Generalised eruptive histiocytosis preceded by systemic symptoms.

Generalised eruptive histiocytosis is a rare proliferative disease that typically presents with indolent cutaneous eruptions. We describe the case of a 73-year-old man presenting with diffuse, asymptomatic crops of pink to dusky red papules preceded by general malaise, myalgias, fluctuating fever, chills, and weight loss. Histological evaluation revealed a non-Langerhans cell histiocytic dermal infiltrate with spindle cell features and chronic inflammation, reactive for CD68 and negative for both S100 and CD1a. Malignancy screening was negative. This report aims to highlight a unique presentation of generalised eruptive histiocytosis, emphasise histological findings, and discuss considerations for malignancy screening.

In Vivo Reflectance Confocal Microscopy as a Response Monitoring Tool for Actinic Keratoses Undergoing Cryotherapy and Photodynamic Therapy.

Reflectance confocal microscopy (RCM) presents a non-invasive method to image actinic keratosis (AK) at a cellular level. However, RCM criteria for AK response monitoring vary across studies and a universal, standardized approach is lacking. We aimed to identify reliable AK response criteria and to compare the clinical and RCM evaluation of responses across AK severity grades. Twenty patients were included and randomized to receive either cryotherapy (n = 10) or PDT (n = 10). Clinical assessment and RCM evaluation of 12 criteria were performed in AK lesions and photodamaged skin at baseline, 3 and 6 months. We identified the RCM criteria that reliably characterize AK at baseline and display significant reduction following treatment. Those with the highest baseline odds ratio (OR), good interobserver agreement, and most significant change over time were atypical honeycomb pattern (OR: 12.7, CI: 5.7-28.1), hyperkeratosis (OR: 13.6, CI: 5.3-34.9), stratum corneum disruption (OR: 7.8, CI: 3.5-17.3), and disarranged epidermal pattern (OR: 6.5, CI: 2.9-14.8). Clinical evaluation demonstrated a significant treatment response without relapse. However, in grade 2 AK, 10/12 RCM parameters increased from 3 to 6 months, which suggested early subclinical recurrence detection by RCM. Incorporating standardized RCM protocols for the assessment of AK may enable a more meaningful comparison across clinical trials, while allowing for the early detection of relapses and evaluation of biological responses to therapy over time.

Response to Ipilimumab/Nivolumab Rechallenge and BRAF Inhibitor/MEK Inhibitor Rechallenge in a Patient with Advanced Metastatic Melanoma Previously Treated with BRAF Targeted Therapy and Immunotherapy.

Little is known about the optimal sequencing of targeted therapy and immunotherapy in the treatment of patients with BRAFV600-mutated metastatic melanoma. BRAF/MEK inhibition often has the benefit of rapid disease regression; however, resistance is frequently seen with long-term use. Treatment with immune checkpoint inhibitors offers the potential for long-term response but displays a lower rate of objective response. The benefit of synergy between therapies is apparent; however, there is limited data regarding optimal sequencing in the treatment of advanced melanoma. We present the case of a 62-year-old gentleman with advanced BRAFV600-mutated melanoma who followed an unconventional treatment path. After progressing on single-agent vemurafenib, he had response to multiple modalities of immunotherapy before progression. After, he had a substantial response to multiple BRAF/MEK inhibitor rechallenges before developing resistance. The patient is now stable after a retrial of combination immunotherapy. Our case illustrates that with the right sequencing of therapy, meaningful clinical responses can be elicited with rechallenging of targeted therapy and immunotherapy in metastatic melanoma.

Widespread Hypertrophic Lichen Planus following Programmed Cell Death Ligand 1 Blockade.

Hypertrophic lichen planus (HLP) may not have the typical histological findings of lichen planus and often mimics squamous cell carcinoma (SCC). Distinguishing between the two can pose a diagnostic challenge. Here, we present a case of eruptive HLP mimicking SCC in the context of programmed cell death ligand 1 (PD-L1) immune checkpoint inhibition. A 73-year-old woman recently treated with durvalumab, an anti-PD-L1 antibody, presented to our clinic with diffuse hyperkeratotic papules and plaques previously thought to be eruptive SCC. The lesions did not respond to topical fluorouracil and continued to appear despite discontinuation of immunotherapy. Further histological analysis revealed intraepidermal epithelial proliferation with lichenoid inflammation. Subsequent treatment with topical corticosteroids significantly improved the size and number of lesions. The diagnosis of HLP was made based on histological features and response to topical steroids in the context of recent immunotherapy. This case reveals HLP as a potential adverse effect of PD-L1 inhibition and highlights the need for additional diagnostic assessment in patients presenting with eruptive hyperkeratotic lesions, especially on the lower extremities.

Comparison of knowledge, perception and attitudes of concussion in previously concussed versus non-concussed youth soccer players.

OBJECTIVES: To examine if history of concussion is correlated with a difference in knowledge, attitude, and perception of concussive injuries in youth soccer players. METHODS: A convenience sample of youth soccer athletes aged 14 to 18 years completed a survey assessing prior history of concussive injury, knowledge of concussive injury, self-reporting attitudes, and perception of the injury. The survey consists of 16 knowledge questions (eleven on a scale of 1-2, and five on a scale of 1-4) and 12 attitude questions (seven on a scale of 1-4, and five on a scale of 1-5). The primary outcomes are the total scores calculated by summing the standardized raw scores for all knowledge questions and attitude questions, respectively. Linear regression was used to estimate the mean difference in the primary outcomes between previously concussed and non-concussed athletes (calculated as previously concussed - non-concussed). RESULTS: Surveys were obtained from 90 athletes, with 32 (36%) previously sustaining at least one concussion. Thirty-one out of these 32 concussions were diagnosed by a medical provider. On average, the mean total raw scores of all knowledge questions are 34.6 (82.2% of 42 possible points) and 33.7 (80.2% of 42 total points) for previously concussed and non-concussed athletes, respectively, and the mean total raw scores of all attitude questions are 38.7 (72.9% of 53 possible points) and 39.6 (74.7% of 53 possible points), respectively. Mean differences estimated from univariate linear regression in the standardized total scores of knowledge questions and attitude questions are 1.56(95% confidence interval: -1.52-4.65) and -1.23 (%95 confidence interval: -4.64-2.19), respectively. Adjusting for age and years of playing soccer gave similar results. CONCLUSION: Although we did not find significant differences between previously concussed and non-concussed athletes in either the knowledge or the attitude questions as measured by their total scores, this study showed a high level of awareness of concussion in youth soccer players, while still highlighting a need for education. Limited distinctions were made among subgroups of players, suggesting directions of future research in investigating the role that outside factors may have on knowledge and perception of concussion.