A prospective study of the epidemiological and clinical patterns of recurrent dermatophytosis at a tertiary care hospital in India.

BACKGROUND: Recurrent and clinically unresponsive dermatophytosis is being increasingly encountered in our country. It runs a protracted course with exacerbations and remissions. However, there is little information regarding the extent of the problem and the characteristics of recurrent dermatophytosis in published literature. AIMS: We sought to determine the prevalence, risk factors and clinical patterns of recurrent dermatophytosis in our institution. We also investigated the causative dermatophyte species and antifungal susceptibility patterns in these species. METHODS: One hundred and fifty patients with recurrent dermatophytosis attending the outpatient department of the Postgraduate Institute of Medical Education and Research, Chandigarh, India were enrolled in the study conducted from January 2015 to December 2015. A detailed history was obtained in all patients, who were then subjected to a clinical examination and investigations including a wet preparation for direct microscopic examination, fungal culture and antifungal susceptibility tests. RESULTS: Recurrent dermatophytosis was seen in 9.3% of all patients with dermatophytosis in our study. Trichophyton mentagrophytes was the most common species identified (36 patients, 40%) samples followed by T. rubrum (29 patients, 32.2%). In-vitro antifungal susceptibility testing showed that the range of minimum inhibitory concentrations (MIC) on was lowest for itraconazole (0.015-1), followed by terbinafine (0.015-16), fluconazole (0.03-32) and griseofulvin (0.5-128) in increasing order. LIMITATION: A limitation of this study was the absence of a suitable control group (eg. patients with first episode of typical tinea). CONCLUSION: Recurrence of dermatophytosis was not explainable on the basis of a high (MIC) alone. Misuse of topical corticosteroids, a high number of familial contacts, poor compliance to treatment over periods of years, and various host factors, seem to have all contributed to this outbreak of dermatophytosis in India.

A prospective study to validate various clinical criteria used in classification of leprosy: a study from a tertiary care center in India.

BACKGROUND: Various clinical criteria are used to categorize leprosy patients into paucibacillary (PB) and multibacillary (MB), thus aiding in appropriate treatment. However, comprehensive studies validating these criteria are minimal. AIMS: To assess sensitivity and specificity of different clinical criteria individually and in combination for classifying leprosy into PB/MB spectrum. METHOD: A prospective study was conducted wherein 50 newly diagnosed, untreated leprosy cases were recruited and classified into PB and MB using the following clinical criteria: number of skin lesions (NSL), number of body areas affected (NBAA), and size of largest skin lesion (SLSL). Patients with pure neuritic leprosy, diffuse macular type of lepromatous leprosy, and with reactions were excluded. Sensitivity and specificity of these clinical criteria in classification was calculated taking histopathological findings as gold standard. RESULTS: Among 50 patients, 37 were males and 13 were females with a mean age of 32.08 ± 16.55 years. The sensitivity and specificity of NSL, NBAA, and SLSL was 94.74 and 87.1%, 94.74 and 61.29%, and 73.68 and 16.13%, respectively. Combining all three criteria, the sensitivity increased to 100%, but specificity decreased drastically to 12.9%. The ROC curve for NSL, NBAA, and SLSL showed a cutoff of ≥6 skin lesions, ≥3 body areas affected, and ≤2 cm lesion to classify as MB. CONCLUSION: The current WHO system of leprosy classification based on NSL seems to be best among available clinical criteria. Uniform and sensible application of this criteria itself assures appropriate categorizing and leprosy treatment with reasonable sensitivity and specificity.

Minocycline successfully treats exaggerated granulomatous hypersensitivity reaction to Mw immunotherapy.

Mycobacterium W (Mw) vaccine has been found to be effective in the treatment of leprosy and warts. Despite increasing use of Mw immunotherapy, data on its safety is limited. We report a series of eight patients who developed persisting injection site granulomatous reaction following Mw immunotherapy and were successfully treated with minocycline. Eight patients with persistent nodular swelling at the site of Mw injections were identified. Seven of them had received Mw immunotherapy for cutaneous warts and one for verrucous epidermal nevus. The lesions were firm, erythematous, succulent, non-tender nodules confined to the sites of Mw vaccine injections. In 6 of these patients nodules also involved the previously injected areas. Skin biopsy from all patients showed eosinophil rich inflammation admixed with histiocytes and lymphocytes. In addition granulomas were seen in all with septal and nodular panniculitis in four patients. Broken and granular acid-fast bacilli were identified in two cases. All patients were treated with oral minocycline 100 mg/day for a mean of 9 weeks and showed good clinical response. Granulomatous reaction is a rare but significant adverse effect of Mw immunotherapy at cosmetically and functionally imperative sites. Oral minocycline appears to be effective therapy in this situation.

IgG/IgA pemphigus reactive with desmoglein 1 with additional undetermined reactivity with epidermal basement membrane zone.

IgG/IgA pemphigus is an extremely rare subset of pemphigus, showing anti-keratinocyte cell surface antibodies of both IgG and IgA classes. Herein, we describe a unique case of IgG/IgA pemphigus with clinical features of edematous erythema and peripheral vesiculopustules. Histopathology showed the presence of subcorneal pustules and acantholytic blisters in the mid-epidermis with neutrophilic infiltration and eosinophilic spongiosis. Direct immunofluorescence of perilesional skin showed both IgG and IgA deposits to keratinocyte cell surfaces and unusual granular deposits of IgG, IgM, and C3 along basement membrane zone. On enzyme linked immunosorbent assay , the auto-antibodies were found to be reactive to desmoglein 1 antigen. Various clinical, histopathological, and immunological findings in our case overlapped with the features of IgA pemphigus, pemphigus herpetiformis, and pemphigus foliaceus. These findings indicate that IgG/IgA pemphigus may be a transitional form between IgA pemphigus and pemphigus herpetiformis, and thus provides insight into the pathogenicity of this rare disorder.