The effects of the COVID-19 pandemic on the diagnosis and prognosis of melanoma 2 years after the pandemic in two Romanian counties.

Background: The COVID-19 pandemic disrupted the healthcare system and negatively affected the diagnosis and management of melanoma worldwide. The purpose of this study is to investigate the long-term effects of the COVID-19 pandemic on the diagnosis and prognosis of melanoma. Materials and methods: This retrospective cohort study included histopathologically confirmed melanoma cases from March 2019 to February 2023 in Cluj and Bihor counties. Data from the post-COVID-19 period (March 2021 to February 2023) were compared to the pre-COVID-19 period (March 2019 to February 2020) and the COVID-19 period (March 2020 to February 2021). Patient characteristics, monthly diagnostics, histological subtypes, and key histological features were analyzed using statistical tests. Results: The number of melanoma cases diagnosed annually decreased by 31.37 and 23.75% in the first and second post-pandemic years, respectively, compared to pre-pandemic numbers. Diagnostic rates also decreased by 14.9 and 5.4% in the first and second post-pandemic years, respectively, compared to the pandemic period. Prognostic factors worsened in the post-pandemic period, with higher Breslow index and mitotic rate, and increased ulceration and thick melanomas compared to the pre-pandemic period. Conclusion: The COVID-19 pandemic had a long-lasting impact on the diagnosis of melanoma in Romania, resulting in advanced stages and unfavorable prognostic factors. Larger global studies are needed to comprehensively understand the pandemic's long-term effects on the diagnosis of melanoma.

Laparoscopic Adrenalectomy: Tailoring Approaches for the Optimal Resection of Adrenal Tumors.

In this study, we investigated the outcomes of laparoscopic approaches for adrenal tumor resection in 67 patients from a single center with a median age of 51 (range 40-79). Predominantly comprising women, the majority of patients were overweight or obese. Adrenal tumors larger than 6 cm were mostly treated using the laparoscopic transperitoneal method (p < 0.001). Our results revealed that patients subjected to the retroperitoneal approach exhibited quicker recovery, as evidenced by faster resumption of oral intake and ambulation, along with reduced intraoperative blood loss and shorter hospitalization (p-value < 0.05). In contrast, patients subjected to the transperitoneal approach experienced minimal complications, though not statistically significant, despite the technique's intricacy and slower recovery. These findings emphasize the significance of tailoring the surgical approach to individual patient characteristics, with particular emphasis on the tumor size. The choice between the retroperitoneal and transperitoneal methods should be informed by patient-specific attributes to optimize surgical outcomes. This study underscores the need for a comprehensive evaluation of factors such as tumor characteristics and postoperative recovery when determining the most suitable laparoscopic approach for adrenal tumor resection. Ultimately, the pursuit of individualized treatment strategies will contribute to improved patient outcomes in adrenal tumor surgery.

Severe Acute Ischemia of Glans Penis after Achieving Treatment with Only Hyperbaric Oxygen Therapy: A Rare Case Report and Systematic Literature Review.

Acute ischemia of the glands is a severe complication after circumcision. We outline the challenging case of a seventeen-year-old boy with glandular ischemia (GI) that appeared shortly after circumcision. Methods: We present a case report and literature review related to glans ischemia, and the complications of circumcision are reviewed. We note that there are very few cases described in the literature. Our patient was successfully treated with hyperbaric oxygen therapy (HBOT) after four days of no positive effect after all medical and surgical treatments written in the literature: Subcutaneous enoxaparin, local application of a glyceryl trinitrate, continuous epidural perfusion, intravenous pentoxifylline, alprostadil, intraoperative drainage, and aspiration with saline solution and epinephrine. Clinical improvement was noted at the first session of HBOT. A number of days after the operation, the penis looked normal and was healing. Complete healing of the penile glans was successfully realized one month after surgery. Conclusion: Based on the review and the case presented, we conclude that HBOT is the treatment of choice for acute ischemia of the penile glans, especially when other treatments do not work.

The Many Roles of Dermoscopy in Melanoma Detection.

Dermoscopy is a non-invasive method of examination that aids the clinician in many ways, especially in early skin cancer detection. Melanoma is one of the most aggressive forms of skin cancer that can affect individuals of any age, having an increasing incidence worldwide. The gold standard for melanoma diagnosis is histopathological examination, but dermoscopy is also very important for its detection. To highlight the many roles of dermoscopy, we analyzed 200 melanocytic lesions. The main objective of this study was to detect through dermoscopy hints of melanomagenesis in the studied lot. The most suspicious were 10 lesions which proved to be melanomas confirmed through histopathology. The second objective of this study was to establish if dermoscopy can aid in estimating the Breslow index (tumoral thickness) of the melanomas and to compare the results to the histopathological examination. We found that the tumoral thickness may be estimated through dermoscopy, but the histopathological examination is superior. To conclude, the aim of this study was to showcase the versatility and many roles of dermoscopy, besides being one of the most important tools for early melanoma diagnosis.

Impact of the COVID-19 Pandemic on Melanoma Diagnosis in Romania-Data from Two University Centers.

The COVID-19 pandemic affected the healthcare system in our country and led non-COVID patients to postpone medical visits that were not urgent. The purpose of this study was to investigate the impact of the first year of the COVID-19 pandemic on the trends in melanoma diagnosis and to compare the pathological characteristics of melanoma patients before and during the pandemic. The number of primary cutaneous melanomas diagnosed each month between 1 March 2019 and 29 February 2020 (pre-COVID-19) and between 1 March 2020 and 28 February 2021 (COVID-19) in the North-Western Region of Romania (Cluj and Bihor counties) was determined. The pathological characteristics of melanomas diagnosed in the two intervals were compared. The number of melanoma diagnoses substantially decreased during the pandemic, with 66 (-19.3%) fewer cutaneous melanomas being diagnosed in the first year of the pandemic when compared with the previous year. The tumor thickness and mitotic rate were significantly higher in cases found during the COVID-19 pandemic. Our study suggests that COVID-19 has delayed diagnosis in patients with melanoma, leading to the detection of thicker melanomas that may increase morbidity and mortality. Further studies are needed to determine the consequences of this delay on outcomes.

A prospective study on hyperhomocysteinemia as an aggravating factor in chronic venous insufficiency.

The role of hyperhomocysteinemia (HH) in the etiopathogenetics of systemic thrombotic events has been confirmed by numerous studies. However, it has been insufficiently studied as an etiopathogenic factor in chronic venous insufficiency (CVI). The present prospective study included 166 patients with CVI at stages C3-C6. Homocysteine levels and the inflammatory, metabolic and procoagulant profiles of the patients were determined. High-performance liquid chromatography was used to determine the homocysteine level. Within the patients with HH, the thromboembolic risk was analyzed. Smoking was determined to represent the most common procoagulant factor (21.67%), whereas in the subgroup of women, abortions represented a procoagulant factor for 31.93%. The metabolic profile was altered in approximately half of all cases (42.77%), whereas proinflammatory status was a contributing factor in 23.50% of the cases. HH was present in 54.22% of the CVI patients, mainly in the moderate HH category (53.01%), mostly linked to venous ulcers, thrombophlebitis and pulmonary thromboembolisms. The highest average values of homocysteine were recorded in patients >75 years old and when the venous disease age was >20 years (15.03 µmol/l). In summary, in the present study, HH was a contributing factor of CVI alongside the chronic inflammation that is well known in CVI, which increased thrombogenic risk, especially in elderly patients with an advanced age of venous disease.

Ophthalmic herpes zoster with severe complications in an immunocompromised patient: A case report and review of the literature.

The increasing incidence for herpes zoster, including its ophthalmic form, is based on physiological (senescence) and acquired immunosuppression, particularly under oncologic treatment. The immunocompromised status of the patient favors the appearance of severe complications. The patient, aged 54, with chronic lymphocytic leukemia, presented 1 week from the onset with an erythematous, vesicular-bullous rash on the right trigeminal nerve's ophthalmic dermatome, marked edema, intense pain and large submandibular ganglion masses. There were cutaneous (necrotic ulcerations superinfected with methicillin-resistant Staphylococcus aureus), ocular (keratoconjunctivitis, total ophthalmoplegia, lagophthalmia, anterior hemorrhagic uveitis with hyphema and right eye blindness) and neurological (postherpetic neuralgia) complications. Systemic therapy was performed with acyclovir, antibiotics, supportive, rebalancing and symptomatics. With regards to treatment for skin ulcers, disinfection and necrectomy were performed, and epithelialization agents were subsequently administrated. At the ocular level, the ophthalmologist carefully monitored the patient and administered antivirals, antibiotics, epithelialization agents and autologous serum. The evolution of the case recorded severe, disabling complications, with extensive eyelid necrosis and definitive blindness. In this case, the severity of the ophthalmic herpes zoster (OHZ) was favored by the synergistic action of four factors: Acquired immunosuppression (chronic lymphocytic leukemia), delayed consultation, superinfectious lesions and patient non-compliance regarding the chronic lymphocytic leukemia treatment.

Cutaneous manifestations associated with anosmia, ageusia and enteritis in SARS-CoV-2 infection - A possible pattern? Observational study and review of the literature.

BACKGROUND: The cutaneous manifestations of coronavirus disease 2019 (COVID-19) have been covered insufficiently in the literature. METHODS: Thirty-nine patients admitted to the study hospital with confirmed COVID-19 who experienced various skin manifestations during hospitalization or in the convalescence period, were analysed retrospectively. RESULTS: Thirty-nine patients with COVID-19, admitted to the study hospital between 23 March and 12 September 2020, had intra-infectious rash or lesions of cutaneous vasculitis during convalescence. The most common cutaneous manifestations of COVID-19 were erythematous and erythematous papular rash. Twenty-seven of the 39 patients had anosmia (69.2%), 26 patients had ageusia (66.7%), 34 patients had pneumonia (87.2%) and 24 patients had intra-infectious enterocolitis (61.5%). Skin biopsies were rarely performed in these patients. This article reports the results of biopsies performed in two patients, showing histopathological and immunohistochemical changes in erythematous rash and erythema multiforme-like lesions. Both skin biopsies revealed early fibrous remodelling of the dermis, suggesting similarity with changes that occur in the lungs and other tissues in patients with COVID-19. CONCLUSIONS: Correlations between skin lesions and anosmia, ageusia and enteritis in patients with COVID-19 do not seem to be accidental, but are associated with a similar response to ACE2 receptor expression in these tissues.

Hydroxyurea-induced superinfected ulcerations: Two case reports and review of the literature.

The chronic use of hydroxyurea (HU) in some oncologic and non-oncologic diseases (psoriasis, sickle cell anemia) can be accompanied by side effects, both systemic and mucocutaneous. The most severe adverse events known in HU therapy are leg ulcers and cutaneous carcinomas. At skin level may also appear: xerosis, persistent pruritus, skin color changes (erythema, hyperpigmentation), cutaneous atrophy. Likewise, oral ulcerations and stomatitis may occur at mucosal level. Hair damage can be expressed through alopecia and nail damage through melanonychia and oncycholysis. First case, a 63-year-old woman with severe psoriasis vulgaris and chronic granulocytic leukemia, with 5 years of HU therapy, was admitted to hospital for submammary and palmoplantar ulcers, superinfected with methicillin-resistant Staphylococcus aureus and Proteus mirabilis. Clinical exam showed that the patient had also cutaneous atrophy, marked palmoplantar xerosis and melanonychia. The second case, a 72-year-old woman with primary thrombocytemia, treated with HU for 3 years, presented with necrotic leg ulcers that were superinfected with Pseudomonas aeruginosa, Enterobacter and E. Coli. The patient associates cellulitis, microbial eczema and xeroderma. In both cases, after HU discontinuation, systemic antibiotics, topical epithelizing agents and emollients, the ulcers had a slow favorable evolution. In our cases, the ulcers appeared after 5, respectively 3 years of HU therapy. It is stressed that in the first case, which had associated psoriasis, after 1 year of 1 g of HU/day, the psoriatic lesions completely disappeared. The severe progression of the ulcers was also favored by the superinfection of the ulcers with 2, respectively, 3 identified germs for which appropriate systemic antibiotics was required.

A 10-year retrospective study of melanoma stage at diagnosis in the academic emergency hospital of Sibiu county.

Melanoma is considered to be the most aggressive skin cancer, with an increasing incidence worldwide. An accurate staging of melanoma is crucial in describing the cancer status, estimating prognosis and deciding the optimal treatment solution. In the present study, melanoma staging highlights the importance of early detection, most of the patients having been diagnosed with advanced stages of this skin cancer. A retrospective study was conducted among 117 patients of the Academic Emergency County Hospital of Sibiu, diagnosed with melanoma between 2007 and 2016. The staging of the patients with melanoma was made using the American Joint Committee on Cancer (AJCC) 7th edition, and reconsidered in the light of the AJCC 8th edition. The results showed that the majority of the cases had distant metastases, 40.17% were diagnosed with stage IV melanoma. 25.65% of the patients were diagnosed with stage III melanoma, having a regional disease. The rest of the cases had localized melanoma (stages I and II, 30.76%), while only 3.42% of them were diagnosed with melanoma in situ, the melanoma type with the greatest chances of survival. Analyzing the Breslow index, it was observed that the most common tumor thickness was 2.1 to 4 mm (34.19%). In conclusion, as the incidence of melanoma increases in Romania, further efforts are needed to improve the early detection of melanoma. There are hopes that with the correct and early diagnosis of melanoma, the mortality rate of this neoplasm will decrease in the future.

A Case of Generalized, Superinfected Dermatitis and Inguinal Mycobacterium Lymphadenitis - TB or not TB?

Dear Editor, Eczema is an inflammatory dermatitis mediated by cellular immunity, with an etiology in which environmental, immunological, and genetic factors are involved. Skin inflammation through proinflammatory cytokines creates a favorable environment for microbial antigens and optimal conditions for infection (1). In case of underlying immunosuppression, inflammatory features of dermatitis and superimposed infections are more severe. The presence of minor trauma of the skin in the form of fissures can favor both easier inoculation of some bacterial germs, leading to a dermatitis superinfection, and/or the transcutaneous inoculation of atypical mycobacteria, with a possibility of developing localized types of tuberculous lymphadenitis (TLA). TLA, the localized type of systemic tuberculosis (TB) infection, is the most common form of extra-pulmonary TB in developing countries (2), while lymphadenitis due to atypical mycobacteria is a localized disease, more frequently seen in developed countries (3,4). In tuberculosis, the transmission of Mycobacterium tuberculosis is airborne, while in atypical mycobacterium lymphadenitis transmission can be both airborne or by ingestion or inoculation (5). In both forms of TB, lymphadenopathy evolves towards abscess and presents fibrotic scars or calcifications upon healing (6). A positive diagnosis involves a clinical and epidemiological investigation, a purified protein derivative (PPD) skin test, ultrasound, and CT / MRI of lymph node masses. A lymph node biopsy is used to confirm the diagnosis of TB and PCR, while positive culture confirms the etiology of TB lymphadenitis. The differential diagnosis of TLA is difficult: neoplastic, bacterial, or viral and fungal infections, sarcoidosis, Castleman's disease, drug reactions, etc. (5). TB-induced immunosuppression may favor the development of fungal and bacterial infections, sometimes severe and poorly responsive to treatment. On the other hand, immunosuppressive conditions increase the risk of extra-pulmonary TB (2). A 40-year old woman who had experienced recurrent episodes of dermatitis over the previous 7 years was hospitalized with fever, malaise, and a disseminated erythematous and crusted, exudative, and flexural itching rash (Figure 1). There were fetid, purulent secretions at the conjunctival, auricular, genital, and umbilical areas. The clinical exam also revealed lymphadenopathy syndrome (large, painful submandibular, cervical, and axillar bilateral lymph nodes; an indurated, painful, and adherent left inguinal lymph node of 5-6 cm). Microbial cultures isolated multiple multi-drug-resistant bacteria (SAH-MRSA, Acinetobacter baumannii, Enterococcus faecalis, E. coli, Enterobacter) and Candida albicans in the oral cavity and conjunctival, auricular, nasal, umbilical, and genital areas. The skin biopsy confirmed the diagnosis of dermatitis. PPD skin test was 21 mm. Other tests (HIV and syphilis serology, blood culture, chest X-ray) were negative. Systemic treatment with vancomycin, metronidazole, fluconazole, local antiseptic compresses, and topical corticosteroid ointments was initiated. 2 days after starting the treatment with vancomycin, Redman syndrome occurred (headache, dyspnea, colicky pains, myalgia, rush, fever (39 °C), hypotension (80/40 mmHg), and tachycardia (100 bpm)). This syndrome resolved upon discontinuation of Vancomycin. Further treatment with imipenem/cilastatinand linezolid for 14 days lead to a favorable response with amelioration of the symptoms. Biopsy of the submandibular lymph node raised the suspicion of Castleman's disease; however, due to the overall incomplete clinical picture (no night sweats, no weight reduction, lack of hepatosplenomegaly and peripheral neuropathy), we decided to perform a biopsy of an inguinal lymph node. The histopathological aspect suggested TLA (lymphoid hyperplasia predominantly diffuse, reactive, presenting tuberculous follicles with central caseous necrosis) (Figure 2). A combination of specific antituberculous drugs (isoniazid, rifampicin, pyrazinamide, and ethambutol) for 6 months resolved the lymphadenopathy syndrome with no further recurrence of eczema and skin infections. Certain delayed hypersensitivity mechanisms are involved both in dermatitis and in TB. CD4 lymphocytes are the primary mediators of anti-TB immunity, while proinflammatory cytokines mediate the activation of macrophages involved in controlling bacillary growth (1). In cases of superinfected dermatitis, microbial exotoxins penetrate the skin barrier more easily due to inflammation. Released cytokines (IL-1, TNF, and IL12) favor the expression of E-selectin on endothelial vascular growth factor and on skin lymphocyte antigen expression, with amplification of initial skin inflammation and creating favorable conditions for microbial colonization and infection (7). The common denominator in dermatitis and TB are the circulating immune complexes (up to 56% of TB cases), which are formed by the interaction between an antibody and bacterial antigen (8), which was in this case evidenced by increased levels of IgA and IgG. In our case, the frequent recurrences of infected dermatitis with multiple multi-drug-resistant germs that were poorly responsive to treatment and displayed a severe evolution towards generalization as well as the lymphadenopathy and the persistence of a biological inflammatory syndrome indicated that another immunosuppressive cause could be involved. Isolated bacterial and fungal germs changed the immune status of the patient. The risk of mycobacterium infection was increased by the environment they created and the patient's underlying skin inflammation. The diagnosis of TB lymphadenitis was established by the histopathologist, but in the absence of PCR we could not determine whether the TB infection was caused by Mycobacterium tuberculosis or by atypical mycobacteria. Given that there was no evidence of other sites of TB infection, we conjectured that inoculation of mycobacterium took place at the skin lesion and that an atypical mycobacterium might have contributed to the etiology of the TLA. In our case, the anti-tuberculous drugs and skin infection treatment with follow-up of the side-effects led to complete remission of mycobacterium lymphadenitis, dermatitis, and infectious processes, without relapses. In conclusion, in the present case chronic dermatitis alongside infection with multi-drug-resistant germs led to an immunosuppressive status which, when associated with the presence of multiple skin ports of entry, allowed a mycobacterial infection at the inguinal lymph node level. Inguinal TLA induced severe dermatitis and difficulties in diagnosis and treatment.

A rare case of multiple clear cell acanthoma with a relatively rapid development of the lower legs.

Clear cell acanthoma, firstly described by Degos as "an epidermal tumor with a particular aspect", although quite a rare lesion, raised an important interest because it may be easily confused with other dermatologic lesions, in the absence of a histopathological examination. Its clinical aspect is of a solitary nodule, with a red-brown varying color, with a size of 3 mm to 2 mm, sometimes covered with a thin scall. We present a case of a multiple rare cell acanthoma (seven nodular formations), having a rapid development (about two months) diagnosed in a 71-year-old patient within the lower 1/3 of the right shin.