Endogenous Endophthalmitis Caused by Aspergillus lentulus in an Immunocompromised Patient with Lung Cancer

A 78-year-old man with a history of lung cancer, chemotherapy, radiotherapy, and coronavirus disease 2019 infection experienced visual deterioration of two-weeks' duration in his right eye. There was multifocal, yellowish-white retinitis foci, vascular engorgement, and scattered intraretinal hemorrhages extending from posterior pole to retinal periphery in the right eye, whereas the left eye was normal. Intravitreal vancomycin, ceftazidime, clindamycin, and dexamethasone were given for endogenous endophthalmitis initially. Vitreous culture confirmed the presence of Aspergillus lentulus, and he was treated with intravitreal amphotericin-B and voriconazole injections together with systemic amphotericin-B, voriconazole, posaconazole, and micafungin therapy. During follow-up, vitreoretinal surgery was performed because of rhegmatogenous retinal detachment, and he received one additional cycle of chemotherapy due to recurrence of the cancer. Although the retina was attached, enucleation was eventually required due to painful red eye. Atypical squamous cells beneath the neurosensory retina suggesting metastasis were noted on histopathological examination. Timely ocular examination is crucial for any immunocompromised patient having ocular symptoms. High level of suspicion for a fungal etiology is a must in these patients.

Can we manage the melanocytic lesions with peripheral globules according to the grade of dysplasia?

BACKGROUND/OBJECTIVES: Although excision of melanocytic nevi with high-grade dysplasia is recommended by the World Health Organization (WHO), clinical studies investigating the approach based on the grading dysplasia of melanocytic lesions with peripheral globules (PGs) are lacking. We investigated the grades of dysplasia and their distinguishable dermoscopic and clinical features to provide accurate data for managing these lesions. METHODS: We retrospectively classified histologically confirmed melanocytic lesions with PGs according to the 2018 WHO Classification of Skin Tumours criteria in a university hospital in Turkey. Dermoscopic features, lesions, and patient characteristics were recorded. RESULTS: Sixty-six lesions of 56 patients were included. After classification, 9.1% (n: 6) of lesions were melanomas, 39.4% (n: 26) were high-grade dysplastic nevi, and 50% (n: 33) were low-grade dysplastic nevi (n: 33, 50%). There was one nevus with no dysplasia (n: 1, 1.5%). Univariate analysis revealed that ≥31 years of age, irregular shape of peripheral globules, black colour, total colour count, and maximum diameter of the lesion were associated with high-grade dysplasia and melanoma. In the multivariate analyses, ≥31 years of age (OR = 3.80, 95% CI, 1.17-12.37), irregular shape of peripheral globules (OR = 3.90, 95% CI, 1.15-13.2), and total colour count (OR = 3.21, 95% CI, 1.2-8.5) were significant predictive factors for the lesions with high-grade dysplasia and melanomas. CONCLUSIONS: To avoid the underdiagnosis of both melanomas and high-grade dysplastic nevi with PGs, the irregular shape of peripheral globules and multiple colours after the third decade may be useful in making an excision decision. The risk increases every 1-year increase in age. Excision is suggested for all melanocytic lesions with PGs for patients 60 years or older because of the high risk of melanoma and melanocytic nevus with high-grade dysplasia.

Embedded Episcleral Foreign Body Mimicking Nodular Anterior Scleritis.

A 56-year-old man was referred to our clinic for unilateral nodular scleritis unresponsive to systemic corticosteroids. A localized, nodular hyperemia on the nasal bulbar conjunctiva surrounding a central cyst-like lesion together with vascular engorgement was observed on slit-lamp examination of the left eye. No abnormal fundoscopic findings were noted. Surgical exploration revealed an embedded episcleral brown colored, soft to touch, splinter-like organic foreign body (FB) which was confirmed by the histopathological examination. Nodular hyperemia resolved during the postoperative follow-up period, and mild scar tissue accompanied by scleral thinning developed in the left nasal bulbar conjunctiva. Ocular injury associated with FBs may cause significant ocular morbidity depending on the nature and location of the FB. Severe visual disability may occur if left untreated. Subconjunctival FBs are rare and may present with a clinical picture mimicking episcleritis or scleritis. History of trauma involving a FB should always be assessed for an accurate differential diagnosis and appropriate management of patients with anterior scleritis.

Febrile ulceronecrotic Mucha-Habermann disease during pregnancy: A case report.

Febrile ulceronecrotic Mucha-Habermann disease (FUMHD) is a rare and severe form of 'pityriasis lichenoides et varioliformis acuta', with a progressive and potentially fatal course. To the best of our knowledge, there has been no reported case of FUMDH during pregnancy before. Due to life-threatening nature of the disease and the lack of evidence-based treatment, management of FUMHD in pregnancy is a therapeutic challenge. Additionally, some of the drugs that are effective in the treatment are contraindicated in pregnancy. Herein, we report a 27-year-old woman diagnosed with FUMHD in her 19th week of pregnancy and treated with ceftriaxone and erythromycin.

Challenges in the Diagnosis of Intraocular Lymphoma

Intraocular lymphomas are among the rare malignancies that present with a wide variety of clinical manifestations. Differential diagnosis can be very troublesome due to its mimicking nature, insidious disease onset, and partial treatment response to steroids. The most important step in diagnosis is a high index of suspicion. Signs of the disease are now easier to detect using multimodal imaging techniques. In this case series, we reviewed the clinical characteristics of two women aged 70 and 71 years and a 72-year-old man with intraocular lymphoma and described their multimodal imaging findings in detail. Bilateral eye involvement was present in all three cases at our first ophthalmological examination. While the disease first presented with ocular involvement in two of the three cases, ocular involvement was detected seven years after initial heart involvement in one patient. All three patients had diffuse large B-cell lymphomas (one diagnosed with retinal biopsy, one with conjunctival biopsy, and the remaining with stereotactic brain biopsy). Intraocular lymphoma should be diagnosed and treated using a multidisciplinary approach, and we share our experience in this case series.

Comparison of the local effects of different intracameral cefuroxime solutions on rabbit cornea.

PURPOSE: We aimed to compare the local effects of intracameral cefuroxime diluted in normal saline (SF groups) against those of cefuroxime in balanced salt solution (BSS group) on the cornea of rabbits. MATERIALS AND METHODS: Fourteen New Zealand albino rabbits were randomised into two groups. The right eyes of the rabbits in the SF group I were injected intracamerally with 1 mg cefuroxime diluted with 0.1 mL normal saline (n = 7), whereas the right eyes of the BSS group II were injected with 1 mg intracameral cefuroxime diluted with 0.1 mL with balance salt solution, and the left eyes of all rabbits received no treatment group III (control group). Corneal thickness was measured with pachymetry before and 1 week after the injection. Corneal samples were evaluated with light, specular and electron microscopy. RESULTS: Mean endothelial cell count was lower in the SF than in the BSS and control groups. Although an increase in corneal thickness was found in both treatment groups, this was not the case for the control group. The corneal endothelium preserved its hexagonal structure in all groups. Although both treatment groups showed a loss of endothelial microvilli, this was more prevalent in the SF group. However, microvilli were preserved in the control group. Dissolution of tight junctions in corneal endothelium was observed in the SF group only. Mitochondrial swelling, coarsening of endoplasmic reticulum, cytoplasmic vacuolisation, and increased endothelial cell sizes were the same in both treatment groups but was not observed in the control group. Thicker and more oedematous corneal stroma were observed in the SF group compared with the BSS and control groups. CONCLUSION: Dilution of intracameral cefuroxime in BSS yielded superior results compared with dilution in normal saline owing to toxicity to the endothelial cells and decline in the endothelial cell number, resulting in intracellular and intercellular morphological changes. BSS or any other solution with proven safety should be used in clinical studies.

Dermoscopic pattern of Kyrle's disease.

The clinical diagnosis of Kyrle's disease may sometimes be challenging, due to the clinical similarity of lesions to other pruritic dermatosis. Although the dermoscopy is being increasingly used in daily practice, there is insufficient data in literature describing the dermoscopic patterns of Kyrle's disease, since only one report has been published to date. Herein we report our dermoscopic observation with additional diagnostic tips in a case who was diagnosed with Kyrle's disease histopathologically.

Dermoscopic pattern of Kyrles disease

Abstract The clinical diagnosis of Kyrle's disease may sometimes be challenging, due to the clinical similarity of lesions to other pruritic dermatosis. Although the dermoscopy is being increasingly used in daily practice, there is insufficient data in literature describing the dermoscopic patterns of Kyrle's disease, since only one report has been published to date. Herein we report our dermoscopic observation with additional diagnostic tips in a case who was diagnosed with Kyrle's disease histopathologically.

Topically applied 1% voriconazole induces dysplastic changes on the ocular surface: animal study.

PURPOSE: To identify the risk of inducing ocular surface dysplasia following topical administration of 1% voriconazole eye drop. METHODS: Fourteen noninflamed healthy eyes of 14 white adult New Zealand rabbits were included in the study. The rabbits were randomly divided into two groups comprised of 7 rabbits each. Group 1 received topical 1% voriconazole and Group 2 received topical saline as the control group. In all animals, right eye was selected for the study. In Group 1 (Voriconazole Group), single drop of voriconazole was instilled every 10 min consecutively for 17 times a day for 60 days. In Group 2 (Control Group), single drop of saline was instilled every 10 min consecutively for 17 times a day for 60 days. At two months, animals were sacrificed and study eyes were enucleated with the eyelids. The specimens were stained with hematoxylin-eosin and histopathologic changes in cornea, bulbar and palpebral conjunctiva were evaluated under light microscope. RESULTS: There were no macroscopically visible lesions on the ocular surface of any rabbits. Histopathological evaluation showed mild to moderate dysplasia localized mainly in the limbus and extending to the adjacent cornea and bulbar conjunctiva in all rabbits in Voriconazole Group. Severe dysplasia or carcinoma in situ was not observed. In the Control Group, dysplasia was not observed, at all. CONCLUSION: This animal study provides a possible relationship between topically administered 1% voriconazole and ocular surface dysplasia. We recommend ophthalmologists to be aware of the risk of ocular surface dysplasia in patients received voriconazole eye drop.

Lupus Band Test in Patients with Borderline Systemic Lupus Erythematosus with Discoid Lesions.

Patients with lupus erythematosus (LE) that have discoid lesions who fulfill the four diagnostic criteria of systemic lupus erythematosus (SLE) with only mucocutaneous findings and antinuclear antibody (ANA) positivity were classified as borderline SLE in the literature. Objective of this study was to determine the place of borderline SLE with discoid lesions on the LE spectrum according to the lupus band test (LBT). Lesional and sun-protected non-lesional (SPNL) skin LBTs of 94 patients with LE that had discoid lesions were retrospectively evaluated. Firstly, patients were divided into two main groups: discoid LE (DLE; group A) and SLE (Group B); three subgroups were then classified as DLE (Group A), borderline SLE (Group B1) and SLE (Group B2) using another method. Each group had its own comparisons. Immunoreactant (IR) deposition was observed on the lesional skin in all patients and on the SPNL skin in 42 (44.7%). In patients with borderline SLE, the deposition of IgM was lower on the lesional LBTs, whereas isolated IgG was higher than SLE; thus, it shows similarity with DLE. Additionally, it was also closer to DLE because of the low deposition of C3, multiple IRs, and a double conjugate of IRs on the SPNL skin. However, it showed similarity with SLE in the high percentage of LBT positivity and more immunoglobulin M (IgM) and immunoglobulin G (IgG) deposition on the SPNL skin. The deposition of multiple conjugates on SPNL skin in patients with LE with discoid lesions may reflect systemic involvement. Despite the fact that LBT positivity on SPNL skin in borderline SLE was higher than DLE, less deposition of multiple conjugates compared to SLE indicates that the classification of borderline SLE with discoid lesions in the LE spectrum is questionable.

Unilateral Adult Xanthogranulomatous Infiltration of the Conjunctiva, Limbus and Sclera Leading to a Combined Ophthalmic Artery and Central Retinal Vein Occlusion.

OBJECTIVE: To describe the features of a female patient with a biopsy-proven xanthogranulomatous infiltration of the conjunctiva, limbus and sclera who had an exudative retinal detachment, combined ophthalmic artery and central retinal vein occlusion unilaterally. METHOD: A-53-year old otherwise healthy woman presenting with a painful visual loss in her right eye underwent an ophthalmic examination, meticulous systemic work-up and histopathologic assessment. RESULTS: Ophthalmic examination revealed multiple subconjunctival masses, upper limbal infiltrations, trace cells in the anterior chamber, pale looking posterior fundus, 360 degree scattered retinal hemorrhages and marked exudative retinal detachment in her right eye. Left eye was completely normal.A biopsy taken from one of the subconjunctival masses demonstrated a diffuse infiltration of the histiocytes and this was interpreted as a xanthogranulomatous infiltration with the help of immunohistochemical staining techniques. CONCLUSION: Present case is the only reported adult case with xanthogranulomatous-like infiltration of the eyeball featuring both anterior and posterior segment involvement without any concomitant major systemic disturbances.

Transition to Virtual Microscopy in Medical Undergraduate Pathology Education: First Experience of Turkey in Dokuz Eylül University Hospital.

OBJECTIVE: Pathology education includes an important visual part supporting a wide range of theoretical knowledge. However, the use of traditional microscopes in pathology education has declined over the last decade and there is a lack of interest for microscopy. Virtual microscopy, which was first described in 1985 and has experienced a revolution since 2000, is an alternative technique to conventional microscopy, in which microscopic slides are scanned to form digital images and stored in the web. The aim of this study was to evaluate the use of virtual microscopy in practical pathology sessions and its effects on our students and undergraduate education at our faculty. MATERIAL AND METHOD: Second and third year medical students who were used to conventional microscopes were included in the study. The practical sessions were carried out via virtual slides and the effect of the new technique was investigated by a scale at the end of each session. Academic staff from the pathology department joined sessions to promote discussion and respond to questions. Student ratings were analysed statistically. RESULTS: The evaluation of the ratings showed that the students were easily adapted to the use of virtual microscopy. They found it user-friendly and thought that the opportunity of viewing slides at home was advantageous. Collaboration between students and interactive discussions was also improved with this technique. CONCLUSION: It was concluded that the use of virtual microscopy could contribute to the pathology education of our students.

The role of BRAF mutation in patients with high-risk malignant melanoma treated with high-dose adjuvant interferon therapy.

Data regarding the prognostic importance of BRAFV600 tumor mutations in high-risk, non-metastatic, stage 2 and 3 malignant melanoma (MM) patients are controversial. There is not sufficient information in the medical literature regarding the reliability of BRAF mutations as a predictive factor in prognosis and adjuvant treatment decision issues in this patient group. The data of 50 operated high-risk, non-metastatic, stage 2B/2C and 3 MM patients who received high-dose interferon alfa-2b therapy were evaluated retrospectively. BRAF mutations were analyzed by using microarray-based molecular methods. The associations between BRAF mutations and both clinicopathological characteristics and survival were assessed. Of the 50 patients, 52 % was female and 48 % was male, and the median age was 51.5 years. Twenty-three (46 %) and 27 (54 %) patients had stage 2B/2C and stage 3 disease, respectively. BRAF mutation was detected in 21 patients. The median overall survival (OS) was 58.1 months, whereas the median disease-free survival (DFS) was 22.7 months. When the OS and DFS were compared according to the BRAF mutation status, no difference was detected between the two groups. BRAF mutations were detected more frequently in tumors with mitosis and ulceration; however, no statistically significant difference was observed in other clinicopathological parameters. In conclusion, it is not appropriate to use BRAF mutations as a prognostic and predictive marker for selecting the treatment and assessing its outcomes in patients with early stage, high-risk MM.

Trichoscopic findings in alopecia areata and their relation to disease activity, severity and clinical subtype in Turkish patients.

BACKGROUND/OBJECTIVE: Trichoscopic studies of alopecia areata are helpful in the non-invasive diagnosis and prediction of the course of the disease. The objective was to determine the relationship of trichoscopic findings in alopecia areata with disease activity, severity and clinical subtype in Turkish patients. METHODS: Trichoscopic examinations of 39 patients with alopecia areata were compared with 309 alopecia patients including psoriasis (n = 31), seborrhoeic dermatitis (n = 112), female androgenetic alopecia (n = 138), male androgenetic alopecia (n = 63), female androgenetic alopecia of male pattern (n = 5), telogen effluvium (n = 22) and trichotillomania (n = 4). A χ(2) test and logistic regression analysis were used for the statistical analysis. The odds ratios were calculated by cross tabulation. RESULTS: There was no relationship between the alopecia areata subtype and trichoscopic findings. On the other hand, a honeycomb hyperpigmentation pattern, cumulus-like clustered white dots, white dots and black dotted pigmentation related to severe disease, while exclamation mark hairs related to mild disease. Exclamation mark hairs were found to be related to active disease while atypical red vessels and white dots were negatively related to disease activity. CONCLUSION: In our study, further characteristic trichoscopic findings were detected in alopecia areata such as clustered white dots, multi-hair follicular unit, hidden hairs and black dotted pigmentation, in addition to previous findings. Hence, it is concluded that the identification and prediction of alopecia areata might be straightforward with the help of these new signs such as activation and severity findings.

[Pemphigoid gestationis: light microscopic and direct immunofluorescense findings]. / Gestasyonel Pemfigoid: Isik Mikroskopik ve Direkt Immünflöresan Bulgulari

Pemphigoid gestationis is a rare vesiculobullous dermatosis of pregnancy and puerperium. It is commonly seen in second or third trimester. Skin lesions are characterized by pruritic, urticarial plaques with the development of tense vesicles and bullae. Histopathology demonstrates a subepidermal eosinophil-rich vesiculation. Direct immunofluorescence microscopy reveals linear complement 3 and immunoglobulin G deposition along the basement membrane. We present a rare case of pemphigoid gestationis occurring in a 33-year-old pregnancy woman with symptom of generalized pruritis. Pemphigoid gestationis should be kept in mind in the differential diagnosis of vesiculobullous dermatitis of pregnancy.