Clinical and bacteriological profile and outcome of sepsis in dermatology ward in tertiary care center in New Delhi.

BACKGROUND: There is paucity of data regarding the clinical and bacteriological profile of sepsis in dermatology in-patients. AIMS: To study the frequency, etiology, and outcome of sepsis dermatology in-patients. METHODS: The study was conducted in a 30-bedded dermatology ward of a tertiary care center. Sepsis was defined by presence of ≥2 SIRS (systemic inflammatory response syndrome) criteria along with evidence of infection (clinically obvious/culture proven infection of skin or internal organs). Patients were also assessed for known (common) risk factors of sepsis. In suspected sepsis patients, at least two samples of blood cultures by venepuncture were taken. Pus, skin swab, urine, and sputum samples were also collected for culture as needed with avoidance of contamination. RESULTS: Among 860 admitted patients studied from November 2004 to July 2006, 103 (12%) fulfilled SIRS criteria. Of these, 63 had nonsepsis causes of SIRS positivity, while 40 (4.65%) had sepsis. Majority of the sepsis patient had vesicobullous diseases (42.5%), erythroderma (25%), toxic epidermal necrolysis (TEN) (22.5%). Severe sepsis developed in 17 (42.5%) patients, while 15 (37.5%) died. Methicillin-resistant Staphylococcus aureus (MRSA) was the commonest organism isolated (99; 25.9%) in all culture specimens followed by Acinetobacter spp. (52; 13.6%), Pseudomonas spp. (40; 10.5%), Methicillin-sensitive S. aureus (MSSA: 33; 8.7%), and Klebsiella spp. (22; 5.8%). Various risk factors affecting mortality and sensitivity patterns for various isolates were also analyzed. CONCLUSION: Sepsis occurred in 40 (4.65%) inpatients in dermatology ward. The frequency of sepsis was highest in TEN (90%), followed by drug-induced maculopapular rash (20.0%), erythroderma (17.5%), and vesicobullous diseases (8.5%). MRSA, acinetobacter, pseudomonas, MSSA, and Klebsiella were important etiological agents involved in sepsis in dermatology in-patients.

Primary tuberculosis of glans penis after intravesical Bacillus Calmette Guerin immunotherapy.

A 55-year-old male with carcinoma in situ of urinary bladder was treated with weekly intravesical injections of Bacillus Calmette Guerin (BCG) vaccine. Three days after the sixth injection, he developed low grade fever and multiple grouped punched out, 2-3 mm ulcers around meatus and corona glandis. In addition, multiple, firm, indurated, nontender papules and few deeper nodules were present on the proximal part of glans penis, along with bilateral enlarged, matted and nontender inguinal lymph nodes. There was no history suggestive of sexually transmitted diseases and high risk behavior. Chest X-ray was within normal limits, and Mantoux, Venereal Disease Research Laboratory (VDRL) and HIV antibody tests were negative. The biopsy from the penile ulcer revealed epithelioid cell granuloma with Langhans giant cells. Fine needle aspiration cytology from the lymph node also revealed epithelioid cell granuloma and acid fast bacilli on Ziehl Neelsen's stain. The tissue biopsy grew Mycobacterium tuberculosis. The BCG immunotherapy was stopped and patient was treated with four drug antitubercular therapy with isoniazid, rifampicin, ethambutol, and pyrazinamide in standard daily doses along with pyridoxine. The edema resolved and the ulcers started healing within 2 weeks, and at 6 weeks after starting antitubercular therapy almost complete healing occurred. To the best of our knowledge, we describe the first case of an Indian patient with BCG induced primary tuberculosis of penis after immunotherapy for carcinoma urinary bladder and review the previously described cases to increase awareness of this condition in dermatologists and venereologists.

Standard guidelines of care: Keloids and hypertrophic scars.

Keloids and hypertrophic scars (HTS) are the result of overgrowth of fibrous tissue, following healing of a cutaneous injury, and cause morbidity. There are several treatment modalities which are useful for the management of keloids, though no single modality is completely effective. The most commonly used modalities are pressure, silicone gel sheet, intralesional steroids, 5-fluorouracil (5 FU), cryotherapy, surgical excision, and lasers. They may be used either singly or, as is done more commonly, in combinations. Any qualified dermatologist who has attained postgraduate qualification in dermatology can treat keloids and HTS. Some procedures, such as cryosurgery and surgical excision, may require additional training in dermatologic surgery. Most modalities for keloids, including intralesional injections and mechanical therapies such as pressure and silicone gel based products, can be given/prescribed on OPD basis. Surgical excision requires a minor operation theater with the facility to handle emergencies. It is important to counsel the patient about the nature of the problem. One should realize that keloid will only improve and not disappear completely. Patients should be informed about the high recurrence rates. Different modalities carry risk of adverse effects and complications and the treating physician needs to be aware of these and patients should be informed about them.

Involvement of male genitalia in leprosy.

Four hundred and sixty-seven male patients with leprosy were screened for genital involvement. Genital lesions were observed in 6.6% of all male cases of leprosy. They were seen most frequently in lepromatous leprosy (25.8%), followed by borderline lepromatous (13.3%) and borderline tuberculoid (1.4%) leprosy.

Atopy and alopecia areata in North Indians.

This study was undertaken with the aim of evaluating the effect of associated atopy on severity and age at onset of alopecia areata in north Indians. Presence of atopy was elicited by detailed history, examination and intracutaneous tests. Chisquare test was carried out to evaluate statistical significance. One hundred patients (76 males and 24 females) with alopecia areata were evaluated. Historical evidence of atopy was present in 50 including patients alone (23), Patients and first degree relatives (11) and first degree relatives alone (16). Intracutaneous tests were positive in 23 out of 50 patients tested randomly. There was a trend towards increasing frequency of severe alopecia as evidence of atopy became stronger e.g. both patient and first degree relative with atopy or positive intracutaneous test but results did not attain statistical significance. Similarly the onset and duration of alopecia areata was not significantly related to the presence of atopy. It is concluded that in north Indians with alopecia areata, the presence of atopy is not significantly associated with severe alopecia or onset at younger age.

Evaluation of patch test in identification of causative agent in drug rashes due to antiepileptics.

Patch test was evaluated for the identification of causative agent in cutaneous eruptions due to antiepileptics. Patch tests were carried out in twenty patients and ten controls with carbamazepine, phenytoin sodium, phenobarbitone and sodium valproate. Sodium valproate was found tobe irritant in 1 and 5% concentration and further dilution is recommended for patch testing. Patch test was positive in 14 (70%) patients and in 7 with suspected drug alone, and remaining 7 were positive with more than one antiepileptic drug. We recommended patch test for identification of causative drug in rashes due to antiepileptics.

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.

CT findings in involvement of the paranasal sinuses by lepromatous leprosy.

The role of nasal infection in the transmission of leprosy has been extensively studied. Leprosy can affect the paranasal sinuses due to mucosal continuity and bacillaemia. This prospective study was performed on 25 untreated patients with lepromatous leprosy. 5 mm contiguous axial and coronal CT sections of paranasal sinuses, on soft tissue and bone windows, were obtained in all patients. Each sinus was examined for mucosal thickening, soft tissue densities and bony outlines. Representative biopsies were taken from ethmoid sinus to confirm the radiological diagnosis in 12 patients with multiple paranasal sinus involvement. Ethmoid aircells were involved in 20 patients (80%). Maxillary, frontal and sphenoid sinuses showed abnormalities in 12, four and three patients, respectively. The ethmoid biopsy showed involvement by lepromatous leprosy in seven of 12 patients (58.3%). Involvement of paranasal sinuses is common in lepromatous leprosy and is of considerable epidemiological significance.

Inhibition of apoptosis by ionomycin and zinc in peripheral blood mononuclear cells (PBMC) of leprosy patients.

PBMC from tuberculoid (BT/TT) and lepromatous leprosy (BL/LL) leprosy patients showed spontaneous apoptosis when cultured in the absence of mitogen for 24 h, which was inhibited by anti-tumour necrosis factor-alpha (TNF-alpha) antibodies. Apoptosis was also inhibited by ionomycin and zinc, which also increased IL-2 and decreased TNF-alpha production. The increase in IL-2 production suggests a mechanism whereby dietary supplements with zinc might alter the cell-mediated immunity response in leprosy patients.

Immunological defect in leprosy patients: altered T-lymphocyte signals.

The early events of activation were studied in paucibacillary (TT/BT) and multibacillary (BL/LL) leprosy patients by stimulation of their lymphocytes with mitogenic agents (calcium ionophore A23187/PMA) and Micobacterium leprae antigen (PGL-1). Maximum proliferation in response to PMA/A23187 and PGL-1 was observed in the BT/TT patients and the control group, respectively. Inositol triphosphate (IP3) and calcium were constitutively elevated in BT/TT and LL/BL patients. PMA/A23187 caused an increase in both IP3 and [Ca2+]i in BT/TT patients and controls. PGL-1 marginally increased IP3 levels in BT/TT patients. In the LL/BL patients, although PMA/A23187 increased IP3 levels, but no change was seen in [Ca2+]i, PGL-1 had no effect. Protein kinase C levels were seen to be associated with particulate fractions in BT/TT patients and were found to increase further in response to PMA/A23187. PGL-1 did not increase translocation of protein kinase C in controls or LL/BL patients. A preactivated and sensitised state of T-lymphocytes was observed in BT/TT patients, responsive to antigen and mitogens, whereas the cells of LL/BL patients were unresponsive to PGL-1. The altered signal transduction events characterised in the MB patients thus correlate well with the anergic state of their cells.

Spontaneous apoptosis in peripheral blood mononuclear cells of leprosy patients: role of cytokines.

Peripheral blood mononuclear cells from leprosy patients underwent spontaneous apoptosis upon culture for 24 h. The apoptosis was inhibited by anti-TNFalpha antibodies and to a certain extent by anti-IL-1alpha and IL-6, thus showing that T(H)2-type cytokines (mainly TNFalpha) are responsible for inducing apoptosis. This cytokine-mediated apoptosis could be inhibited by ionomycin and zinc, thereby suggesting that these metal ions can be used to decrease the levels of these inflammatory cytokines in various diseases.