A Breast Lump in an Elderly Lady - Carcinoma or else ?.

Breast tuberculosis (TB) is rare form of extra-pulmonary TB. It is most commonly seen in women of reproductive age group, especially in young, multiparous women who are breast feeding. In geriatric women, breast TB in some cases simulates with breast carcinoma due to common signs which include hard breast lump with nodular surface, ulceration, fixity to skin, discharging sinus, retraction of nipple, axillary lymphadenopathy etc. Hence, it is very difficult to differentiate breast TB from breast cancer, especially in elderly women on clinical ground only, and therefore, histopathological diagnosis is mandatory. Fine needle aspiration cytology is frequently inconclusive due to very small amount of tissue material, and open biopsy or lumpectomy followed by histopathological examination is necessary to confirm the diagnosis of breast TB. Six-month course of anti-tuberculous therapy - ATT (rifampicin, isoniazid, pyrazinamide and ethambutol) is adequate for complete resolution. Here, we report a case of breast TB in an elderly women presenting with left sided breast lump with ulceration of overlying skin and ipsilateral axillary lymphadenopathy. This case of tuberculous mastitis was suspected to be carcinoma due to presence of hard, tender, breast lump with irregular margin, nodular surface, ulceration, purulent discharge and ipsilateral axillary lymphadenopathy in absence of any constitutional symptoms of TB, and heterogenous, hypoechoic mass on USG, which was confirmed by histopathological examination of resected breast lump and responded fully to ATT.

SCORTEN: does it need modification?

BACKGROUND: Toxic epidermal necrolysis (TEN) is a drug induced acute life threatening condition with mortality ranging from about 15 to 60%. A 'severity of illness' score termed as SCORTEN has been developed to predict mortality in TEN cases at the time of admission. It is calculated by giving one point for each of predetermined seven variables, evaluated during first 24 hours of admission. Total score ranging from 1-7 predicts a probability of mortality from 0.03 to 0.90. AIM: A prospective study was conducted to analyze efficacy of 'SCORTEN' in TEN cases to predict mortality during their management. METHODS: All cases of TEN reporting for management to the hospital were assessed using 'SCORTEN' on day one and day five to predict probable mortality, this data was then compared with ultimate outcome. RESULTS: During the study period, we treated 10 cases of TEN, all induced by drugs, patient's age ranging from 03 to 70 years and body surface area (BSA) involvement from 10 to 95%. Three cases succumbed to death. These cases were analyzed with SCORTEN to predict probability of mortality at the time of admission and day five. We encountered some variations from the original study. It was observed that if patients are analyzed with SCORTEN on a daily/alternate day basis, it will serve as a better predictor of mortality. CONCLUSION: Body surface area (BSA) involvement and age probably need more weightage in calculations. Besides malignancy, tuberculosis and pre-existing diabetes also need to be included while predicting mortality.

Keloidal granuloma faciale with extrafacial lesions.

Granuloma faciale (GF) is a rare cutaneous disorder characterized by one to several soft, erythematous to livid papules, plaques or nodules, usually occurring on the face. Extrafacial lesions are uncommon. A 52-year-old lady with multiple asymptomatic, variously sized brownish-black colored, firm, sharply circumscribed plaques resembling keloids on both cheeks and extrafacial lesions on the right arm and the right breast is presented for its unusual keloidal appearance and typical histopathological findings. She failed to respond to oral dapsone 100 mg daily administered for 3 months. Local infiltration of triamcinolone combined with cryotherapy led to only partial flattening of the lesions. All the skin lesions were excised surgically followed by flap transfer grafting on both cheeks. The cosmetic outcome was highly satisfactory.

Effects of BCG Vaccination on Evolution of Leprosy.

BACKGROUND: BCG vaccine is considered to have immunoprophylactic potential in leprosy. However controversy exists about the extent of prophylaxis it provides. In view of this, a study was undertaken to see the evolution of disease in established cases of leprosy who were already vaccinated with BCG and to compare it with the cases of leprosy who were not vaccinated with BCG. METHODS: 114 newly diagnosed cases of leprosy were studied. Patients were divided into two groups-BCG vaccinated and non-vaccinated. Clinical diagnosis of leprosy was confirmed by bacteriological and histopathological studies in each case. All patients were given standard anti leprosy treatment and were evaluated monthly for a minimum period of one year. RESULTS: All the cases were males in the age group of 20 to 50 years. 25.4% of cases had received BCG vaccine and 74.6% were not vaccinated for the same. No significant difference was observed in the incidence of different types of leprosy in vaccinated and non-vaccinated groups. 25.9% cases in non-vaccinated group developed lepra reaction as compared to 13.8% in vaccinated group. The incidence of deformities and disabilities in vaccinated group was only 10.3% as against 18.8% in non-vaccinated group. The rate of bacillary clearance appeared faster in vaccinated group. CONCLUSIONS: Although there is no significant difference in the pattern of different types of leprosy in BCG vaccinated and non-vaccinated cases, there is reduction in the incidence of reactions as well as deformities and disabilities in BCG vaccinated cases as compared to non-vaccinated cases.

Immunodominant B-cell epitope in the Mce1A mammalian cell entry protein of Mycobacterium tuberculosis cross-reacting with glutathione S-transferase.

The TB1-5 76C monoclonal antibody raised against a synthetic 60-mer peptide in the N-terminal part of the Mce1A mammalian cell entry protein of Mycobacterium tuberculosis has previously been shown to react with a linear epitope in the KRRITPKD region, residues 131-138 in Mce1A, and to cross-react with Mce1F. Six additional monoclonal antibodies raised against the same peptide were also shown to cross-react with Mce1F. Four of them reacted with a linear epitope in the same area, indicating that this area is immunodominant but showed distinct differrences in fine specificity. Two monoclonal antibodies did not react with synthetic peptides from this region on the solid phase in enzyme-linked immunosorbent assay, indicating greater influence of conformation on reactivity. None of the monoclonal antibodies reacted with 14-mer synthetic peptides from the corresponding area in Mce2A, Mce3A, Mce4A, M. avium, M. smegmatis or M. leprae. The reaction pattern of the monoclonal antibodies was analysed in relation to our model of the Mce1A molecule (AK Das et al. Biochem Biophys Res Commun 2003;302:442-7). The epitope is located on the surface of Mce1A, at the distal beta-strand-loop region in the beta-domain supporting its potential role in promoting uptake of M. tuberculosis in host cells. Monoclonal antibody TB1-5 19C cross-reacted with glutathione S-transferase of Schistosoma japonicum containing a PKE triplet. Monoclonal antibody TB1-5 76C gave a major band at about 44 kDa in Western blotting of M. tuberculosis sonicate, whereas polyclonal rabbit anti-Mce1A peptide antibodies reacting with the extended TTPKNPTKRRITPKDVI area of Mce1A showed a distinct band above the 160 kDa molecular mass standard.

Diltiazem vs. nifedipine in chilblains: a clinical trial.

BACKGROUND: The treatment of chilblains remains unsatisfactory. Nifedipine in higher doses remains the mainstay of treatment. AIMS: To compare the efficacy of diltiazem with that of nifedipine, and to determine the efficacy of nifedipine in lower doses, 36 chilblains cases were studied. MATERIAL AND METHODS: Group A (12 patients) was treated with diltiazem 60 mg thrice daily, and Group B (24 patients) with 10 mg nifedipine thrice daily till complete relief and then maintained on a sustained release preparation of nifedipine 20 mg twice daily. RESULTS: Two patients in Group A showed complete relief in 7 days, and 3 patients in about 21 days, but in 7 cases there was little or no response. In group B, 21 cases showed 80-90% relief by the fourteenth day. CONCLUSIONS: We conclude that nifedipine remains the drug of choice in chilblains but can be used in a smaller dosage in the Indian population. Diltiazem is less effective in the conventional dose, which may be optimized.

Serum Zinc Levels in Cutaneous Disorders.

Serum zinc levels were studied in 75 patients of different cutaneous disorders and 24 healthy controls. It was found to be significantly lower in acne vulgaris (71.5 ± 21.5µgm/100ml), leprosy(85.9 ± 26.9µgm/100ml) and psoriasis (93.3 ± 25.9µgm/100ml) as compared to healthy controls (105.3 ± 30.1µgm/100ml). No significant correlation was found in other cutaneous disorders studied i.e. vitiligo and aphthous ulcers where serum zinc levels were found to be 97.3 ± 26.6 µgm/100ml and 105.2 ± 23.5 µgm/100ml respectively.

Clinical and bacteriological study of urethral discharge.

A clinics-bacteriological study of 52 patients with urethritis was carried out. All the patients were evaluated clinically and bacteriologically at the beginning and end of the treatment. Majority of the patients belonged to the age group 21-30 years (58%). Incidence of gonococcal urethritis was 65% and Non gonococcal Urethritis (NGU) 35%. The common organisms causing NGU were chlamydia (28%) ureaplasma (11%) and mycoplasma (11%). Neisseria gonorrhoea was resistant to penicillin in (38%), ciprolloxacin in 67, and to noriloxaein in 6% cases. High incidence of HIV positivity was found in gonorrhoea (21%).

Presence of M. leprae in tissues in slit skin smear negative multibacillary (MB) patients after WHO-MBR.

This study looked for M. leprae in the lymph node, nerve and skin of multibacillary (MB) leprosy patients who become slit skin smear negative after the completion of WHO-MBR. Twenty-five WHO-MBR-treated multibacillary leprosy patients were studied; borderline lepromatous (BL) leprosy (n = 11) and lepromatous (LL) leprosy (n = 14)). Fifteen patients had reaction (erythema nodosum leprosum 11, upgrading reaction 4) either at presentation or during therapy. All patients attained slit skin smear negativity after WHO-MBR (range 24-39 months. Sixteen (64%) patients with multibacillary leprosy showed fragmented bacilli in skin and nerve biopsy or lymph node aspirates after WHO-MBR. Lymph node aspirates alone revealed M. leprae in seven patients, followed by nerve in two and skin in one patient. Four cases showed M. leprae at all sites followed by nerve and skin or lymph node in one case each. A pretreatment bacteriological index (BI) of 4+ or more was significantly associated with the presence of M. leprae at the end of treatment. Also, significantly more lymph node aspirates contained M. leprae in comparison with nerve or skin biopsies. All seven cases in whom treatment was extended beyond 24 months showed M. leprae in tissues even after attaining slit smear negativity. In conclusion, M. leprae persist in tissues after 2 years of WHO-MBR and patients with an initial BI of 4+ or more need to be closely followed up after stopping MDT.

Palmoplantar lesions in leprosy.

Palms and soles are considered immune to leprosy. A study was carried out to assess the frequency of lesions over palms and soles and to correlate their occurrence with various parameters. Two hundred eighty leprosy patients were screened for lesions over palms and soles. Palmo-plantar lesions were observed in 10% of the patients screened. Slit-skin smears and biopsies were done from routine sites and palmo-plantar lesions. Histopathology and slit-skin smear confirmed the presence of disease. Eight were in type I reaction, and 50% of patients with type I reaction screened showed lesions over palms and/or soles. The reason for this is not known; probably inapparent lesions become apparent during reactions. Lesions of various morphology were observed. Silky hand was observed in one case.

Macular lesions in leprosy: a clinical, bacteriological and histopathological study.

Among 150 untreated patients of leprosy, 19 had only macular lesions; three were of the indeterminate type, and eight each were of the tuberculoid and the borderline types, according to the Indian Association of Leprologists (IAL, 1981) classification. The clinical, bacteriological, and histopathological parameters of these 19 patients were studied both before and after six months of WHO Multi Drug Therapy (MDT/1982). A single macule was present in seven (36.84%) patients. In twelve (63.16%), two or more were seen. In eighteen (94.74%), one or more peripheral nerves were enlarged. The size of the macules varied from 5 to 15 cm, and there were no changes seen even after treatment. In most (94.74%) of the patients, the macules were hypopigmented. The surfaces were rough and dry in seven (36.84%) but smooth in the other twelve (63.16%). The margins were well defined in the seven (36.84%) patients with single macules but ill defined in the other twelve (63.16%). After six months of antileprosy treatment, the single macules showed some resolution. Slit skin smear examination was negative in all cases before and after treatment. Clinico-histopathological correlations were seen in only six (31.58%) patients; the clinical diagnoses were indeterminate and tuberculoid leprosy in three (15.79%) patients each. In the indeterminate group, the clinico-histopathological correlation was 100%; it was 37.50% in the tuberculoid group. There were no correlations between the clinical and histopathological parameters in thirteen (68.42%) cases. After six months of treatment, the histopathology became nonspecific in all patients. The lepromin test was positive in six (31.58%) patients; four were of the tuberculoid group and one each from the indeterminate and borderline leprosy groups. Hence, although macular lesions can be seen throughout the leprosy spectrum, it is difficult to correlate their clinical, bacteriological and histopathological parameters.

Study of ethmoid sinus involvement in multibacillary leprosy.

The nasal mucosal involvement in lepromatous leprosy is well recognized. Currently interest has centred around the involvement of paranasal sinuses in leprosy. They act as a reservoir and constant source of reinfection to the nasal mucosa. In the present prospective study 25 untreated patients with multi-bacillary leprosy were included. Clinical examination, computed tomography (CT) scan of paranasal sinuses, ethmoid sinus endoscopy and biopsy were carried out in all patients, to investigate the involvement of the paranasal sinuses in leprosy. Ethmoid sinus involvement was noted in 20 patients on CT scan. Bilateral involvement was more common (65 per cent). Anterior ethmoids were more commonly affected (65 per cent). On ethmoid sinus endoscopy abnormal mucosa was noted in 17 patients (68 per cent). Ethmoid sinus biopsy was confirmative in 16 patients (64 per cent). Statistically significant correlation was found between CT findings, sinus endoscopy and sinus biopsy findings.

Atypical post-kala-azar dermal leishmaniasis resembling histoid leprosy.

An adult male with atypical lesions of post-kala-azar dermal leishmaniasis (PKDL) is described. He had extensive ulcerated noduloplaque lesions on his hands, feet and genitalia. He had been diagnosed and treated for leprosy in the past. He came from an area endemic for kala-azar and leprosy and had a previous history of kala-azar. There was an abundance of Leishman Donovan bodies in slitskin smears and in histopathology sections. There was a good therapeutic response to sodium stibogluconate. An ulcerative variant of PKDL has been described but is extremely rare. Extensive lesions with ulceration have not been described before to the best of our knowledge. The epidemiological significance of the case is discussed.

Concurrent leprosy and HIV infection: a report of three cases.

Three cases of concurrent infection with HIV and leprosy are reported. One had developed borderline lepromatous leprosy one year after identifying HIV infection, while the other two had indeterminate leprosy and both conditions were identified at the same time in these two patients. All three cases showed satisfactory response to standard antileprosy multidrug therapy.

A comparative study of liver function tests in patients of chronic liver disorders with and without cutaneous manifestations.

Forty six cases of chronic liver disorders with and without cutaneous manifestations were studied for abnormalities of liver function tests. 27 cases were associated with cutaneous manifestations and 19 cases without cutaneous manifestations. A higher serum bilirubin level was seen in all cases with cutaneous manifestations. Serum bilirubin was significantly high (P<0.05) in patients of chronic active hepatitis with cutaneous manifestations. Serum alkaline phosphatase and serum glutamic pyruvic transaminase (SGPT) levels were significantly high in chronic active hepatitis and alcoholic liver disease without cutaneous manifestations respectively.

Pattern of skin diseases among civil population and armed forces personnel at Pune.

The pattern of skin disorders among 11393 civil and 8123 defence service personnel who attended out-patient department (OPD) from January 1989 to December 1994 is presented. Infective dermatoses were more common in civil population (41.2%) as compared to defence service personnel (36.3%). Fungal infection was common in both groups (15.1% and 17.2%) whereas parasitic infestations and pyoderma were more common in civil population (12.8% and 6.1%) as compared to service personnel (7.8% and 3.6%). Among non-infective dermatoses eczemas were more common in civil population (17.3%) as compared to Armed Forces personnel (11.7%), whereas papulosquamous disorders, pigmentary disorders, acne and alopecia were more common in Armed Forces personnel (13.5%, 13.4% 8.7% and 6.2%) as compared to civil population (10.8%, 10.1%, 6.4% and 4.1%). The incidence of other skin disorders did not differ much between the two groups.

Herpes zoster in patients with HIV infection.

Five hundred twenty seven HIV seropositive male cases were observed for herpes zoster for a period of five years. Overall incidence of herpes zoster in HIV infection was found to be 11.8%. Herpes zoster was presenting symptom in 50% cases. It developed in first year of follow up in 38.8% cases, in second and third year of follow up in 4.8% cases each and in fourth year in 1.6% case. Majority of cases (89%) were in age group of 20 - 40 years. Thoracic dermatome (68%) was commonest to get involved followed by cervical (14.5%), trigeminal (9.7%) and lumbosacral (8%). Among other associations of HIV seropositive herpes zoster cases 24.2% cases had tuberculosis and 4.8% cases had hepatitis B virus infection. The skin lesions of herpes zoster in majority of cases were bullous, haemorrhagic and necrotic.