Phototherapy causing a purpuric eruption in a neonate.

Neonatal jaundice is a frequent condition in newborns and is commonly treated with phototherapy. We describe the case of a neonate with hemolytic disease of the newborn who developed a rarely described purpuric eruption. Laboratory testing revealed elevated porphyrins.

Adult Scurvy Presenting with Painful Purpura on the Legs.

Prolonged vitamin C deficiency can result in numerous metabolic abnormalities like impaired tissue repair and defective collagen synthesis. This case report describes a middle-age Japanese man presenting painful purpura on his lower limbs, severe anemia, and altered consciousness. The patient had been eating a selective diet lacking in vegetables and fruits since childhood. A serum analysis demonstrated a low level of vitamin C. The patient was treated with vitamin supplementation and psychological intervention. Scurvy is an under-considered illness with a favorable prognosis if diagnosed early while it is still sporadically encountered in some patients with malabsorption or malnutrition even in modern times.

[Scurvy presenting with low-extremity necrotic and purpuric ulcers: Two cases]. / Ulcères nécrotiques et purpuriques des membres inférieurs révélant un scorbut : à propos de deux observations.

BACKGROUND: Scurvy is a clinical syndrome resulting from ascorbic acid deficiency. Although presently rare in the developed world, it continues to occur within certain susceptible populations, particularly the elderly and those with dietary habits with low vitamin C intake. CASES: Two men aged 87 and 69 were referred with multifactorial, progressive ulceration of the lower limbs, without scarring, in a context of arterial disease and other associated comorbidities. In both cases, the level of vitamin C was undetectable. An improvement in the necrotic component and in the purpura was promptly observed after vitamin C supplementation. CONCLUSIONS: Diagnosis of scurvy can be challenging. This report highlights the importance of maintaining a high index of suspicion for scurvy in atypical necrotic ulcerations of lower extremities with poor response to standard therapy especially in populations at high risk of vitamin C deficiency. Early diagnosis can improve patient prognosis.

A comparative study with a 755 nm picosecond Alexandrite laser with a diffractive lens array and a 532 nm/1064 nm Nd:YAG with a holographic optic.

BACKGROUND AND OBJECTIVES: This study was performed to better understand the cutaneous effects of using a fractional picosecond laser at 755 nm with a diffractive lens array and a picosecond Nd:YAG laser at 532 mn and 1064 nm with a holographic optic. We characterized the injuries created by these devices on skin clinically and histologically over 24 hours. With this information we modeled the effects of these devices on a cutaneous target. METHODS: Eight patients, representing Fitzpatrick skin types I-VI, were treated on their backs with a picosecond Alexandrite laser with a diffractive lens array, as well as a picosecond Nd:YAG laser at 532 nm and 1064 nm with a holographic optic. Photographs were taken 15 minutes and 24 hours after treatments. Punch biopsies were obtained at 24 hours and examined histologically. RESULTS: Treatment with the picosecond Nd:YAG laser at both 532 nm and 1064 nm with the holographic optic revealed erythema and small scatted areas of petechial hemorrhage areas immediately and in many cases at 24 hours after treatment. The 755 nm picosecond Alexandrite laser with diffractive lens array produced erythema immediately after treatment, which largely dissipated 24 hours later. Histologies revealed intra-epidermal vacuoles with all three wavelengths. Fractional picosecond Nd:YAG laser at 532 nm and 1064 nm with the holographic optic showed focal areas of dermal and intra-epidermal hemorrhage with areas of vascular damage in some patients. CONCLUSIONS: This study demonstrates that both fractional picosecond devices produce vacuoles in the skin, which are most likely due to areas of laser induced optical breakdown (LIOB). In the patients (skin type II-IV) we observed scatter areas of hemorrhage in the skin, due to vascular damage with the 532 nm and 1064 nm, but not with 755 nm wavelengths. Lasers Surg. Med. 50:37-44, 2018. © 2017 Wiley Periodicals, Inc.

A Case of Scurvy-Uncommon Disease-Presenting as Panniculitis, Purpura, and Oligoarthritis.

IMPORTANCE: Scurvy remains prevalent in certain populations, including addicts, people of low socioeconomic status, and the severely malnourished. It classically presents as follicular hyperkeratosis and perifollicular hemorrhage of the lower extremities, as well as bleeding in other areas such as the gingiva and joints. This case presentation and literature review highlights the common pathophysiological findings associated with scurvy and current methods of diagnosis and treatment. OBSERVATION: The patient described in this case presented with sudden oligoarthritis and purpura of the lower extremities. Following progression of the patient's symptoms and a low vitamin C serum concentration, the patient was treated with vitamin C supplementation and dramatically improved. This was considered to be the result of an underlying vitamin C deficiency secondary to insufficient fruit and vegetable intake due to allergies. CONCLUSIONS AND RELEVANCE: This case highlights the importance of maintaining a high index of suspicion for scurvy in atypical presentations of purpura not better explained by another disease or in additional populations at high risk of vitamin C deficiency. Early diagnosis by either a primary care physician or dermatologist can expedite the treatment process and improve patient prognosis.

Haemodynamic instability of uncommon aetiology in Switzerland.

In Switzerland, vitamin C deficiency is a rare condition. Nonetheless, in clinical practice, there are some patients exhibiting a vitamin C deficiency as a result of an unbalanced diet or intestinal malabsorption. We report the clinical history of a 55-year-old man known for alcoholism and insufficient intake of fresh fruits and vegetables. He was admitted to the intensive care unit, for haemodynamic instability caused by blood loss due to fragile vessels (skin, gastrointestinal). Further analyses revealed a severe lack of vitamin C. The patient received a high dose of intravenous substitutive treatment, leading to a favourable clinical outcome.

Laser and energy-based devices' complications in dermatology.

Laser dermatology is an ever-expanding part of the specialty used extensively for both aesthetic and medical conditions. Advances in laser technology have led to an expansion in the number of devices available, with as a consequence an increase in the total number of complications. Fortunately, the current technology has improved greatly which adds to the safety profile of such devices; nevertheless, thorough knowledge of laser complications and how to avoid them is paramount for any practitioner who uses such technology.

[Infantile scurvy: Two cases]. / Scorbut chez l'enfant: deux cas.

BACKGROUND: Scurvy is the classic and most severe form of vitamin C deficiency. This condition has become extremely rare among children in the industrialized countries. PATIENTS AND METHODS: We report the case of two boys presenting bone pain associated with haemorrhagic gingivitis, with perifollicular purpura of the lower limbs in one boy. The children had an unbalanced diet. Scurvy was associated with vitamin D and iron deficiency. The dermatological and radiological abnormalities seen were characteristic and a favourable outcome was rapidly obtained following supplementation. DISCUSSION: The possibility of this forgotten historical illness should not be overlooked in the presence of these dermatological and rheumatologic signs, since this can help avoid unnecessary or excessively aggressive investigations.

Gua Sha a traditional Chinese healing technique that could mimick physical abuse: a potential issue with forensic implications. A case study.

Gua Sha (press-stroking) is a traditional Chinese healing technique utilized to combat pain, common cold, heatstroke, and respiratory problems. Patterned ecchymoses may appear due to the action of scraping and scratching repeatedly in a unidirectional manner, with a smooth edge over a lubricated area. They may be very informative, since they, generally, reproduce the shape of the injurious agent. However, many confounding factors can make the identification of the lesions difficult. A case of a 43 year-old Chinese woman, hospitalized for abdominal pain, is reported. An unusual pattern of reddish ecchymoses on the back was present. After a careful investigation, ecchymoses were attributed to Gua Sha. The case demonstrated that clinicians and forensic pathologists should also consider press-stroking, and other similar techniques in adults who present scratch-like marks or ecchymoses on various body districts, even if they have an unusual pattern.

Purpuric eruption in a transfused neonate receiving phototherapy.

We describe the clinical and biochemical findings in a neonate requiring multiple blood transfusions and phototherapy for alloimmune hemolytic anemia and unconjugated hyperbilirubinemia, respectively. In this newborn, a severe photosensitivity reaction developed and laboratory testing revealed elevated serum and urine porphyrins at the time of the eruption. The cause of the transient porphyrinemia was likely multifactorial. Possible mechanisms include poor hepatic metabolism and reticulocyte hemolysis. However, the exact pathogenesis remains unclear at this time.

The spectrum of pigmented purpuric dermatosis and mycosis fungoides: atypical T-cell dyscrasia.

We report the case of a healthy 17-year-old adolescent boy with an unremarkable medical history who presented with an asymptomatic fixed rash on the abdomen, buttocks, and legs. The rash initially developed in a small area on the right leg 2 years prior and had progressed slowly. Prior biopsies were consistent with pigmented purpura. Clinical examination revealed multiple annular purpuric patches on the abdomen, buttocks, and legs covering approximately 20% of the body surface area without lymphadenopathy or hepatosplenomegaly. Additional biopsies demonstrated changes consistent with mycosis fungoides (MF). T-cell receptor g gene rearrangements demonstrated clonality. The patient was diagnosed with stage IB MF of the pigmented purpura-like variant. The patient responded well to psoralen plus UVA therapy. It has been proposed that pigmented purpuric dermatosis (PPD) is a form of cutaneous T-cell lymphoid dyscrasia and that T-cell gene rearrangement studies should be obtained for prognostic evaluation in patients with widespread disease. In our patient, the clinical appearance of the lesions, pathologic findings, and gene rearrangement studies led to the diagnosis of MF. Until the potential for evolution of PPD to malignant disease is better understood, further evaluation of MF in patients with an unusual presentation of pigmented purpura is warranted.

Treatment of purpura with lasers and light sources.

The potential for bruising is a frequent concern for patients undergoing minimally invasive procedures, particularly injection-based soft tissue fillers and botulinum toxin type A. Decreasing the risk of this side effect with good technique and careful patient selection is key, but interventions that quicken the resolution of bruising are also helpful. Many practitioners have employed the theory of selective photothermolysis, using laser and light devices, to target hemoglobin and its breakdown products to speed time to bruise resolution. 585-595 nm pulsed dye, pulsed 532 nm and 1064 nm long-pulsed neodymium-doped yttrium aluminum garnet (Nd:YAG) lasers and intense pulsed light may be utilized with best results achieved when treatment is performed 1-2 days after the appearance of purpura. Specific therapy recommendations, side effects and contraindications will be addressed in this review.

Purpura and fillers: a review of pre-procedural, intra-procedural, and post-procedural considerations.

Injectable aesthetic fillers are associated with the common and expected side effect of purpura or bruising. There are pre-procedural, intra-procedural and post-procedural considerations that can potentially minimize bruising. Traditional and newer techniques are discussed in this review and the benefits and risks of each technique will be provided.

Köebner phenomenon induced by cupping therapy in a psoriasis patient.

Psoriasis is a chronic, immune-mediated inflammatory and refractory disease. The koebner phenomenon, which can be induced by trauma, is common in psoriasis patients. Herein, we report a patient with psoriasis who was treated by cupping therapy and subsequently developed the koebner phenomenon (KP) at the cupped sites. To our knowledge, it is the first report about cupping therapy leading to KP in a psoriasis patient.

Reduced platelet aggregation in a boy with scurvy.

Pediatric scurvy is a rare condition characterized by perifollicular petechiae and bruising, hemorrhagic gingivitis and musculoskeletal symptoms, all assumed to be predominantly related to abnormal collagen structure. We report on a 9-year-old autistic boy with vitamin C deficiency due to a highly limited food range presenting with multiple petechiae, gum bleeding and debilitating bone pain, in whom platelet aggregometry revealed a distinctly reduced thrombocyte aggregation, normalizing after vitamin C supplementation. This observation indicates that platelet dysfunction may additionally contribute to the hemorrhagic diathesis in scurvy, and demonstrates that ascorbic acid deficiency should be considered in children with an otherwise unexplained acquired thrombocytopathy.

Safety protocols for gua sha (press-stroking) and baguan (cupping).

Gua sha (press-stroking) and Baguan (cupping) are therapeutic procedures of traditional East Asian medicine (TEAM) that are also practiced in integrative clinical as well as domestic or familial settings. They may be defined as instrument assisted mechanical stimulation of the body surface that intentionally creates therapeutic petechiae and ecchymosis representing extravasation of blood in the subcutis. Blood and 'other potentially infectious material' (OPIM) can sometimes be drawn through the surface of the skin leading to potential contamination of instruments and to risk of bloodborne pathogen exposure. Neither the literature nor the current national standards of the acupuncture profession sufficiently address safety standards for Gua sha and Baguan. This paper presents the nature of the potential risks and applies current hospital safety standards as proposed protocols for Gua sha and Baguan.