Punch grafting for the treatment of ulcerated atrophie blanche.

Case report: A 79-year-old woman presented with a large painful ulcer on the lateral aspect of her left leg over a 6-month period and was diagnosed of ulcerated atrophie blanche. On an outpatient basis punch grafting was performed and 3 weeks after, complete epithelization was achieved. Discussion: Ulcerated atrophie blanche is a misdiagnosed disorder with painful lesions and, consequently, a high impact on quality of life. Atrophie blanche describes porcelain-white colored, red-dotted atrophic plaques on legs or feet. It may be due to multiple causes, usually associated with alterations in the microcirculation. All causes of atrophie blanche can be included in the term livedoid vasculopathy, a type of occlusive vasculopathy without vasculitis. Many patients with atrophie blanche and livedoid vasculopathy have also chronic venous insufficiency. Etiological treatment should be prescribed in order to avoid progression of the lesions. In case of chronic venous insufficiency, control of venous hypertension is essential. Without anti-edema measures, superficial, very painful, and resistant ulcers may appear. These ulcers can be considered a wound on scar tissue; therefore, it must be treated as a hard-to-heal wound. As we show in this case, punch grafting is an effective therapeutic alternative for wound closure and pain reduction of ulcerated atrophie blanche.

Autoantibodies to intrinsic factor can jeopardize pernicious anemia diagnosis: a case report.

Vitamin B12 deficiency may cause neurological and hematological alterations. Its assessment should be easy considering that the access to its measurement is available in majority of the clinical laboratories. The presence of technical interference when measuring vitamin B12 can lead to an erroneous or a more difficult diagnosis of conditions as pernicious anemia. We report a case in which an interference in the evaluation of vitamin B12 concentration led to the realization of invasive tests and almost a misdiagnosis of a patient who actually had pernicious anemia. Professionals need to be aware of these interferences when we assess outcomes.

Skin manifestations in patients hospitalized with confirmed COVID-19 disease: a cross-sectional study in a tertiary hospital.

BACKGROUND: COVID-19 cutaneous manifestations have been recently described and classified in five different clinical patterns, including acral erythema-edema (pseudo-chilblain), maculopapular exanthemas, vesicular eruptions, urticarial lesions, and livedo or necrosis. OBJECTIVES: The objective of this study was to examine the skin of hospitalized patients with a confirmed diagnosis of COVID-19 disease and describe the real prevalence of skin manifestations. METHODS: A cross-sectional study, which included hospitalized patients in Cruces University Hospital from April 14-30, 2020, with a laboratory-confirmed diagnosis of COVID-19 (with polymerase chain reaction and/or serology tests), was conducted. Entire body surface examination was performed by experienced dermatologists to search for cutaneous manifestations related to COVID-19 disease. RESULTS: From a sample of 75 patients, 14 (18.7%) developed cutaneous manifestations possibly related to COVID-19. We found six patients with acral erythema-edema (pseudo-chilblain) (42.8%), four patients with maculopapular exanthemas (28.6%), two patients with urticarial lesions (14.3%), one patient with livedo reticularis-like lesions (7.15%), and one patient with vesicular eruption (7.15%). CONCLUSIONS: Our study provides a more plausible relationship between the main cutaneous patterns and COVID-19 in hospitalized patients as all of them had a confirmatory laboratory test. Skin manifestations are frequent but mild with spontaneous resolution. These findings are nonspecific and can be similar to other viral infections and adverse drug reactions in hospitalized patients.

Biomarkers of heart failure in pleural fluid.

BACKGROUND: The objective of this study was to compare the diagnostic accuracy of pleural fluid brain natriuretic peptide (BNP), N-terminal pro-BNP (NT-pro-BNP) and ST2, which are biomarkers of myocyte stress, for diagnosing pleural effusions due to heart failure (HF). BNP and ST2 have not been previously evaluated in pleural fluid. METHODS: The three biomarkers were measured in the pleural fluid of 90 cardiac effusions and 91 noncardiac effusions by commercially available methodologies. The area under the curve (AUC) quantified the overall diagnostic accuracy of the tests. RESULTS: Pleural fluid NT-pro-BNP, BNP, and ST2 demonstrated AUCs of 0.96, 0.90 and 0.59, respectively, for diagnosing effusions due to HF. The cutoff values of 1,300 and 115 pg/mL, respectively, for NT-pro-BNP and BNP had the best discriminating properties. The reference level for BNP was particularly accurate in men > 75 years of age (AUC, 0.98), but age, gender, and serum creatinine level did not influence the NT-pro-BNP levels. Of the 20 patients whose cardiac effusions were misclassified as exudates by the criteria of Light et al, 18 patients (90%) and 14 patients (70%), respectively, would have been correctly categorized by NT-pro-BNP and BNP, whereas only 10 patients (50%) would have been appropriately classified by the serum-pleural protein gradient. CONCLUSIONS: The pleural fluid NT-pro-BNP level is very useful in establishing the diagnosis of HF-associated effusions, and it confirms this diagnosis better than pleural BNP levels. The measurement of NT-pro-BNP rather than the serum-to-pleural protein gradient is recommended for identifying mislabeled cardiac transudates. The pleural fluid ST2 level is not helpful in diagnosing HF.