An 'Exo-Tick' Problem: A Sudden Increase in Tick Bite - A Case Series.

Ticks are blood-sucking arthropod ectoparasites of vertebrates, which are vectors of many diseases. They cause varied skin manifestations, which occur either due to the attachment of the tick to the host or due to the infections it spreads. Dermoscopy serves as a precise diagnostic tool for tick bites and also helps in ensuring complete removal of the tick. Prompt removal and identification of the tick, along with appropriate antibiotic therapy, are important aspects of the management of this condition. Herein, we present a case series of nine patients with tick bites, by ticks of similar morphology but at different body sites and with varied predisposing factors.

Frequency and management of respiratory incidents in invasive home ventilation.

There has been a rise in the number of patients requiring long-term ventilation, both in the in-hospital and the out-of-hospital setting. Despite this, little is known about the subsequent clinical course of these patients following hospital discharge. The purpose of this study was to determine the frequency and management of respiratory incidents in patients with invasive out-of-hospital ventilation living in a nursing home allied to a weaning centre. We evaluated retrospectively the protocols that are used to monitor the patients over a period of 2 months. The average time from hospital discharge was 386 ± 330 days. Of the total 17 patients, 9 (53%) patients remained free from any respiratory incidents, while the remaining 8 (47%) patients were responsible for a total of 95 respiratory incidents. Patients that suffered respiratory incidents had been ventilated at home for an average of 194 days, while the others were receiving out-of-hospital ventilation for an average of 557 days. Desaturation (17), dyspnoea (17) and reduced general condition (10) were the most common respiratory incidents. Also, the use of an Ambu bag (bag valve mask; 17), request for a pneumologist review (12) and replacement of the tracheal cannula (7) were the most common interventions. Respiratory incidents are common in invasive home mechanical ventilation, and so home mechanical ventilation needed to be organized safely. Being allied to a weaning centre helps to organize invasive home mechanical ventilation in a safe manner over the long-term ventilation.

Comparison of High Resolution Ultrasonography with Clinical Examination in the Assessment of Peripheral Nerve Involvement in Leprosy.

CONTEXT: Assessment of peripheral nerves in leprosy by clinical methods is subject to considerable inter-observer variability. High resolution ultrasonography (HRUS) can assess peripheral nerves more objectively. AIMS: To compare the findings of peripheral nerve involvement in newly diagnosed cases of leprosy by clinical and sonological methods. SETTINGS AND DESIGN: Cross sectional study in a tertiary care teaching hospital. SUBJECTS AND METHODS: Four pairs of peripheral nerves of 40 newly diagnosed patients with leprosy were examined clinically and by HRUS. STATISTICAL ANALYSIS USED: Agreement between clinical examination and HRUS using kappa statistic; sensitivity; specificity; and predictive values. RESULTS: Of the 320 nerves examined, 71 (22.18%) were abnormal clinically and 63 (19.7%) sonologically. Sonological abnormalities were increased cross sectional area (n = 63; 100%), hypoechogenicity with loss of fascicular architecture (n = 46; 73%) and increased vascularity (n = 35; 55.6%). There was moderate agreement (Cohen's K = 0.59) between clinical and sonological findings. HRUS findings were abnormal in 18 (7.2%) nerves that were clinically normal. HRUS was normal in 26 (36.6%) nerves which were clinically abnormal. Sensitivity of HRUS compared to clinical examination was 63%; specificity 92.7%; positive predictive value 71.4%; and negative predictive value 89.9%. Increased cross sectional area agreed with clinical findings the most. CONCLUSIONS: HRUS has low sensitivity (63%) and high specificity (92.7%) to identify abnormal peripheral nerves in leprosy, compared to clinical examination. It could detect abnormality of some (n = 18, 7.2%) clinically normal nerves, but showed normal findings of some nerves (n = 26, 36.6%), which were considered clinically abnormal.

Chronic Kidney Disease in Patients with Psoriasis -A Hospital Based Cross Sectional Study.

BACKGROUND: Psoriasis is a multi-system inflammatory disease where skin and joints are the primary targets. Recently, some studies had shown the association of psoriasis with kidney disease. AIMS: To study the association of psoriasis with chronic kidney disease (CKD) in a tertiary health care center. METHODOLOGY: The study was conducted in the Department of Dermatology in a tertiary care center in Kerala. The study was a descriptive cross-sectional study for 6 months from August 2017 to January 2018. A total of 104 patients with psoriasis were studied. Clinical data was collected. Glomerular filtration rate (GFR) and albumin creatinine ratio (ACR) were found out to know the presence of CKD. Descriptive and inferential statistical analysis has been carried out in the present study. OBSERVATIONS: Of the 104 patients, 14 were diagnosed as having CKD. Of the 14 CKD patients, 12 had severe psoriasis, 2 had moderate psoriasis, and none had mild psoriasis. The risk factors for CKD (presence of diabetes mellitus/hypertension or intake of drugs-non-steroidal anti-inflammatory drugs [NSAIDs]/cyclosporine) were present in 9 out of 14 CKD patients. The duration of psoriasis was more than 10 years in 10 CKD patients. CONCLUSION: Our study demonstrated that psoriatic patients have an increased risk of developing CKD and this risk is found to increase with the severity and duration of psoriasis. Our results require confirmation in large-patient populations in prospective studies or case-control studies.

Sub-polar lepromatous leprosy localized to the face.

Leprosy is an infectious disease characterized by a wide spectrum of clinical manifestations, ranging from tuberculoid to lepromatous disease with immunologically unstable borderline forms in between. In clinical practice cases often do not conform to a classical textbook description, which may lead to misdiagnosis if not properly investigated. A 22-year-old patient presented to us with erythematous plaques localized to the face. Slit skin smear for Mycobacterium leprae was positive from lesional as well as non-lesional skin. A biopsy from a plaque showed diffuse atrophy of the epidermis with a subepidermal cell free zone (grenz zone). The cellular infiltrate was composed of foamy macrophages admixed with lymphocytes in the dermis. Fite-Faraco staining revealed clumps of acid-fast bacilli within the macrophages. Based on the skin smear and histopathology findings, a diagnosis of sub-polar lepromatous leprosy was made and the patient was started on multidrug therapy. The exact pathogenesis of localized multibacillary disease is not known. Our case highlights the importance of skin smear and biopsy in all suspected cases of Hansen disease. We conclude that routine skin smear in all new leprosy cases is mandatory to differentiate localized multibacillary cases from paucibacillary cases for the purpose of accurate categorization and treatment.

Methotrexate iontophoresis versus coal tar ointment in palmoplantar psoriasis: A pilot study.

BACKGROUND: Palmoplantar psoriasis is often disabling and refractory to conventional therapy. Systemic drugs are indicated in its severe form, but side effects are a concern with their use. Methotrexate is one such systemic drug which is effective and cheap. To reduce systemic toxicity, methotrexate has been tried topically but results have been inconsistent due to poor drug penetration into the skin by passive diffusion. Iontophoresis may enhance its absorption and efficacy. AIM: To evaluate the efficacy and safety of topical methotrexate iontophoresis in comparison with coal tar ointment in the treatment of palmoplantar psoriasis. METHODS: Thirty-one patients with palmar and/or plantar psoriasis were selected for the study and 28 patients completed it. The side having more severe involvement was treated while the other palm/sole served as a control. Iontophoresis using methotrexate solution was carried out on the study palm/sole with the injectable preparation of methotrexate (50 mg/2 ml) once a week for the first 4 weeks and subsequently every two weeks, for a total of six sittings. The control palm/sole was treated with coal tar ointment on other days. Erythema, scaling, induration and fissuring scores were noted in both groups before and after treatment. RESULTS: Both study and control groups showed decreases in scores but the reduction was more in the study group, the difference being statistically significant. LIMITATIONS: Drawbacks of our study include the small sample size and the lack of follow-up. The study and control arms were not exactly matched and the study was not blinded. CONCLUSION: Methotrexate iontophoresis was safe and more effective than coal tar ointmentin palmoplantarpsoriasis.

Carbamazepine--the commonest cause of toxic epidermal necrolysis and Stevens-Johnson syndrome: a study of 7 years.

BACKGROUND: Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are a group of severe life threatening drug reactions. The drugs commonly implicated as the cause of these drug reactions vary depending on host factors and the prescription pattern of drugs in that particular area. AIM: The aim of the study was to find the drugs implicated as the cause of SJS/TEN in the patients admitted in the dermatology ward at the Medical College, Thrissur and to find the clinical outcome. METHODS: It was a retrospective study of 7 years from 1997 to 2004. The case records of all patients with a clinical diagnosis of TEN or SJS were studied in detail regarding the drugs implicated as the cause, the management and the clinical outcome. RESULTS: During the study period, 41 patients in the age group ranging from 12 to 72 years were treated as inpatients, of which 20 were males and 21 were females. The commonest drug implicated as the cause of SJS/TEN was carbamazepine (44%). The indication for carbamazepine was control of pain in more than 50% of the cases. Presence of a major systemic disease before the onset of SJS/TEN was associated with a bad prognosis. CONCLUSION: The increased use of carbamazepine, especially for control of pain, may be the reason for the increased incidence of SJS/TEN due to the same drug. Awareness about the drugs implicated in life threatening drug reactions will help physicians in preventing them by judicious use of the drugs.

Spontaneous regression in an ulcerated CK7 positive Merkel cell carcinoma.

Merkel cell carcinoma is an aggressive and frequently lethal tumor of the elderly, associated with sun exposure and immunosuppression which is less common in the dark-skinned. We report the case of a 40-year-old woman who presented with multiple slowly progressive, mildly itchy ulcerated plaques of size ranging from 2 × 3 cm to 5 × 7 cm on the left knee of 1 year duration. Skin biopsy showed diffuse dermal infiltration by small round cells with molding of cells and lymphocyte infiltration. The cells stained positive for cytokeratin (CK) 20, CK7, neuron-specific enolase, and chromogranin. The skin lesions underwent spontaneous regression within 1 month of skin biopsy and have not recurred during the past 2 years. The immune mechanisms triggered by biopsy possibly explain the spontaneous regression.

Postpartum pemphigoid gestationis.

Pemphigoid gestationis (PG) or herpes gestationis is a rare autoimmune subepidermal blistering disorder associated with pregnancy. The condition typically develops during the second or third trimester of pregnancy, but has been rarely reported in the first trimester and postpartum period. Here, we report a case of PG that presented for the first time in the postpartum period, associated with a low birth weight baby.

Localized psoriasis herpeticum: Case report and review of literature.

Kaposi's varicelliform eruption (KVE) is a widespread cutaneous eruption caused by viruses, especially herpes simplex virus in patients with pre-existing dermatoses. "Psoriasis herpeticum" refers to the rare occurrence of KVE in patients with psoriasis. We report a case of KVE localized to the face in a patient with exfoliative dermatitis secondary to psoriasis. This case is being reported to make the treating clinician aware of the possibility of KVE in patients with psoriatic erythroderma.

Purpuric macules with vesiculobullous lesions: a novel manifestation of Chikungunya.

BACKGROUND: Chikungunya (CHIK) is an emerging viral disease with a myriad of cutaneous manifestations. AIMS: The aim of our study was to document the morphology and evolution of skin lesions in cases presenting with fever, purpuric macules and vesiculobullous lesions, to confirm its causative relationship with CHIK, and to investigate further in order to delineate possible mechanisms of bulla formation in these cases. MATERIALS AND METHODS: A prospective, descriptive hospital-based study was carried out at a tertiary health care centre in Kerala. A total of 10 patients were enrolled in the study and investigated. RESULTS: All cases had morbilliform eruption prior to onset of purpuric macules. Eight cases developed vesiculobullous lesions that arose either de novo or over a part or whole of the purpuric macules. Skin lesions resolved within an average of 7.6 days leaving post-inflammatory hypopigmentation. IgM CHIK enzyme-linked immunosorbent assay (ELISA) was positive in all 10 patients. Tzanck smear from the bullae showed lymphocytes in most cases along with acantholytic cells, necrotic keratinocytes or occasional neutrophils. Skin biopsy showed intraepidermal or subepidermal bullae. Immunohistochemistry revealed predominantly CD8 positive T lymphocytes in the infiltrate. The prognosis was good with supportive management alone. DISCUSSION: The clinical features in our cases are comparable to the 3 previous reports of vesiculobullous lesions in CHIK affected infants. Based on the current evidence, we hypothesize that at least 2 mechanisms are at play for these skin lesions; CHIK virus induced keratinocyte necrosis followed by a cytotoxic immune response, and possible modulation of rash by drugs. CONCLUSION: With severe epidemics of CHIK spreading from Asia and Africa to the Western hemisphere, we must consider bullous CHIK as a differential diagnosis in cases with fever and purpuric and vesiculobullous lesions.

Activation of the interferon-alpha pathway identifies a subgroup of systemic lupus erythematosus patients with distinct serologic features and active disease.

OBJECTIVE: Gene-expression studies have demonstrated increased expression of interferon (IFN)-inducible genes (IFIGs) in peripheral blood mononuclear cells (PBMCs) of many patients with systemic lupus erythematosus (SLE), with a predominant effect of type I IFN. This study examined the hypothesis that increased disease severity and activity, as well as distinct autoantibody specificities, characterize SLE patients with activation of the type I IFN pathway. METHODS: Freshly isolated PBMCs from 77 SLE patients, 22 disease controls, and 28 healthy donors were subjected to real-time polymerase chain reaction for 3 IFIGs that are preferentially induced by IFNalpha, and the data were used to derive IFNalpha scores for all individuals. Expression of IFIGs was significantly higher in SLE patients compared with disease controls or healthy donors. SLE patients with high and low IFNalpha scores were compared for clinical manifestations of disease, disease severity, disease activity, serologic features, and potential confounders, by bivariate and multivariate analyses. RESULTS: SLE patients with a high IFNalpha score had a significantly higher prevalence of renal disease, a greater number of American College of Rheumatology criteria for SLE, and a higher Systemic Lupus International Collaborating Clinics damage index (SDI) score than did SLE patients with low IFNalpha scores. Patients with high scores showed increased disease activity, as measured by lower C3 levels, hemoglobin levels, absolute lymphocyte counts, and albumin levels, and a higher anti-double-stranded DNA (dsDNA) titer, erythrocyte sedimentation rate, and SLE Disease Activity Index 2000 score. The presence of antibodies specific for Ro, U1 RNP, Sm, and dsDNA, but not phospholipids, was significantly associated with a high IFNalpha score. Logistic regression analysis confirmed that renal disease, higher SDI scores, low complement levels, and presence of anti-RNA binding protein (RBP) autoantibodies were associated with a high IFNalpha score. CONCLUSION: Activation of the IFNalpha pathway defines a subgroup of SLE patients whose condition is characterized by increased disease severity, including renal disease, increased disease activity, reflected in complement activation, and autoreactivity to RBP.

Coordinate overexpression of interferon-alpha-induced genes in systemic lupus erythematosus.

OBJECTIVE: To study the contribution of interferon-alpha (IFNalpha) and IFNgamma to the IFN gene expression signature that has been observed in microarray screens of peripheral blood mononuclear cells (PBMCs) from patients with systemic lupus erythematosus (SLE). METHODS: Quantitative real-time polymerase chain reaction analysis of healthy control PBMCs was used to determine the relative induction of a panel of IFN-inducible genes (IFIGs) by IFNalpha and IFNgamma. PBMCs from 77 SLE patients were compared with those from 22 disease controls and 28 healthy donors for expression of IFIGs. RESULTS: Expression of IFNalpha-inducible genes was significantly higher in SLE PBMCs than in those from disease controls or healthy donors. The level of expression of all IFIGs in PBMCs from SLE patients with IFNalpha pathway activation correlated highly with the inherent responsiveness of those genes to IFNalpha, suggesting coordinate activation of that cytokine pathway. Expression of genes preferentially induced by IFNgamma was not significantly increased in SLE PBMCs compared with control PBMCs. IFNalpha-regulated gene-inducing activity was detected in some SLE plasma samples. CONCLUSION: The coordinate activation of IFNalpha-induced genes is a characteristic of PBMCs from many SLE patients, supporting the hypothesis that IFNalpha is the predominant stimulus for IFIG expression in lupus.