Exanthematous Eruption in a Patient With Known Chronic Graft-vs-Host Disease and Recent Measles Vaccination.

A man in his 40s with a history of allogeneic stem cell transplant for diffuse large B-cell lymphoma and Graft-vs-host disease (GVHD) presented with a generalized eruption 1 week after receiving a measles, mumps, and rubella vaccination. What is your diagnosis?

Red in the face: Approach to diagnosis of red rashes on the face.

BACKGROUND: A red rash on the face in an adult patient is a common presentation to general practice in Australia. Rashes on the face significantly affect quality of life because this is a cosmetically sensitive site. Ascertaining the correct diagnosis is therefore of utmost importance so that appropriate treatment can be initiated. OBJECTIVE: This article discusses the assessment of red rashes on the face in an adult patient. DISCUSSION: Diagnosing a red rash on the face requires assessment of symptomology, age of onset, rash morphology and 'clinical clues' that help delineate between differentials. Although the list of differential diagnoses is wide, many of the common diagnoses can be made clinically without the need for investigations. Investigations such as skin biopsy are useful if the diagnosis is unclear, if the rash is not responding to initial treatment and/or a referral to a dermatologist is being considered.

Reporte de caso de dengue clásico a predominio de sintomatología dermatológica en el marco de la epidemia en la provincia de Misiones 2023-2024 / Case of classic dengue with predominance of dermatologic symptoms in the 2023-2024 epidemic in the province of Misiones

Se presenta un caso femenino de dengue clásico (DC) en el marco de la epidemia 2023-2024 en la provincia de Misiones, con predominio de síntomas dermatológicos de exantemas máculo papulosos, habonosos y eritrodérmicos sobre los síntomas sindrómicos cardinales. Las lesiones presentan componente humoral y de extravasación, sin diátesis ni componentes purpúricos apreciables, presentando una rápida y efectiva evolución al eritema y la normalización con tratamiento antihistamínico y corticoide parenteral. De la misma manera se evalúan alteraciones analíticas hematológicas y hepáticas de gran magnitud, con escasa repercusión clínica, que se mensuran en función del riesgo relativo al dengue hemorrágico (DH) y el pronóstico de la paciente. (AU)

A female case of classic dengue (DC) is presented in the context of the 2023-2024 epidemic in the province of Misiones, with a predominance of dermatologic symptoms of maculopapular, hives, and erythrodermic rashes overlapping the cardinal syndromic symptoms. The lesions have a humoral and extravasation component, without any significant diathesis or purpuric components, showing rapid and effective progression to erythema and normalization with antihistamine and parenteral corticosteroid treatment. Similarly, hematologic and hepatic analytical alterations of great magnitude are evaluated, with little clinical impact, measured in terms of relative risk for hemorrhagic dengue (HD) and the prognosis of the patient. (AU)

A prospective observational study validating the CET score as a screening tool in suspected DRESS syndrome.

BACKGROUND: Drug reaction with eosinophilia and systemic symptoms (DRESS) is an idiosyncratic severe cutaneous adverse reaction that may be potentially life-threatening. Recently, a simple scoring system for the early screening of DRESS patients was derived by combining hsCRP levels, the eosinophil count, and the total body surface area (CET score). The objectives of this study were validating the CET score, and calculating its lead time advantage and cost-benefits compared to RegiSCAR scoring. METHODS: This is a prospective observational case-control study, where 110 consecutive patients diagnosed with drug-induced maculopapular exanthema (MPE) were recruited during the 18 months of the study period. Patients were classified as cases (DRESS) and controls (MPE) using RegiSCAR score cut-off 2 (possible DRESS). They were also simultaneously screened using the CET score, based on which patients were classified as positive or negative. They were subsequently followed up on Day 15 for a second comparison and assessment of lead time and at 3 and 6 weeks to evaluate clinical response. RESULTS: Seventy cases and 40 controls were recruited. At a cut-off of >2.12, the CET score had a sensitivity of 94.3%, a specificity of 60%, a positive predictive value (PPV) of 80.5%, and a negative predictive value (PPV) of 85.7%. The median delay in diagnosing DRESS using RegiSCAR was around 14.5 hours. There was a median cost benefit of 12.1 USD in favor of the CET score. CONCLUSIONS: The CET score had good diagnostic performance in screening DRESS patients with a lead time of 14.5 hours and fewer costs incurred.

Dermoscopy and reflectance confocal microscopy finding of different anatomic sites of Langerhans cell histiocytosis.

BACKGROUND: Recognizing Langerhans cell histiocytosis (LCH) might be a challenge due to its rarity. Reflectance confocal microscopy (RCM) and dermoscopy were emergent promising non-invasive technique as auxiliary tools in diagnosis of different skin conditions. However, the RCM and dermoscopic features of LCH had been less investigated. To reveal the common RCM and dermoscopic features of LCH. MATERIALS AND METHODS: Forty cases of LCH were retrospectively analyzed according to age, locations, clinical, RCM, and dermoscopic features from September 2016 to December 2022. To reveal the differences and common in clinical, RCM, and dermoscopic features that occur in different anatomic location. RESULTS: In the study, sites of predilection include the trunk 31/40 (77.5%), extremity 21/40 (52.5%), face 14/40 (35%), scalp 11/40 (27.5%), vulvar 4/40 (10%), and nail 2/40 (5%). All LCHs had the common RCM features. There were significant differences in clinical and dermoscopic features for age and lesion anatomic site. The common dermoscopic features for scalp, face, trunk, and extremity were the erythematous scaly rash, purplish-red globules or patches, scar-like streaks with ectatic vessels. While the features for nail LCH were purpuric striae, onycholysis and purulent scaly rash, and the erosive erythematous plaque and purulent scaly rash for vulvar LCH. The common RCM features of all LCH showed a focal highly reflective dense image in the surface keratin layer, epidermis architectural disarray, obscuration of dermo-epidermal junction, numerous polygonal, large, medium reflective, short dendrites cells in the epidermis, and dermis. All LCH involving the vulvar and nail did not manifest skin lesions. CONCLUSION: RCM and dermoscopy showed promising value for diagnosis and differentiation of LCH.

Amoxicillin Induced Fever, Rash, and Catatonia - A Case Study.

INTRODUCTION: Adverse drug reactions (ADR) are defined as any harmful or unpleasant events or injuries resulting from the use of any particular drug. Among those antibiotics that cause adverse reactions, amoxicillin is one of them. Catatonia and vasculitic rash are its rare adverse effects. CASE PRESENTATION: A 23-year-old postpartum female, with a history of taking empirical Amoxiclav (amoxicillin-clavulanic acid 625 mg) injection and oral tablets for episiotomy wound, presented with altered sensorium and fever followed by maculopapular rash. On examination, she had generalized rigidity with waxy flexibility that improved by lorazepam challenge and was diagnosed as catatonia. On evaluation, amoxicillin was found to be precipitating catatonia in this patient. CONCLUSION: Since the diagnosis of catatonia is often missed, any cases with clinical presentation of fever, rash, altered sensorium, and generalized rigidity should also be suspected for druginduced ADR and the precipitating factor should be searched for.

An 82-year-old man with new skin lesions after COVID-19 vaccination.

Background: During the height of the SARS CoV-2 (severe acutre respiratory syndrome coronavirus disease 2019 [COVID 19]) pandemic, there have been numerous case reports of cutaneous reactions shortly after COVID-19 vaccine administration. Most reported cases are local injection-site reactions, whereas persistent or delayed cutaneous reactions have not been as common. Methods: We present the case of an 82-year-old man with persistent rash after the second COVID-19 vaccination. Results: A specific diagnosis was confirmed after the third skin biopsy. Conclusion: Patients are frequently referred to an allergist for various cutaneous reactions that occurred after vaccination, concerned about a possible drug allergy. This case emphasizes the importance of keeping a broad differential diagnosis when encountering a persistent skin rash not resolved by oral antihistamines or steroids.

Approach to red, scaly eruptions in the older patient.

BACKGROUND: Older patients with a red scaly eruption often present first to a primary care practitioner. A thorough clinical assessment can help delineate between common causes and assist the clinician with the next steps in management. OBJECTIVE: This article discusses the assessment of acute- to subacute-onset erythematous and scaly plaques that are present on multiple body sites in a patient aged >65 years. DISCUSSION: The differential diagnosis of a red, scaly rash in an older patient includes atopic dermatitis, psoriasis, generalised drug eruption, tinea, scabies and non-bullous pemphigoid. Less common causes include subacute cutaneous lupus and mycosis fungoides. If the diagnosis is unclear after clinical assessment, a skin biopsy sent for histopathology, and/or direct immunofluorescence can be very useful. Management requires consideration of physical impairments, carer availability and cost.

Adult multisystem Langerhans cell histiocytosis with cutaneous involvement manifesting as extensive flexural erosions.

Langerhans cell histiocytosis is a great imitator of other diseases with an often-delayed diagnosis leading to a concerning delay in commencing treatment. We present the case of a male who was previously diagnosed with Hailey-Hailey disease, in whom several treatment options had failed, was referred to the dermatology team for evaluation of a 3-month atypical, extensive, painful and pruritic cutaneous flexural eruption. On systems review, he reported a 2-year history of polyuria and polydipsia. Repeat skin biopsy revealed a prominent histiocytic infiltrate on histopathology with corresponding positive expression of Langerin (CD207), S100, CyclinD1 and p-ERK on immunohistochemistry staining. An MRI of the brain demonstrated posterior pituitary enhancement. The clinical presentation, biopsy and investigations confirmed a diagnosis of a multisystem Langerhans cell histiocytosis, which resulted in longstanding patient morbidity. With considerable multidisciplinary teamwork, a gradual and sustained resolution of his lesions, pain, polyuria and polydipsia was achieved.

Cutaneous immune-related adverse events from immune checkpoint inhibitor therapy: Moving beyond "maculopapular rash".

Uncoupling toxicity from therapeutic effect lies at the foundation of the current state of the field of cutaneous immune-related adverse events to immune checkpoint inhibitor therapy. This will be achieved through understanding the drivers of toxicity, tumor response, and resistance via large, well-powered population-level studies, institutional cohort data, and cellular-level data. Increasing diagnostic specificity through the application of consensus disease definitions has the power to improve clinical care and each approach to research. Cutaneous immune-related adverse events are associated with increased survival, and their treatment must invoke the maintenance of a delicate balance between immunosuppression, anti-tumor effect of immune checkpoint inhibitor therapy, and quality of life. The multidisciplinary care of cancer patients with adverse events is critical to optimizing clinical and translational research outcomes and, as such, dermatologists are vital to moving the study of cutaneous adverse events forward.

Deadly drug rashes: Early recognition and multidisciplinary care.

Potentially deadly drug rashes include Stevens-Johnson syndrome/toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms, acute generalized exanthematous pustulosis, and drug-induced vasculitis. Differentiating them can be a challenge. Factors to consider include timing of rash to drug exposure, rash distribution and clinical appearance, and the presence of systemic features such as mucosal involvement, organ failure, or eosinophilia. Various scoring systems aid in the diagnosis, but skin biopsy is the gold standard. Prompt identification and withdrawal of the suspected offending agent are the crucial first steps in management.