of erythema with purpura, a rare side effect, after the application of 5% EMLA cream. CONCLUSION: We conclude that erythema with purpura is caused by irritation and toxicity associated with EMLA, but the specific mechanism by which the toxic substance affects skin blood vessels is unclear. In response to this situation and for cosmetic needs, we recommend tranexamic acid, in addition to routine therapy, to prevent changes in pigmentation in patients with dermatitis.

Bilateral Blistering Rash Following Gastric Bypass Procedure and Mushroom Soup Diet: Hepatitis C Virus-Seronegative Necrolytic Acral Erythema.

Necrolytic acral erythema (NAE) is an uncommon cutaneous disorder characterized by a symmetric acral distribution of erythematous plaques with underlying epidermal necrosis. While typically presenting in the context of hepatitis C virus (HCV) infection, NAE can also present secondary to nutritional deficiency or systemic disease. We present a case of NAE in a 66-year-old patient with no history of HCV infection status post gastric bypass who had a three-month history of eating only mushroom soup. The patient underwent a punch biopsy and was tested for a variety of nutritional deficiencies. Biopsy demonstrated partial necrosis of the upper epidermis, with subjacent re-epithelialization, squamatization, and vacuolopathy of the basal epidermis. He was treated with zinc replacement therapy after initial trials of tacrolimus and clobetasol were unsuccessful. At follow-up, he had significant improvement of the lesions. This case provides an example of an atypical presentation of NAE in the absence of HCV infection that presented as a complication of gastric bypass-associated nutritional deficiency.

Solving a diagnostic dilemma in a patient with periodic fever-When the pieces of the puzzle finally fit.

The lack of pediatric subspecialists locally prior to 5 years ago, meant that some of our patients with rare, relapsing conditions were left behind. Familial Mediterranean fever can be diagnosed clinically and supported via genetic panel studies. Although neurological symptoms can be non-specific, this system symptomatology may lead patients and carers to seek medical attention. When neurological symptoms progress, seemingly refractory to first-line treatment, or suggestive of colchicine resistance, CNS demyelination should be considered by the neurologist. Abstract: Familial Mediterranean fever (FMF) is an inherited disorder with episodic fevers accompanied by pain in the abdomen, joints, or chest. It is a clinical entity that can be confirmed with a specific genetic mutation. Neurological symptoms have not been a focal point in clinical case descriptions. We aim to present the long road to diagnosing our patient, where the diagnostic clues centered around her neurological symptoms.

A case of erythema ab igne with histopathological features resembling keratosis lichenoides chronica.

This case describes a pediatric patient with a history of ichthyosis vulgaris and global anhidrosis who was diagnosed with erythema ab igne (EAI), a rare dermatosis resulting from chronic heat exposure. After developing progressive, reticulated brown patches on his extremities and abdomen, extensive diagnostic investigations were conducted to rule out autoimmune, vascular, and genetic etiologies. Bloodwork was unrevealing and biopsies showed histologic features closely resembling keratosis lichenoides chronica. Ultimately, after discovering the patient had prolonged exposure to a space heater, the diagnosis of EAI was made. This case underscores the diagnostic challenges in pediatric EAI cases and emphasizes the importance of careful history taking as part of a comprehensive evaluation.

Hidden Agony: Foot Pain Linked to Pet Hair Splinter.

Cutaneous pili migrans is a rare and interesting dermatological condition characterized by embedding a hair or its fragment in the epidermis or superficial dermis, sometimes leading to pain and a serpiginous rash. We present a 28-year-old male who came to the clinic concerned about the sudden onset of pain in his foot over 10 hours. Upon meticulous physical examination, we found a white hair embedded in the skin of the fifth toe of his left foot, which the patient immediately recognized as hair from his dog. Upon removal of the hair, the pain immediately resolved. We believe our case represents the first reported case in Panama, the second in Latin America, and the second associated with dog hair. We anticipate that more cases related to animal hairs will be reported in the coming years due to the increasing popularity of pets in this century.

Assessment of three criteria to establish borrelial infection in suspected lyme neuroborreliosis.

PURPOSE: Diagnosis of (European) Lyme neuroborreliosis has been based on clinical presentation, cerebrospinal fluid (CSF) pleocytosis and demonstration of intrathecal borrelial antibody synthesis (ITBAS) to document Borrelia burgdorferi s. l. INFECTION: It is not known if other criteria to document Borrelia infection may contribute to the diagnosis. METHODS: We compared the sensitivity of three individual criteria (ITBAS, CSF Borrelia culture, and the presence of erythema migrans [EM]) to confirm the diagnosis of early Lyme neuroborreliosis in 280 patients ≥ 15 years of age evaluated at a Lyme borreliosis outpatient clinic in Slovenia. The patients had either radicular pain of new onset or involvement of a cranial nerve but without radicular pain, each in conjunction with CSF pleocytosis. Evaluation was of patients who had each of the three confirmatory criteria assessed, and for whom at least one criterion was positive. RESULTS: Analysis of 280 patients, 120 women and 160 men, median age 57 (range 15-84) years, revealed that ITBAS was the most frequently observed positive criterion (85.4%), followed by EM (52.9%), and by a positive CSF Borrelia culture (9.6%). Of the 280 patients, 154 (55%) met only one criterion (43.2% ITBAS only, 10.7% EM only, and 1.1% positive CSF culture only), whereas 42.1% met two criteria. Only 2.9% of patients were positive by all three criteria. CONCLUSION: Although ITBAS was the most frequent criterion for confirmation for Borrelia infection, the presence of EM alone confirmed an additional 10.7% of patients and a positive CSF Borrelia culture alone added another 1.1%.

Lupus Erythematosus Tumidus Misdiagnosed as Erythema Nodosum from Coccidioidomycosis.

Introduction: Lupus erythematosus tumidus (LET) is a rare photosensitive dermatosis that is categorized as intermittent cutaneous lupus erythematosus. It shares clinical similarities and histopathological features with other skin disorders, such as erythema nodosum, lymphocytic infiltrate of Jessner, and reticular erythematous mucinosis, thus making diagnosis quite challenging. We present a patient with LET whose diagnosis was confirmed after seeing several doctors. Case Presentation: A 52-year-old Hispanic female presented with tender erythematous nodules on her thighs for approximately 1 month. She was suspected of having erythema nodosum secondary to coccidioidomycosis and was prescribed fluconazole 200 mg for 30 days but showed no improvement. However, histopathological and direct immunofluorescence tests later confirmed a diagnosis of LET. The patient was treated with hydroxychloroquine, and the lesions improved remarkably after 2 weeks. Conclusion: LET is a rare dermatosis that closely resembles other dermatologic conditions such as erythema nodosum, lymphocytic infiltrate of Jessner, and reticular erythematous mucinosis. Diagnosis based on clinical features alone should be avoided, and ideally, treatment should only be initiated after confirmatory histopathological testing.

PD-L1 expression in keratinocyte and infiltration of CD4 + T lymphocyte can predict a severe type of erythema multiforme major induced by the anti-PD-1 antibody, pembrolizumab.

Skin toxicity is the most common adverse event of treatment with immune check point inhibitors. Among them, erythema multiforme is a rare occurrence with a frequency of 4%, with most of the cases developing grade 1/2 disease. We experienced high grade erythema multiforme major developing with pembrolizumab treatment for anal canal cancer with extensive skin metastases. Steroid ointment was ineffective, and the skin lesions with blisters expanded to > 45% of the body surface area. The patient was at risk for symptom aggravation, and a pulse therapy with methylprednisolone and increasing the dose of oral prednisolone (1 mg/kg) were started. The skin lesions improved in 1.8 months. Unless urgent and appropriate treatments such as high dose steroid administration were conducted, the skin toxicities could not be controlled. The presence of CD4+ T cells and PD-L1+ keratinocytes in the skin biopsy might be a predictive marker of erythema multiforme major resistant to standard steroid treatment. Supplementary Information: The online version contains supplementary material available at 10.1007/s13691-024-00676-4.

A case of recurrent erythema induratum of Bazin in a patient with myelodysplastic syndrome.

We describe a case of erythema induratum of Bazin (EIB) that presented recurrently on the extremities during treatment with anti-tuberculosis medications. The anti-tuberculosis medications were effective, so they were continued despite the occurrence of the EIB lesions, and those lesions disappeared 5 months after first appearing. EIB is currently considered a multifactorial disorder with many different causes, with tuberculosis being an example, and it is thought to be a hypersensitive immune response to Mycobacterium tuberculosis. The clinical manifestations may fluctuate depending on the immune response of the host. Our patient was affected with myelodysplastic syndrome, and we believe that this was a major factor that interfered with a normal immune response. This case illustrates the importance of providing intensive anti-tuberculosis treatment from the start, and in cases where EIB co-presents, to continue this treatment until the end, in order to prevent relapse.

When Salmonella Manifests Through the Skin: Erythema Nodosum in a Pediatric Case.

Erythema nodosum (EN) is a non-specific nodular dermo-hypodermic rash characterized by the sudden occurrence of painful lumps located especially in the legs following a non-specific reaction to different internal and external antigens. Clinical and histological manifestations are stereotyped, regardless of the etiology. Erythema nodosum is most frequently associated with infections, particularly bacterial and less commonly viral, fungal, and parasitic. Other conditions can be discussed, including systemic diseases, malignant tumors, medicines, and vaccines. In almost half of cases, erythema nodosum is idiopathic if no cause is found. We report a case of erythema nodosum secondary to a Salmonella infection in a seven-year-old male. The peculiarity of our observation is the initial presentation of systemic signs that preceded the gastrointestinal symptoms.

Erythema Migrans in Patients with Post-Traumatic Splenectomy.

Information on asplenic Lyme borreliosis (LB) patients with erythema migrans (EM) is lacking. We compared the course and outcome of 26 EM episodes in 24 post-trauma splenectomized patients (median age 51 years) diagnosed at a single clinical center in Slovenia during 1994-2023 with those of 52 age- and sex-matched patients with EM but with no history of splenectomy. All patients were followed for one year. A comparison of pre-treatment characteristics revealed that EM in splenectomized patients was of shorter duration before diagnosis (4 vs. 8 days, p = 0.034) with a smaller EM diameter (10.5 vs. 14 cm, p = 0.046), and more frequently fulfilled criteria for disseminated LB (3/26, 11.5% vs. 0%, p = 0.034). Treatment failure occurred in 5/26 (19.2%) EM episodes in splenectomized patients versus 0/52 in non-splenectomized patients (p = 0.003). The five treatment failure cases were retreated with antibiotic regimens used to treat EM and had complete resolution of all symptoms/signs. In conclusion, our study showed that splenectomized adult patients with EM differ somewhat in presentation and more often have treatment failure compared with non-splenectomized patients with EM.

Non-Invasive Paraclinical Diagnosis of Hepatocutaneous Syndrome in a Dog.

A 14-year-old, female spayed Bichon Maltese with no other known previous pathologies was presented for dermatological examination after being referred from a private clinic with the suspicion of generalized, treatment-resistant demodicosis. Upon presentation and clinical examination, multiple deep skin scrapings were performed, returning negative parasitological results. Complete blood count and serum biochemistry revealed mild hepatic damage. Abdominal ultrasound revealed an abnormal echostructure of the liver displaying a honeycomb or Swiss cheese-like pattern, reported as pathognomonic for hepatocutaneous syndrome. The owner declined any further paraclinical examination, including skin biopsy and histopathological examination, requesting a treatment protocol that could be pursued at home, considering the age of the dog and its reactive behavior during the examination. The present case report highlights a non-invasive method of diagnosing the hepatocutaneous syndrome in a dog by clinical examination, routine blood testing, and ultrasound assessment of the abdomen, in the absence of the possibility of doing a histopathological diagnosis.