Mucocutaneous manifestations of COVID-19-associated mucormycosis: A retrospective cross-sectional study.

Background Cutaneous mucormycosis has shown a significant upsurge during the COVID-19 pandemic. Due to the rapid progression and high mortality of cutaneous mucormycosis in this context, it is important to identify it early. However, very few studies report detailed clinical descriptions of cutaneous mucormycosis in COVID-19 patients. Objectives To describe mucocutaneous lesions of COVID-19-associated mucormycosis based on clinical morphology and attempt to correlate them with radiological changes. Methods A retrospective cross-sectional study was conducted at a tertiary care centre from 1st April to 31st July 2021. Eligibility criteria included hospitalised adult patients of COVID-19-associated mucormycosis with mucocutaneous lesions. Results All subjects were recently recovering COVID-19 patients diagnosed with cutaneous mucormycosis. One of fifty-three (2%) patients had primary cutaneous mucormycosis, and all of the rest had secondary cutaneous mucormycosis. Secondary cutaneous mucormycosis lesions presented as cutaneous-abscess in 25/52 (48%), nodulo-pustular lesions in 1/52 (2%), necrotic eschar in 1/52 (2%) and ulcero-necrotic in 1/52 (2%). Mucosal lesions were of three broad sub-types: ulcero-necrotic in 1/52 (2%), pustular in 2/52 (4%) and plaques in 1/52 (2%). Twenty out of fifty-two patients (38%) presented with simultaneous mucosal and cutaneous lesions belonging to the above categories. Magnetic resonance imaging of the face showed variable features of cutaneous and subcutaneous tissue involvement, viz. peripherally enhancing collection in the abscess group, "dot in circle sign" and heterogeneous contrast enhancement in the nodulo-pustular group; and fat stranding with infiltration of subcutaneous tissue in cases with necrotic eschar and ulcero-necrotic lesions. Limitations The morphological variety of cutaneous mucormycosis patients in a single-centre study like ours might not be very precise. Thus, there is a need to conduct multi-centric prospective studies with larger sample sizes in the future to substantiate our morphological and radiological findings. Conclusions COVID-19-associated mucormycosis patients in our study presented with a few specific types of mucocutaneous manifestations, with distinct magnetic resonance imaging findings. If corroborated by larger studies, these observations would be helpful in the early diagnosis of this serious illness.

A real-world study of low-dose thalidomide in severe erythema nodosum leprosum highlighting its mechanistic rationale in a resource-constrained target population.

BACKGROUND: Corticosteroids remain the main therapy in erythema nodosum leprosum (ENL), and long-term usage in chronic or recurrent ENL is a cause of significant morbidity and mortality. Thalidomide exerts dramatic effect in controlling ENL and helps reduce the dose of steroids, but the cost is a hindrance to its usage. METHODS: Patients of ENL (steroid naïve and steroid-dependent) were recruited over a 1-year period. An escalating dose of low-dose thalidomide with a reducing dose of prednisolone was titrated depending on the control of disease activity. The primary aim was to reduce the dose of steroids to the lowest effective dose, and the secondary aim was to stop. RESULTS: Sixteen patients of ENL were studied (mean duration of ENL 22.1 months, 15 severe ENL), and a majority (11/16, 68%) were on steroids with a mean duration of 11.27 months. All patients had steroid-related side effects (cushingoid habitus 81.8%, weight gain 54.5%, diabetes mellitus 9%, hyperlipidemia 18.18%, cataract 18.1%, osteoporosis 36.3%, striae 36.3%, acneiform eruptions 18.1%, and myopathy 9%). Steroids could be tapered in a majority of patients (n = 9) within 3 months (mean 2.44 months) with a low dose of thalidomide (25-150 mg/day, mean 78.3 mg) achieving a significant reduction in prednisolone dose (33.16 mg at baseline; 4.28 mg at 3 months, P < 0.05). Steroids could be stopped in 92% of patients by 3.03 months, and both drugs could be stopped in 80% of cases by 5.83 months. CONCLUSION: The rapid and effective control of ENL with low-dose thalidomide in our series is comparable to the historical efficacy of high-dose thalidomide regimens, making it an affordable therapy in resource-constrained settings and an excellent steroid-sparing agent. The rapid onset of disease control is likely attributable to its action via neutrophils.

Lucio phenomenon with concomitant necrotizing fasciitis and acute kidney injury.

Lucio phenomenon is a rare vasculopathy that can occur in patients with Hansen disease, particularly diffuse lepromatous leprosy. It is characterized by retiform purpura and necrotic ulcerations, most commonly affecting the extremities. Diagnosing Lucio phenomenon can be challenging, especially when secondary bacterial infections occur. We report a patient with Lucio phenomenon who presented with acute necrotizing fasciitis of his left upper extremity and a 10-year history of chronic ulcerations. Shortly following admission, he also developed acute kidney injury. The necrotizing fasciitis was treated with prompt surgical debridement and intravenous antibiotics. Biopsy and PCR of a right upper extremity ulcer confirmed the presence of Mycobacterium lepromatosis. Multidrug therapy and prednisone were used to treat the Lucio phenomenon. After initiating treatment, no new lesions developed, kidney function improved, and the patient underwent successful skin graft of his left upper extremity. Although corticosteroid use is controversial, our patient's marked response to multidrug therapy with prednisone highlights the importance of this regimen in severe presentations of Lucio phenomenon. To the best of our knowledge, only two other cases of Lucio phenomenon confirmed to be caused by M. lepromatosis have been reported in living patients (rather than retrospectively identified post-mortem), underscoring the importance of the presented clinical course and treatment regimen.

18F-fluorodeoxyglucose positron emission tomography-based evaluation of systemic and vascular inflammation and assessment of the effect of systemic treatment on inflammation in patients with moderate-to-severe psoriasis: A randomized placebo-controlled pilot study.

BACKGROUND: Psoriasis is a systemic inflammatory disorder associated with an increased risk of cardiovascular disease. OBJECTIVE: To evaluate the utility of [[18]F]-fluorodeoxyglucose positron emission tomography/computed tomography in identifying vascular and systemic inflammation in psoriasis patients with moderate-to-severe disease and to analyze its usefulness in assessing the effect of systemic treatment. METHODS: This was a randomized, double-blind pilot study conducted in a tertiary care center. Baseline standardized uptake value score was estimated by18F-fluorodeoxyglucose positron emission tomography/computed tomography in patients with moderate-to-severe psoriasis and compared with historical controls. Patients were then randomized using computer-generated randomization list into methotrexate or placebo (with or without pioglitazone) groups.18F-fluorodeoxyglucose positron emission tomography/computed tomography was repeated at 12 weeks and composite standardized uptake value score determined. The correlation between Psoriasis Activity and Severity Index and SUVmax was assessed. RESULTS: A total of 16 patients were randomized to different treatment groups. Significant increase in mean SUVmax was observed in the ascending aorta in psoriasis patients as compared to historical controls (2.03 ± 0.53 vs 1.51 ± 0.36, P < 0.03). There was no difference in composite standardized uptake value score after 12 weeks of treatment in any of the treatment groups (P = 0.82), although an improvement in Psoriasis Activity and Severity Index score in the methotrexate arm was observed. No correlation was found between mean SUVmax and Psoriasis Activity and Severity Index scores in various aortic segments (r = 0.3-0.7). LIMITATIONS: Small sample size, short follow-up, historical controls, exclusion of patients with comorbid conditions and lack of surrogate markers of systemic inflammation. CONCLUSION: 18F-fluorodeoxyglucose positron emission tomography imaging showed higher vascular inflammation in ascending aorta of psoriasis patients as compared to historical controls. Systemic treatment with methotrexate and pioglitazone did not influence the vascular inflammation in the short term.

Skin diseases of the nose.

OBJECTIVES: The goal of this study was to review the main lesion types of the nasal skin and appropriate treatment strategies rather than to present a comprehensive list of all diseases that affect the skin that can involve the nose. METHODS: We reviewed the main nasal skin lesion types and available treatment strategies. Nasal skin lesions were classified as benign, premalignant, or malignant. RESULTS: Benign lesions of the nose include nonmalignant tumoral lesions (i.e., freckles, comedo, adenoma sebaceum [Pringle disease], hydrocystoma, fibrous papules, sebaceous hyperplasia, and rhinophyma), autoimmune and inflammatory conditions (i.e., pemphigus, sarcoidosis, systemic lupus erythematosus, facial eosinophilic granuloma, rosacea, herpes zoster infection, leishmaniasis, and leprosy), and vascular lesions (i.e., telangiectasis, hemangioma, and spider nevus). Premalignant lesions are actinic keratosis and keratoacanthoma; and malignant tumors are melanoma, basal cell carcinoma, and squamous cell carcinoma. Regardless of whether or not they are malignant, all facial lesions can yield significant cosmetic discomfort that should be evaluated carefully before commencing any curative or corrective intervention. In general, benign lesions are treated with dermabrasive modalities, such as trichloroacetic acid, phenol, salicylate, and laser ablation. Electrocautery, cryosurgery, and surgical excision are also used, although these methods may result in scar formation, which can sometimes be more problematic than the original lesion itself. CONCLUSION: Any disease that affects the skin, especially those diseases that are triggered by ultraviolet exposure, can involve the face and nose. Cosmetic defects due both to the lesion itself and the intervention must be discussed with the patient, preferably in the presence of a first-degree relative, before commencement of treatment. As a result of heterogeneity of skin lesions of the nose, appropriate education of general practitioners as well as otorhinolaryngologists is mandatory.

Value of C-Arm Cone Beam Computed Tomography Image Fusion in Maximizing the Versatility of Endovascular Robotics.

BACKGROUND: To report our initial experience and highlight the value of using intraoperative C-arm cone beam computed tomography (CT; DynaCT(®)) image fusion guidance along with steerable robotic endovascular catheter navigation to optimize vessel cannulation. METHODS: Between May 2013 and January 2015, all patients who underwent endovascular procedures using DynaCT image fusion technique along with Hansen Magellan vascular robotic catheter were included in this study. As a part of preoperative planning, relevant vessel landmarks were electronically marked in contrast-enhanced multi-slice computed tomography images and stored. At the beginning of procedure, an intraoperative noncontrast C-arm cone beam CT (syngo DynaCT(®), Siemens Medical Solutions USA Inc.) was acquired in the hybrid suite. Preoperative images were then coregistered to intraoperative DynaCT images using aortic wall calcifications and bone landmarks. Stored landmarks were then overlaid on 2-dimensional (2D) live fluoroscopic images as virtual markers that are updated in real-time with C-arm, table movements and image zoom. Vascular access and robotic catheter (Magellan(®), Hansen Medical) was setup per standard. Vessel cannulation was performed based on electronic virtual markers on live fluoroscopy using robotic catheter. The impact of 3-dimensional (3D) image fusion guidance on robotic vessel cannulation was evaluated retrospectively, by assessing quantitative parameters like number of angiograms acquired before vessel cannulation and qualitative parameters like accuracy of vessel ostium and centerline markers. RESULTS: All 17 vessels were cannulated successfully in 14 patients' attempted using robotic catheter and image fusion guidance. Median vessel diameter at origin was 5.4 mm (range, 2.3-13 mm), whereas 12 of 17 (70.6%) vessels had either calcified and/or stenosed origin from parent vessel. Nine of 17 vessels (52.9 %) were cannulated without any contrast injection. Median number of angiograms required before cannulation was 0 (range, 0-2). On qualitative assessment, 14 of 15 vessels (93.3%) had grade = 1 accuracy (guidewire inside virtual ostial marker). Fourteen of 14 vessels had grade = 1 accuracy (virtual centerlines that matched with the actual vessel trajectory during cannulation). CONCLUSIONS: In this small series, the experience of using DynaCT image fusion guidance together with a steerable endovascular robotic catheter indicates that such image fusion strategies can enhance intraoperative 2D fluoroscopy by bringing preoperative 3D information about vascular stenosis and/or calcification, angulation, and take off from main vessel thereby facilitating ultimate vessel cannulation.

TECA (Titrated Extract of Centella Asiatica): new microcirculatory, biomolecular, and vascular application in preventive and clinical medicine. A status paper.

Plant-derived elements used for pharmacological applications constitute an increasing research field. Centella asiatica is widely used mainly as an extract (TECA). Triterpenic fractions, the primary constituents of Centella asiatica, produce a wide range of preventive and therapeutic effects. The modulation of collagen production and deposition in wound healing is of primary importance. TECA is also used to treat several microcirculatory problems, inflammatory skin conditions (leprosy, lupus, varicose ulcers, eczema, atopic dermatitis, psoriasis) and also intestinal problems, fever, amenorrhea and genitourinary conditions. Cognitive functions, anxiety and mental impairment may be also affected by TECA administration. New applications in neurology include nerve growth factor enhancement and applications in neurological degenerative conditions. Interaction with other products is also indicated in this document. The multiplicity of actions of TECA is associated to six important mechanisms, all inter-connected and modulating each other: 1) edema - and capillary filtration - control; 2) a strong antioxidant power, effective on several forms of oxidative stress associated to inflammation or infections and synergic with other antioxidant products; 3) an anti-inflammatory action; 4) a modulation of the collagen production avoiding slower scarring or faster, hyperthrophic scarring and cheloids; 5) a modulating action of local growth factors; 6) a modulation of angiogenesis. This "status" paper - resulting from an expert meeting held in Cobham, Surrey, indicates most of the therapeutic potential of TECA, still to be explored in further studies. The status paper constitutes the basis for a consensus document on TECA to be developed in the next future. This "status" paper opens a new window on an ancient but still partially unexplored product that may become an important value in prevention and treatment of several pre-clinical and risk conditions and in clinically significant disease both as a single products and in association with other 'natural' products.

Lasers for vascular lesions: standard guidelines of care.

INTRODUCTION: Lasers are a good therapeutic tool for congenital and acquired vascular lesions. Technological advances in lasers have reduced the adverse effects and increased the efficacy. MACHINES: Among the various lasers used for treating vascular lesions, pulsed dye laser (PDL) has the best efficacy and safety data. The other machines that are widely available are Nd:YAG laser and intense pulse light (IPL). RATIONALE AND SCOPE OF GUIDELINE: Much variation exists in different machines and techniques, and therefore, establishing standard guidelines has limitations. The guidelines recommended here indicate minimum standards of care for lasers on vascular lesions based on current evidence. PHYSICIAN QUALIFICATION: Laser may be administered by a dermatologist, who has received adequate background training in lasers during post-graduation or later at a center that provides education and training in lasers, or in focused workshops, which provide such trainings. He/she should have adequate knowledge of the lesions being treated, machines, parameters, cooling systems, and aftercare. FACILITY: The procedure may be performed in the physician's minor procedure room with adequate laser safety measures. INDICATIONS: PWS, hemangioma, facial telangiectasia, rosacea, spider angioma, pyogenic granuloma, venous lakes, leg veins. CONTRAINDICATIONS: Absolute: Active local infection, photo-aggravated skin diseases, and medical conditions. Relative: Unstable vitiligo, psoriasis, keloid and keloidal tendencies, patient on isotretinoin, patient who is not cooperative or has unrealistic expectation. PATIENT SELECTION: Patient selection should be done after detailed counseling with respect to the course of lesions, different treatment options, possible results, cost, need for multiple treatments, and possible postoperative complications. TREATMENT SESSIONS: The number of treatments per lesion varies from 2 to 12 or more at 6-8 week intervals. All lesions may not clear completely even after multiple sessions in many cases. Hence, a realistic expectation and proper counseling is very important. LASER PARAMETERS: Laser parameters vary with area, type of lesion, skin color, depth of the lesion, and machine used. A test spot may be performed to determine individual specifications. COMPLICATIONS: Pain, edema, purpura, bleeding, scarring, postinflammatory hyperpigmentation/hypopigmentation, and atrophy changes.

Experience with the hansen robotic system for atrial fibrillation ablation--lessons learned and techniques modified: Hansen in the real world.

INTRODUCTION: The Hansen robotic system has only recently been used in the United States for catheter ablation procedures in humans. Atrial fibrillation (AF) ablation may be performed utilizing this system. We report our management of complications with early experience of this system. METHODS AND RESULTS: All 71 patients in whom the system was utilized were included. In all patients, a 2-operator technique was to be employed; one operator manipulates the ablation catheter via the robot and the other manipulates the circular mapping and intracardiac echocardiogram catheters. There was no procedure-related mortality. All vascular complications occurred in the first 25 procedures performed. There were 6 intraoperative procedural-related complications. These included significant vascular complications (n = 4), one of whom required iliac vein stenting, and 2 cardiac tamponade (one related to a pop-phenomenon)-successfully treated by pericardiocentesis. Early complications (n = 3) were 1 tamponade several hours post-procedure, 1 vascular complication, and 1 pericarditis. Late complications included 5 patients with severe pulmonary vein stenosis (all in first 27 patients) and 1 patient with gastroparesis. All complications were successfully managed without persistent morbidity and occurred earlier in our experience. This led to specific alterations in our vascular access and ablation techniques. These include the use of a longer 14 Fr sheath, through which the robotic sheath is more safely advanced. The choice of ablation catheter and titration of power, particularly when the catheter has a perpendicular orientation to the atrial wall, is also important. CONCLUSIONS: The suggested modifications may make the system easier to use with the potential to reduce complications.

Pentoxifylline: a drug with wide spectrum applications in dermatology.

Pentoxifylline (PTX) is a methylxanthine derivative with a variety of anti-inflammatory effects. Currently, PTX is approved by the Food and Drug Administration for the treatment of intermittent claudication, but studies have shown that it has a variety of physiological effects at the cellular level, which may be important in treating a diverse group of diseases.

[Treatment of skin ulcers in collagen vascular diseases].

The causes of skin ulcers in collagen vascular diseases are complicated, and involve peripheral vascular complications, vasculitis, and thrombosis. It is necessary to determine the treatment, such as oral medication, infusion, ointment and surgery after careful consideration of its causes. This review shows skin manifestations of various collagen vascular diseases and the causes of skin ulcers in these diseases.

Significance of nail changes in leprosy: a clinical review of 357 cases.

Leprosy can cause many nail changes, which have been observed in up to 64% of infected patients. The manifestations of leprosy (clinical, bacteriologic, and histological) are profoundly affected by the patient's immunological status, which also determines the prognosis. Nail changes in leprosy can be caused by neuropathy and trauma, vascular impairment, infections, and miscellaneous changes. Often more than one factor will be important. Paradoxically, nail changes in tuberculoid and lepromatous patients are similar, despite wide differences in pathology. This may be because etiological factors common to both are implicated. Factors only associated with lepromatous disease are invasion of the bones of terminal phalanges by lepromatous granulomas and endarteritis occurring during type 2 lepra reactions. Otherwise, the only difference from tuberculoid leprosy is the time of onset and the symmetry of lesions. Lepromatous patients develop nail changes late in the course of disease. The presentation is usually bilaterally symmetrical. However, these changes are not specific to leprosy, and may be observed in other peripheral neuropathies.

Vascular changes in leprosy and its role in the pathogenesis of leprous neuritis.

The arteriographic pattern of left hand vessels was studied in 20 patients in leprosy by percutaneous brachial arteriography. Arteriographic abnormalities noted consisted of occlusion, narrowing, tortuosity, dilatation, irregularity and incomplete filling of the lumen by contrast medium. Such abnormal findings were seen in all the arteriograms studied and more than one vessel involvement was noted in over 50 percent cases. This study clearly demonstrated that arterial involvement in leprosy was frequent. No correlation was found between motor weakness and vascular abnormalities. There was no difference in arterial lesions between the patients with and without trophic changes. There was also no correlation between the severity of vascular changes and decline in motor nerve conduction. Degree of histopathological abnormalities in the sural nerve biopsy from these patients showed no features of micro angiopathic neuropathy. It is concluded that the observed vascular abnormalities do not contribute significantly in the genesis of neurological deficit in leprosy.

Vascular changes in leprosy and its role in the pathogenesis of leprous neuritis

The arteriographic pattern of left hand vessels was studied in 20 patients in leprosy by percutaneous brachial arteriography. Arteriographic abnormalities noted consisted of occlusion, narrowing, tortuosity, dilatation, irregularity and incomplete filling of the lumen by contrast medium. Such abnormal findings were seen in all the arteriograms studied and more than one vessel involvement was noted in over 50 percent cases. This study clearly demonstrated that arterial involvement in leprosy was frequent. No correlation was found between motor weakness and vascular abnormalities. There was no difference in arterial lesions between the patients with and without trophic changes. There was also no correlation between the severity of vascular changes and decline in motor nerve conduction. Degree of histopathological abnormalities in the sural nerve biopsy from these patients showed no features of micro angiopathic neuropathy. It is concluded that the observed vascular abnormalities do not contribute significantly in the genesis of neurological deficit in leprosy.

Peripheral arteriographic studies in leprosy.

There is a considerable controversy regarding the frequency and significance of vascular lesions in leprosy. Twenty-six cases of leprosy below the age of 40 years, without any local or systemic arterial disease and normal looking hands were subjected to brachial arteriography. One patient had posterior tibial arteriography also. The diagnosis of leprosy was confirmed by histology or bacteriological staining techniques. Biopsy material was studied from the involved areas and similar material was obtained from nine matched control subjects at autopsy. Skin thermometry and reflex vasodilatation was studied in eight cases. Arteriographic abnormalities such as occlusion, narrowing, tortuosity, dilatation, irregularity and incomplete filling were seen in more than two vessels in the hand in 50%, and in the digits in 75% of the cases. The ulnar artery was more frequently involved than the radial. Superficial and deep palmar arches were equally affected. Marked increase in arcuate vessels was noticed in nearly three-quarters of the patients, and in some, arcuate vessles were serving as collaterals. Histologically all sizes of vessles, including the capillaries, showed changes in nearly half the cases. Reflex vasodilation was lost in three cases of dimorphous leprosy and impaired or absent in three out of five cases of lepromatous leprosy. There was no predilection for any form of leprosy to show arterial changes more than the other. This study clearly demonstrates that the arterial involvement in leprosy is very frequent and must be playing an important role in causing mutilation and deformities of hands and feet.