The complex polyploid genome architecture of sugarcane.

Sugarcane, the world's most harvested crop by tonnage, has shaped global history, trade and geopolitics, and is currently responsible for 80% of sugar production worldwide1. While traditional sugarcane breeding methods have effectively generated cultivars adapted to new environments and pathogens, sugar yield improvements have recently plateaued2. The cessation of yield gains may be due to limited genetic diversity within breeding populations, long breeding cycles and the complexity of its genome, the latter preventing breeders from taking advantage of the recent explosion of whole-genome sequencing that has benefited many other crops. Thus, modern sugarcane hybrids are the last remaining major crop without a reference-quality genome. Here we take a major step towards advancing sugarcane biotechnology by generating a polyploid reference genome for R570, a typical modern cultivar derived from interspecific hybridization between the domesticated species (Saccharum officinarum) and the wild species (Saccharum spontaneum). In contrast to the existing single haplotype ('monoploid') representation of R570, our 8.7 billion base assembly contains a complete representation of unique DNA sequences across the approximately 12 chromosome copies in this polyploid genome. Using this highly contiguous genome assembly, we filled a previously unsized gap within an R570 physical genetic map to describe the likely causal genes underlying the single-copy Bru1 brown rust resistance locus. This polyploid genome assembly with fine-grain descriptions of genome architecture and molecular targets for biotechnology will help accelerate molecular and transgenic breeding and adaptation of sugarcane to future environmental conditions.

Dermatological adverse effects of anti-glaucoma eye drops: a review.

Many patients are treated for glaucoma. Like other drugs, anti-glaucoma eye drops may induce dermatological adverse effects. We aim to review the dermatological adverse effects secondary to the active agents in anti-glaucoma eye drops through a literature review. In January 2020, we queried PubMed using the following MeSH terms: glaucoma/drug therapy or glaucoma, open angle/drug therapy cross-referenced with parasympathomimetics/adverse effects or adrenergic agonists/adverse effects or carbonic anhydrase inhibitors/adverse effects or prostaglandins F, synthetic/adverse effects or adrenergic beta antagonists/adverse effects or ophthalmic solutions/adverse effects. The initial search identified 1128 studies, of which 49 were excluded for being in a foreign language, 15 for not involving eye drops, 968 for not focusing on adverse dermatological effects, and 11 for insufficient documentation or redundancy. After adding 38 linked studies, we finally analyzed 123 studies. The ocular and periocular dermatological adverse effects of eye drops are contact dermatitis, hyperpigmentation, prostaglandin analog periorbitopathy, mucous membrane pemphigoid, eyelash depigmentation, skin hypertrichosis, and rare cases of melanoma and skin depigmentation. The reported distant dermatological adverse effects are psoriasis, excessive sweating, lichen planus, alopecia, toxic epidermal necrolysis, erythema multiforme, erythroderma, subacute cutaneous lupus erythematosus, nail pigmentation, and bullous pemphigoid. Most of the cutaneous adverse effects of anti-glaucoma eye drops are ocular and periocular and induced by prostaglandin analogs. Distant adverse effects are rare and sometimes questionable but should be kept in mind, especially mucous membrane pemphigoid, which could lead to blindness. The role of preservatives, such as benzalkonium chloride, should also be considered.

[Debriefing in pediatric emergency care]. / Debriefing in der Kindernotfallversorgung: Grundlage für die Verbesserung der Patientenversorgung.

Communication errors and system problems negatively impact teamwork and shared decision-making and can cause patient harm. However, regular debriefings after critical events positively impact teamwork and patient outcome in pediatric emergency care. Team reflection promotes learning, helps teams to improve and to minimize errors from being repeated in the future. Nevertheless, debriefings in daily practice have not yet become a standard quality marker. Reasons include lack of time, lack of experienced debriefers and lack of support from the key stakeholders. Debriefings can take place at different timepoints with variable duration as needed. Due to the global pandemic, virtual debriefings or hybrid events with a mix of virtual and in-person participation are not only currently relevant but may perhaps also be of future relevance. Debriefings should focus on collaborative learning and future-oriented improvements. Not only life-threatening events but also potentially critical situations such as routine intubations warrant debriefings. Debriefing scripts promote a structured approach and allow even inexperienced moderators to navigate all relevant aspects. In addition to areas of challenge, debriefings should also explore and reinforce positive performance to facilitate learning from success. Debriefers should discuss not only obvious observable accomplishments, but also motivations behind key behaviors. This strategy promotes needs-based learning and focuses on solutions. Helpful strategies include specific questioning techniques, genuine interest and a positive safety culture.

[Fatal interstitial lung disease and pneumocystis during dermatomyositis associated with anti-MDA5 antibodies]. / Dermatomyosite à anticorps anti-MDA-5 compliquée d'une pneumopathie interstitielle et d'une pneumocystose d'évolution fatale.

BACKGROUND: Dermatomyositis (DM) in an auto-immune inflammatory myopathy with skin lesions, and, occasionally, organ involvement. Herein, we report a case of DM during anti-MDA5 antibody therapy associated with interstitial lung disease (ILD) and pneumocystosis. PATIENTS AND METHODS: A 64-year-old woman was hospitalized for impairment of her general health and skin lesions. Dermatological examination revealed classic signs of DM associated with hyperkeratotic papules on the palm creases. This led us to suspect DM with anti-MDA5 antibodies, which was subsequently confirmed by immunologic tests. We also noted dysphonia, exertional dyspnea and proximal muscles weakness. Despite early corticosteroid therapy, combined later with azathioprine, the patient's dyspnoea worsened; one month later, sudden pulmonary decompensation resulted in her admission to intensive care. A chest scan showed evidence of ILD and infectious signs, and the bronchoalveolar lavage was positive for Pneumocystisjiroveci. Despite treatment of this opportunist infection with cotrimoxazole and intensified immunosuppression, the patient died in intensive care. DISCUSSION: Anti-MDA5 antibodies are associated with a specific clinical phenotype and a high degree of risk that should alert the dermatologist to the high likelihood of ILD having a poor prognosis. Associated clinical signs are erythematous, hyperkeratotic or ulcerated papules on the palm creases, as well as fingertip or periungual ulcerations or digital necrosis. This situation is associated with a high risk of pneumocystosis. However, no recommendations concerning prophylaxis are currently available.

[Epidermolysis bullosa acquisita with Brunsting-Perry type pemphigoid: Diagnostic and therapeutic difficulties]. / Épidermolyse bulleuse acquise à type de pemphigoïde de Brunsting-Perry : difficultés diagnostiques et thérapeutiques.

BACKGROUND: Epidermolysis bullosa acquisita (EBA) is a rare auto-immune blistering disease. We report a case of Brunsting-Perry pemphigoid diagnosed by immunoelectron microscopy (IEM). PATIENTS AND METHODS: A 46-year-old man presented very pruriginous vesicles on the face and neck present for 6 years and which were difficult to diagnose and treat. The appearance of atrophic scars and milium cycts evoked EBA, which was confirmed at IEM. Due to limited involvement of the face and the neck, we conclude on EBA of the Brunsting-Perry pemphigoid variant. Treatment with dapsone produced a favorable outcome. DISCUSSION: Diagnosis of EBA is often difficult. In a case review, Asfour et al. collated 60 cases of Brunsting-Perry pemphigoid. These patients had either anti-collagen VII or anti-BP180 and anti-BP230 antibodies. IEM showed cleavage either under the lamina densa or within the lamina lucida, suggesting that Brunsting-Perry pemphigoid is a subtype of EBA or bullous pemphigoid (BP), depending on the paraclinical elements, and localized to the head and neck. The majority of EBA-like cases required systemic therapy, whereas in the presence of BP antibodies, topical corticosteroids were effective. CONCLUSION: We report a case of EBA of the Brunsting-Perry pemphigoid type, diagnosed by IEM after 6 years of progression. We highlight the diagnostic and nosological difficulties of Brunsting-Perry pemphigoid. Classification of this dermatosis as a subtype of EBA or BP may enable effective adaptation of therapeutic management, which has not as yet been coded.

[Extra-nodal NK/T-cell lymphoma, nasal-type, revealed by cutaneous and ocular involvement]. / Atteintes cutanée et oculaire révélatrices d'un lymphome T/NK extra-nodal de type nasal.

BACKGROUND: Extra-nodal NK/T-cell lymphoma (ENKTL) is a form of highly malignant non-Hodgkin's lymphoma. There are two types: nasal forms primarily affecting the oropharyngeal sphere and so-called nasal-type extra-nasal forms in which primary skin involvement is the most common feature enabling diagnosis. Herein, we report a case of systemic nasal-type ENKTL (ENKTL-NT) that was diagnosed based on skin involvement associated with ocular involvement. PATIENTS AND METHODS: A 67-year-old female patient, without immunodepression, was admitted to the dermatology department for a worsening inflammatory scaly patch of skin on her right calf. Secondarily, further lesions appeared on her body as well as a generalized macropapular rash and sores. These were associated with fever spikes, as well as ophthalmoplegia and edema, preventing her from opening her right eyelid. Tests for infectious, autoimmune and inflammatory disorders were negative. A cerebro-orbital scan revealed infiltration and contrast enhancement of the right periocular fat without any mass effect or cerebral extension. A positron emission tomography (PET) scan revealed multiple hypermetabolic skin lesions. Histological analyses indicated dermal-hypodermal lymphomatous tumor proliferation, and immunohistochemical analyses revealed lymphocytes expressing NK-cell markers (strong CD56+ expression), cytotoxic markers (granzyme B and TIA-1), and the presence of Epstein Barr virus (EBV) in the tumor cells. The patient was diagnosed with systemic ENKTL-NT. Her condition deteriorated rapidly, with the onset of refractory macrophage activation syndrome leading to death due to multiple organ failure. DISCUSSION: Skin involvement in ENKTL is non-specific and uncommon, which can delay diagnosis. Treatment is based on polychemotherapy comprising L-asparaginase and possibly consolidation therapy with autologous or allogeneic hematopoietic stem cell transplantation. The prognosis of ENKTL-NT is poor due the more aggressive nature of the disease compared with the nasal forms, with frequent visceral involvement and macrophage activation syndrome. Skin involvement seems to be a poor prognostic factor. Although ocular involvement is documented, its association with skin involvement is rare and mainly secondary to nasal forms of ENKTL. This case of an extra-nasal form of ENKTL-NT with systemic involvement illustrates the difficulty of diagnosis and the poor prognosis of this type of lymphoma.

[Characteristics of chronic wounds in substance abuse: A retrospective study of 58 patients]. / Caractéristiques des plaies chroniques chez les toxicomanes : étude rétrospective de 58 patients.

BACKGROUND: Drug addiction causes chronic wounds (CW) responsible for severe complications. Very few studies are available on this topic. The aim of our study was to describe the demographic, clinical and etiological characteristics as well as the course of CW in drug addicts. PATIENTS AND METHODS: This was a retrospective and prospective multicenter study including all drug addicts with CW. RESULTS: We included 58 patients (17 prospectively), 84.5% of whom were male, of median age 43 years, presenting multiple CW as a result of intravenous (78.2%), inhaled (41.1%) and/or snorted (20%) drug abuse. Addiction to opioids (68.4%), cocaine (47.4%) and/or cannabis (40.4%) was ended and/or treated through substitution in 79.3% of patients. CW were fibrinous and necrotic (42.9 to 53.6%), recurrent (54.2%), and in some cases had been present for more than 1 year (61.5%). Intravenous drug addiction was associated with large, fibrinous, ulcers in a setting of venous and lymphatic insufficiency (74%). Only 23% of these wounds involved the upper limbs. Necrotic ulcers associated with clinical arteriopathy were described mainly with inhaled addiction. Abscesses (50%) and erysipelas (29.3%) were the most common cutaneous complications. After 3 months, 50% of CW were improved and 29.2% of patients were lost to follow-up. DISCUSSION: Drug abuse-related CW occurred preferentially in young men with history of intravenous abuse. For the most part, CW were seen on the legs and were associated with venous and lymphatic insufficiency, and the resulting major risk for cutaneous infection increased morbidity and mortality in this population in whom medical follow-up is inherently complicated.

Silver absorption and toxicity evaluation of silver wound dressings in 40 patients with chronic wounds.

BACKGROUND: Silver-containing dressings are considered to be safe even though there have been some reports of complications, including argyria and various organ system dysfunctions. Despite the widespread use of silver dressings, little research has been done regarding the absorption and toxicity of silver. OBJECTIVE: We aimed to study the systemic absorption of silver in patients with chronic inflammatory wounds and to determine associated factors of systemic silver absorption and evaluated its association with silver toxicity. PATIENTS AND METHOD: Prospective, longitudinal, observational, multicentre, open-label pilot study. Patients from the Dermatology Departments of Lorraine (France) with the following inclusion criteria: (i) a chronic wound of more than 6 weeks and (ii) an ulcer needing silver-containing dressing were included. Before and after 28 days of treatment, clinical characteristics of the wound were recorded; hemogram, hepatic and renal functions, albumin sera and serum silver level were measured. RESULTS: Half of the cases displayed raised levels of silver after 1 month of treatment. Predictive factors for systemic silver absorption were wound area, anaemia and malnutrition with anaemia and malnutrition confirmed on multivariate analysis. Wound vascularization may also play a role, as a higher absorption was observed in cases of wound granulation without arterial components. No toxicity was detected. This work has also emphasized the slow elimination of silver from the body. CONCLUSION: Both long-term application and iterative treatments with silver dressings should be discouraged, especially in the elderly, who often suffer from malnutrition and anaemia to avoid potential cumulative toxicity.

Trends in hospitalization rates for psoriasis flares since the introduction of biologics: a time series in France between 2005 and 2015.

BACKGROUND: In the late 2000s, the introduction of biologics transformed the prognosis for patients with moderate-to-severe psoriasis. We hypothesized that treatment with biologics may associate with a reduction in the hospitalization rate for psoriasis flares. OBJECTIVE: To analyse changes over time in the hospitalization rate for psoriasis flares. METHODS: We included inpatient stays in any of nine French hospitals between 2005 and 2015 for a psoriasis flare, as documented in the national inpatient database. In two centres, we also analysed data from the individual patients' electronic medical records. RESULTS: A total of 3572 stays were included. The introduction of biologics was not associated with a decrease in the number of hospitalizations for a psoriasis flare; on the contrary, we observed a non-significant increase in the number of hospitalizations (13 hospitalizations for psoriasis flares per quarter per 10 000 beds). In the two-centre study, the introduction of biologics was associated with a significant increase in the hospitalization of patients receiving topical treatments only (520 hospitalizations per year per 10 000 beds) and those with a first psoriasis flare. CONCLUSION: The number of hospitalizations for a psoriasis flare tended to increase between 2005 and 2015. The availability of additional treatment options might have increased patient demand and/or broadened the indications in clinical practice.

Distinctive cutaneous and systemic features associated with specific antimyositis antibodies in adults with dermatomyositis: a prospective multicentric study of 117 patients.

BACKGROUND: Identification of myositis-specific autoantibodies (MSAs) for dermatomyositis (DM) could allow the characterization of an antibody-associated clinical phenotype. OBJECTIVE: We sought to define the clinical phenotype of DM and the risk of cancer, interstitial lung disease (ILD) and calcinosis based on MSA. METHODS: A 3.5-year multicentre prospective study of adult DM patients was conducted to determine the clinical phenotype associated with MSAs and the presence of cancer, ILD and calcinosis. RESULTS: MSAs were detected in 47.1% of 117 included patients. Patients with antimelanoma differentiation-associated protein-5 antibodies (13.7%) had significantly more palmar violaceous macules/papules [odds ratio (OR) 9.9], mechanic's hands (OR 8), cutaneous necrosis (OR 3.2), articular involvement (OR 15.2) and a higher risk of ILD (OR 25.3). Patients with antitranscriptional intermediary factor-1 antibodies (11.1%), antinuclear matrix protein-2 antibodies (6.8%) and antiaminoacyl-transfer RNA synthetase (5.1%) had, respectively, significantly more poikiloderma (OR 5.9), calcinosis (OR 9.8) and articular involvement (OR 15.2). Cutaneous necrosis was the only clinical manifestation significantly associated with cancer (OR 3.1). CONCLUSION: Recognition of the adult DM phenotype associated with MSAs would allow more accurate appraisal of the risk of cancer, ILD and calcinosis.

[Rare presentations of infantile hemangiomas: 4 cases]. / Présentations rares d'hémangiomes infantiles : 4 cas.

BACKGROUND: Infantile hemangioma (IH) is a common benign vascular tumor in children. In most cases, diagnosis is based entirely on clinical examination. When the diagnosis is uncertain, the first-line complementary examination is Doppler ultrasound. We report 4 cases of atypical infantile hemangiomas with delayed diagnosis and non-contributory imaging. PATIENTS AND METHODS: One child had congenital purple papules and nodules on the back of the foot, the second had inaugural ulceration of the buttocks, and the last two presented telangiectasia, either isolated or on an erythematous macula. In two cases, ultrasound showed no vascular lesions, and in the other two cases, the absence of hyperemia did not allow a diagnosis of IH to be made. For one patient, diagnosis was made on the basis of cutaneous biopsy, and for the other three, on the basis of clinical course. DISCUSSION: We report 4 rare forms of infantile hemangioma resulting in initial diagnostic error. The atypical nature of some IHs may direct the clinician and the radiologist toward other diagnoses that in some cases have no vascular contingent. It is important for the dermatologist to be aware of these rare forms of IH in order to reduce the time to diagnosis and allow early initiation of appropriate management.

[Scalp burns induced by hair bleaching]. / Brûlure du cuir chevelu induite par les décolorations capillaires.

BACKGROUND: Hair bleaching is increasingly being carried out in hairdressing salons. The products used are a mixture of hydrogen peroxide and persulfates, both active chemical agents. Scalp burns secondary to hair bleaching are a traumatic adverse effect rarely discussed in publications that continue to be little known among healthcare professionals. PATIENTS AND METHODS: We report the case of a 15-year-old girl with a plaque of scarring alopecia on the vertex. This lesion resulted from a deep burn following a hair-bleaching procedure. Healing took around 4 months, resulting in discomfort for our patient. DISCUSSION: This is a rare case of scarring alopecia following a basic chemical burn to the scalp. The oxidation reaction induced by the mixture of hydrogen peroxide and persulfates, prepared in a basic medium, causes bleaching of the melanin pigments in hair. The clinical presentation of a single, well limited, painful, oozing ulceration located at the vertex was similar to the other cases published in the literature. Although a chemical burning mechanism is most often incriminated, the procedure is always coupled with use of a heat source and associated thermal burn may occur. The delayed appearance of the lesion appears to be caused by the forming of surfactants by the hydrogen peroxide/persulfate mixture, resulting in slow dissolution of the oxidizing compounds within the stratum corneum.

A foot tumour as late cutaneous Lyme borreliosis: a new entity?

Acrodermatitis chronica atrophicans (ACA) is the late cutaneous form of Lyme borreliosis. The early inflammatory phase manifests with a bluish-red discoloration and doughy swelling of the skin. The atrophic phase represents a late-phase process with red discoloration, and a thin and wrinkled appearance of the skin. We present a patient who exhibited a previously undescribed form of late cutaneous Lyme borreliosis (LCLB) with a foot tumour. A 64-year-old woman had a large tumorous lesion on the right sole. The tumour size and deformation of the feet made wearing shoes difficult. On skin histology, a granulomatous lymphohistiocytic infiltrate with plasma cells was noticed. In fact, the patient recalled tick bites 2 or 3 years before. Borrelia burgdorferi (Bb) serology was highly positive and a polymerase chain reaction analysis on the skin biopsy detected Bb sensu lato, genospecies B. afzelii. We diagnosed LCLB and antibiotics were prescribed. On the more recent examination, the tumour had totally disappeared; the skin was atrophic and dry with only few scales. We report an atypical case of European LCLB, suggesting that ACA is not the only possible presentation of LCLB. The diagnosis of ACA is often clinically missed for months or years, and may be mistaken at the inflammation phase for vascular disorders, erysipelas or bursitis/arthritis, and at the atrophic phase for lichen sclerosus atrophicus, morphoea or anetoderma. To our knowledge, no such tumorous LCLB has previously been described.

Factors associated with the choice of the first biologic in psoriasis: real-life analysis from the Psobioteq cohort.

BACKGROUND: Decision-making is a complex process. The aim of our study was to assess factors associated with the choice of the first biological treatment in patients with moderate-to-severe psoriasis. METHODS: Data on all patients included in the French prospective, observational, cohort, Psobioteq and initiating a first biologic prescription between July 2012 and July 2016 were analysed. Demographic information and clinical features were collected during routine clinical assessments by the dermatology team at the recruiting centres using a standardized case report form. The primary outcome was the nature of the first biologic treatment. Four groups were identified as follows: adalimumab, etanercept, ustekinumab and infliximab groups. Factors associated with the choice of the first biological agent were determined by a multinomial logistic regression model adjusted on year of inclusion. RESULTS: The study population included the 830 biological-naïve patients who initiated a first biological agent. The mean age was 46.6 years (±SD 13.9), and 318 patients (38.3%) were female. The most commonly prescribed biologic was adalimumab: 355 (42.8%) patients, then etanercept (n = 247, 29.8%), ustekinumab (n = 194, 23.4%) and infliximab (n = 34, 4.0%). In the multinomial logistic regression analysis, patients were significantly more likely to receive adalimumab if they had a severe psoriasis as defined by baseline PASI or if they had psoriatic arthritis compared to etanercept (aOR, 0.42; 95% CI, 0.16-1.07) and ustekinumab (aOR, 0.15; 95% CI, 0.04-0.52). Patients were significantly more likely to receive ustekinumab (aOR, 2.39; 95% CI, 1.04-5.50) if they had a positive screening for latent tuberculosis compared to adalimumab. Younger patients were also more likely to receive ustekinumab. Patients with chronic obstructive pulmonary disease were more likely to be prescribed ustekinumab or etanercept compared to adalimumab. There was a trend in favour of etanercept prescription in patients with cardiovascular comorbidities, metabolic syndrome and in patients with a history of cancer. CONCLUSION: We identified patient- and disease-related factors that have important influence on the choice of the first biological agent in clinical practice. Clinicians appear to have a holistic approach to patient characteristics when choosing a biological agent in psoriasis.

[Hypersensitivity to platinum salts and taxanes: The value of skin tests and tolerance induction procedures]. / Hypersensibilité aux sels de platine et aux taxanes : intérêt des tests cutanés et des inductions de tolérance.

AIM: The rate of hypersensitivity reactions to platinum salts (PS) and taxanes (TX) is on the increase. The aim of our study was to show the value of skin testing and efficacy of rapid drug desensitization. PATIENTS AND METHODS: This was a retrospective study conducted between January 2007 and February 2016 in patients consulting for immediate or delayed hypersensitivity to PS and TX. Skin prick tests (pT) and intradermal reaction tests (IDR) were performed according to the ENDA/EAACI recommendations. We used a 12-step desensitization protocol for rapid drug desensitization. RESULTS: Among the 99 patients included (30 men, 69 women, age 60.4) PS were suspected in 86 cases and taxanes in 13 cases. Skin tests were positive in 25 patients (7 pT, 18 IDR), 23 for platinum salts and 2 for taxanes. Rapid drug desensitization was proposed in 50 patients and performed in 33 (30 PS and 3 TX), proved effective in 29 patients, with protocol adaptation being necessary in 7 cases, and was ineffective in 4 patients. The skin tests for the latter 4 patients were positive. Seventy-five percent of patients with positive skin tests to oxaliplatin presented hypersensitivity reactions during desensitization, i.e. twice as many as patients having negative skin tests. Two percent of patient for PS and 7% for TX had cross reactivity. CONCLUSION: This French study confirms the efficacy of the 12-step protocol that allows patients to receive chemotherapy after hypersensitivity reaction. Skin test permits the detection of cross-reactions but their practice must be considered based on the patient's history.

[Erysipelas without fever or biologic inflammation during tocilizumab therapy]. / Érysipèle sans fièvre ni syndrome inflammatoire lors d'un traitement par tocilizumab.

BACKGROUND: Tocilizumab (TCZ) is a monoclonal antibody that inhibits the interleukin 6 (IL-6) signalling pathway. This treatment is extremely effective in rheumatoid arthritis (RA), which may well be accompanied by serious infections presenting misleading clinical pictures. Herein we report a case of a typical bacterial dermo-hypodermitis in a female patient treated with TCZ. PATIENTS AND METHODS: An 80-year-old woman treated with methotrexate (MTX) and TCZ for RA presented dermo-hypodermitis on her left leg 8 days after receiving her 13th infusion of TCZ. She exhibited neither fever nor biological inflammatory syndrome. Oral amoxicillin (3g/d) was initiated on an outpatient basis. Two weeks later, the patient was apyretic and her laboratory results were normal, although local inflammatory signs persisted. TCZ infusion was postponed and she was given intravenous amoxicillin (4g/d) for 2days, followed by oral amoxicillin, resulting in rapid recovery. Subsequent courses of TCZ were administered without incident. DISCUSSION: During the course of treatment with TCZ, this patient presented delineated bacterial cellulitis in the form of erysipelas, which was noteworthy on account of the absence of fever and of biological inflammatory syndrome. While there have been reports of severe cases of cellulitis during TCZ treatment, to our knowledge, there have been none of erysipelas. Attenuation of local and systemic inflammatory symptoms is widely reported, and is directly associated with the anti-IL-6 action of TCZ. Patients with RA are especially susceptible to opportunistic or severe infections as a result of the disease itself and of associated treatments, and increased vigilance is called for with regard to infections that may be transformed and potentially more severe as a result of TCZ.

[Vaccination status in psoriasis patients on immunosuppressant therapy (including biologics)]. / Couverture vaccinale avant et après instauration d'un traitement immunosuppresseur (y compris biothérapie) pour psoriasis.

OBJECTIVES: To evaluate the vaccine coverage of psoriasis patients prior to initiating or changing immunosuppressant therapy, and to verify that the prescribed vaccines have been administered. PATIENTS AND METHODS: We conducted a bi-centre, observational, cross-sectional study over 9 months. Psoriasis patients in whom immunosuppressant therapy (comprising cyclosporine, methotrexate, etanercept, infliximab, adalimumab or ustekinumab) was indicated were included. Medical history, previous treatments, vaccination status, viral serology results (for hepatitis B, measles, and chickenpox), and reasons for non-vaccination were assessed via questionnaire. RESULTS: Sixty-eight patients were included. One third brought their immunization records. Overall, 54.4% had already received immunosuppressant therapy; of these, 9 were up to date for influenza and 3 were up to date for pneumococcus. Only one patient was up to date for all of the recommended vaccinations. A total of 61% of patients were seronegative for hepatitis B. The following vaccines were updated: DTP (in 2 patients), DTP-pertussis (12), influenza (22), pneumococcus (45), and hepatitis B (6). None of the three patients with plans to travel to yellow fever-endemic countries had been vaccinated. In all, 53 (78%) stated that they had already had chickenpox and 43 (63.2%) stated that they had had one of the following three diseases: measles, rubella, or mumps. Fifty-two patients were serologically tested for chickenpox, and 98% were immunized. The most common reasons for not updating the immunization schedule were the absence of any notification or proposal by the patient's doctor and oversight. CONCLUSION: This study should help raise awareness among patients and health professionals concerning the new vaccination recommendations for a population particularly at risk of infection.

[Annular leukocytoclastic vasculitis: A particular form of small vessel vasculitis?]. / Vasculite leucocytoclasique annulaire : une forme particulière de vasculite des petits vaisseaux ?

BACKGROUND: Leukocytoclastic vasculitis is characterized by necrotizing inflammation around small blood vessels, composed mainly of neutrophils. Skin lesions in leukocytoclastic vasculitis are polymorphous, but a rare annular variant exists of which dermatologists must be aware. Herein we present a new case of this entity. PATIENTS AND METHODS: We report the case of a 74-year-old man who developed annular purpuric infiltrated lesions mainly on the lower limbs, with leukocytoclastic vasculitis being confirmed by histology. This annular leukocytoclastic vasculitis regressed spontaneously with no recurrence after 6 months. The aetiology was not established. DISCUSSION: Annular leukocytoclastic vasculitis is rare, and the mechanisms underlying annularity and peripheral spread as well as the aetiology remain unexplained. This form of vasculitis with unusual clinical features may constitute a new entity in the subclass of immune complex small vessel vasculitis within the Chapel Hill classification. While the aetiology and physiopathology of this vasculitis are unknown, despite the possibility of recurrence, skin involvement appears isolated and the condition carries a good prognosis.

[Extensive digital necrosis during dermatomyositis associated with MDA-5 antibodies]. / Nécroses digitales étendues au cours d'une dermatomyosite avec anticorps anti-MDA-5.

BACKGROUND: Dermatomyositis (DM) is an inflammatory disease associated with auto-antibodies in 50 to 70% of cases. A new antibody, anti MDA-5, has been described in association with a specific type of DM involving severe interstitial lung disease and minimal muscle disease. We report the first case of DM with MDA-5 antibodies and with interstitial lung disease and rapidly extensive digital necrosis. PATIENTS AND METHODS: A 28-year-old male was hospitalized for asthenia, myalgia and subacute dyspnea. Examination demonstrated skin lesions with edema on every digit associated with purpuric and cyanotic lesions, as well as erythematous papules on the helix and the elbows, and Gottron's papules. Systemic corticosteroid therapy was initiated. The immunoprecipitation results indicated the presence of anti-MDA-5 antibodies. Despite corticosteroid therapy, the patient's respiratory status gradually deteriorated towards pulmonary fibrosis and rapidly extensive necrosis appeared on all fingers and toes. Theses effects were resistant to cyclophosphamide and immunoglobulin but were stabilized by cyclosporine. DISCUSSION: Anti-MDA-5 antibodies are specific to DM and constitute a risk factor for severe interstitial lung disease (70% of cases) with a higher risk of mortality (40%). The cutaneous presentation of this DM is specific with palmar papules and mucocutaneous ulceration. Rapidly extensive digital necrosis has not been previously reported. No treatment has demonstrated superiority. CONCLUSION: We report the first case of DM with anti-MDA-5 antibodies involving interstitial lung disease and massive digital necrosis. Because of the pulmonary risk, in the presence of clinical lesions containing anti-MDA-5 DM, screening for these antibodies should be carried out.