Bullous Pemphigoid Associated With Dipeptidyl Peptidase-4 Inhibitors: A Case Report and Review of Current Evidence.

Dipeptidyl peptidase-4 inhibitors (DPP-4i), or gliptins, are a widely used glucose-lowering agents. A growing amount of evidence pointed to a possible role of DPP-4i in the induction of bullous pemphigoid (BP), which is an auto-immune skin blistering disease that mainly affects the elderly. In this article we discuss a case of DPP-4i associated BP and we provide an updated review of the current knowledge regarding this emerging entity. Use of DPP-4i, particularly vildagliptin, was found to significantly increase the risk of BP. BP180 would be in the center of the aberrant immune response. DPP-4i induced BP is thought to be associated with male gender, mucosal involvement, and milder inflammatory phenotype especially in Asian population. Generally, patients may not remit fully after DPP-4i withdrawal only and require either topical or systemic glucocorticoid courses.

Dermoscopy of Onychomycosis: A Systematic Review.

INTRODUCTION: Onychomycosis represents a global burden accounting for about 50% of nail consultations. Several studies have tried to assess the dermoscopic features of onychomycosis. With the multiplication of papers, several "new" dermoscopic signs keep being added leading to some inconsistency in onychoscopic terminology. OBJECTIVE: This study aimed to summarize the existing literature on the dermoscopic features of onychomycosis and propose a unified onychoscopic terminology. METHODS: The literature search was performed using PubMed and Scopus databases up to October 30, 2021 to identify eligible contributions. In total, 33 records (2111 patients) were included. RESULTS: The main dermoscopic signs of onychomycosis are "ruin appearance", "longitudinal striae" and "spikes" on the proximal margin of onycholytic areas, with a specificity of 99.38%, 83.78%, and 85.64% respectively. The "aurora borealis" sign had the highest sensitivity and specificity. CONCLUSIONS: The current review provides a framework for issues related to the onychoscopic terminology of onychomycosis and is intended to serve as an aid for students, teachers, and researchers. We proposed a unifying terminology to describe dermoscopic signs of onychomycosis. Dermoscopic signs of onychomycosis show good specificity and are useful in distinguishing nail psoriasis, trauma, and onychomycosis. It helps differentiate fungal melanonychia from nail melanoma, nevi, and melanocytic activation.

Whitish patches on the buccal mucosa: Role of dermoscopy.

Morsicatio is caused by chronic self-inflicted biting of the buccal mucosa that results in clinically whitish plaques. It is frequently confused with other dermatological mucosal disorders. To avoid needless invasive procedures, dermoscopy can help with differential diagnosis. Dermoscopy shows whitish and yellowish structureless areas and lines, small erosions, and some white scales. The lack of additional, more specific signs such as Wickham striae is crucial to guide the diagnosis.

Efficiency and herding analysis in gold-backed cryptocurrencies.

This study analyses and compares the behavior of the gold-backed, conventional cryptocurrency, and gold markets capable of detecting the existence of herding and deducing the efficiency degree. In addition, this empirical work tried to examine the COVID-19 pandemic's influence on both cryptocurrency performances. This work developed a new method that discloses herding biases using persistence and efficiency metrics. Besides, this paper investigated the nonlinear dynamic properties of the gold-backed, conventional cryptocurrencies and Gold by estimating the Multifractal Detrended Fluctuation Analysis (MFDFA). It also assessed the inefficiency of these markets through an efficiency index (IEI) and tested the effect of COVID-19 on their dynamics. The findings of this investigation indicate that the gold-backed cryptocurrency (X8X) is the most efficient market in the long-term trading market. However, the conventional cryptocurrency market (Bitcoin) is the most efficient on the short trade horizon. Besides, gold-backed cryptocurrency markets present a smaller level of herding behavior than conventional cryptocurrencies on tall scales. Nevertheless, we noted the positive and negative effects of the pandemic on each cryptocurrency market dynamics. To the best of the authors' knowledge, this study is the first investigation that uses multifractal analysis to quantify the impact of the COVID-19 spread on gold-backed cryptocurrencies and detects the presence of herding behavior.

How the cryptocurrency market has performed during COVID 19? A multifractal analysis.

Cryptocurrency markets are complex systems based on speculation. Where investors interact using strategies that generate some biases responsible for endogenous instabilities. This paper investigated the herding biases by quantifying the self-similarity intensity of cryptocurrency returns' during the COVID-19 pandemic. The main purpose of this work was to study the level of cryptocurrency efficiency through multifractal analysis before and after the coronavirus pandemic. The empirical results proved that COVID-19 has a positive impact on the cryptocurrency market efficiency.

[Kinetics, diagnostic and prognostic value of procalcitonin after cardiac surgery]. / Cinétique et intérêt diagnostique et pronostique de la procalcitonine après chirurgie cardiaque.

Cardiac surgery with cardiopulmonary bypass (CPB) can cause a systemic inflammatory response (SIRS) making difficult the interpretation of inflammatory markers. Procalcitonin (PCT) is a marker of inflammation that appears to be a good early marker of infection after cardiac surgery. To study the kinetics of PCT after cardiac surgery with CPB and to determine its diagnostic and prognostic value. This is a prospective observational study including 40 adult patients consecutively operated for a coronary or valve surgery with CPB, so programmed or semi-urgent. The anesthetic protocol was standardized for all patients. A determination of PCT and CRP was performed before the CEC, at the decision of the CEC (H0), 4 hours after (H4), then H24, H48, H72 and H96. The rate of PCT and CRP increased significantly from the H4 until 4(th) day compared to baseline. (p<0.05). The concentration of PCT increased at the end of CPB, reaching its peak on 1(st) day (0.96±1.00 ng/mL) and then declined rapidly to J2, J3 and J4. CRP showed a slower kinetics with a peak on day 2 (204±81 mg/L) and decreased more slowly. PCT levels showed no significant variation depending on the type of surgery and they were significantly increased in cases of severe SIRS, late postoperative infection and postoperative renal dysfunction (PORD). However, the rates of CRP were not correlated with these complications. According to ROC curve analysis, a threshold value of 0.958 ng/mL PCT measured on the 1(st) day after surgery had a sensitivity of 85% and a specificity of 95% for the prediction of severe SIRS with organ dysfunction. For a threshold of 1.2 ng/mL measured at day 1 postoperatively, the PCT has a sensitivity of 100% and a specificity of 96% for predicting late infection. For a threshold value of 0.475 ng/mL measured at the decision of the CPB, the PCT has a sensitivity of 80% and a specificity of 69% for predicting PORD. PCT levels were correlated with severity scores. They were also correlated with length of stayin ICU. According to ROC curve analysis, a cutoff of 0.737 ng/mL measured at 1(st )postoperative day, the PCT has a sensitivity of 76% and a specificity of 91% for the prediction of an ICU stay of more 3 days with AUC=0.818. The PCT is a marker that has a fast kinetics and can early predict severe SIRS, and late postoperative infection as well as PORD.

N-terminal pro-brain natriuretic peptide identifies patients at risk for occurence of postoperative atrial fibrillation in cardiac surgery with cardiopulmonary bypass.

Atrial fibrillation (AF) is the most common arrhythmia after cardiac surgery with cardiopulmonary bypass (CPB).The value of N-terminal (Nt)-pro brain natriuretic peptide (BNP) in predicting AF complicating cardiac surgery is not well studied. Our objective is to determine its predictive value in the occurrence of AF after cardiac surgery with CPB. In a prospective observational study, including patients scheduled for cardiac surgery with CPB, we collected blood samples for each patient: the first one immediately after the induction of anesthesia and before CPB. The subsequent samples were taken at the end of the CBP (H0), 4 hours later (H4), and every day during the first four days (H24, H48, H72 and H96). Nt-proBNP and cardiac troponin (cTnI) were measured in each sample. The levels of Nt-proBNP were significantly increased in patients who developed AF. The receiver operating characteristic curve (ROC) analysis of Nt-proBNP studied at different times showed that assays at the end of the CPB and at H4 had the maximum area under the curve (AUC). A threshold value of 353.5 pg/mL of Nt-proBNP at the end of the CPB showed a sensitivity of 71% and a specificity of 84% for the prediction of AF and an AUC of 0.711. The threshold value (307.5 pg/mL) of Nt- proBNP measured at H4 had the same sensitivity but a lower specificity (74%) and AUC = 0.709. We conclude that Nt-proBNP values of 353 and 307 pg/mL at 0 and 4 hour after CPB could predict occurrence of AF.

[Usefulness of magnetic resonance imaging in the diagnosis of early rheumatoid arthritis: a prospective study of 20 cases]. / Intérêt de l'Imagerie par Résonance Magnétique dans le diagnostic des formes débutantes de la Polyarthrite Rhumatoïde : Etude prospective à propos de 20 cas.

BACKGROUND: Diagnosing early rheumatoid arthritis is difficult and radiographic signs are often late. MRI detects erosions at an early stage and visualizes synovitis, bone edema and tenosynovitis. AIM: To assess the value of MRI for diagnosis of early forms of rheumatoid arthritis. METHODS: Prospective study involving 20 patients who had non erosive rheumatoid arthritis lasting for less than 2 years. MRI of the hand was performed by sequences coronal and axial T1-weighted, T2 with saturated fat signal (FatSat) FatSat and T1 with gadolinium injection. RESULTS: The median age of patients was 52 years and sex ratio M/F of 0.05. The median disease duration was 9 months. Ten patients had antibodies Anti-Cyclic citrullinated protein positive. The MRI was abnormal in 75% of patients. This review found 36 erosions which 50% were in carpal bones, 55 joints with synovitis mainly localized midcarpal and metacarpophalangeal. Bone edema was found mainly in carpal bones. Tenosynovitis affected most frequently the flexor tendons. Seventy percent of patients without anti-Cyclic citrullinated protein had a pathological MRI. CONCLUSION: MRI has an important role in detecting infraradiological lesions in early RA. This contributes to early diagnosis and initiation effective treatment.

Acute myocardial infarction in a patient with hypofibrinogenemia: a case report.

INTRODUCTION: Congenital fibrinogen deficiency is a rare coagulation disorder usually responsible for hemorrhagic diathesis. However, it can be associated with thrombosis and there have been limited reports of arterial thrombotic complications in these patients. CASE PRESENTATION: A 42-year-old Tunisian man with congenital hypofibrinogenemia and no cardiovascular risk factors presented with new onset prolonged angina pectoris. An electrocardiogram showed features of inferior acute myocardial infarction. His troponin levels had reached 17 ng/L. Laboratory findings confirmed hypofibrinogenemia and ruled out thrombophilia. Echocardiography was not useful in providing diagnostic elements but did show preserved left ventricular function. Coronary angiography was not performed and our patient did not receive any anticoagulant treatment due to the major risk of bleeding. Magnetic resonance imaging confirmed myocardial necrosis. Our patient was managed with aspirin, a beta-blocker, an angiotensin-converting enzyme inhibitor and statin medication. The treatment was well tolerated and no ischemic recurrence was detected. CONCLUSION: Although coronary thrombosis is a rare event in patients with fibrinogen deficiency, this condition is of major interest in view of the difficulties observed in managing these patients.

A delayed diagnosis of lepromatous leprosy: pitfalls and clues to early recognition.

PURPOSE: To remind special attention to atypical symptoms of Hansen's disease, we report a case of an atypical case due to a delayed diagnosis. BACKGROUND: Clinical features of leprosy are well known, cutaneous lesions and involvement of the peripheral nerves being the cardinal clinical signs. Among these presentations, systemic involvement, including mucous membranes of the upper respiratory tract and eyes, is rarely reported even if it is still commonly seen in endemic areas, in particular lepromatous leprosy. CASE REPORT: We describe here a new case of Hansen's disease in a 51-year-old Tunisian woman with an atypical presentation and a delayed diagnosis. The early symptoms of the disease were different from the main clinical signs of Hansen's disease since they involved the upper respiratory tract and the eyes. A nasal smear was positive for acid-fast bacilli, thus confirming the diagnosis of bacilliferous leprosy. Histological findings suggested the diagnosis of leprosy and were somewhat more characteristic of the borderline lepromatous type. CONCLUSION: Diagnosis of Hansen's disease in patients with neither apparent skin lesions nor neurological signs is still problematic. Clinicians should not only pay attention to the more obvious signs in their own fields of expertise but should be aware of the possible systemic involvement of leprosy.

Atherogenic lipid profile in Behçet's disease: evidence of alteration of HDL subclasses.

BACKGROUND AND AIMS: Behçet's disease (BD) is an inflammatory vasculitis, most common in the Mediterranean area and Asia. Evidence for accelerated atherosclerosis in BD has been observed. The relationship between cardiovascular risk factors and accelerated atherosclerosis in patients with BD is still controversial. The aim of this study was to evaluate the lipid profile and to investigate the low-density lipoprotein (LDL) size and the distribution of high-density lipoprotein (HDL) subpopulations in BD patients. METHODS: Thirty six BD patients were compared to 36 healthy controls. Total cholesterol (TC), triglycerides (TG) and HDL-cholesterol (HDL-C) levels were measured using standard techniques. HDL subclasses and LDL-C size were estimated using polyacrylamide linear gradient gel electrophoresis. The LDL-C/HDL-C ratio was also calculated. High-sensitive C-reactive protein (hsCRP) level was measured by a turbidimetric method. Homocysteine (Hcy) level was determined using a liquid chromatography tandem mass spectrometry (LC/MS/MS). RESULTS: In BD patients, HDL-C levels as well as its subfraction levels were decreased (respectively, p <10(-6) and p <10(-3)). Percentage of HDL2 subpopulation was also decreased (p=0.02). HDL3 subfraction was significantly higher (p=0.02). The LDL-C/HDL-C ratio and CRP level were increased (respectively, p=10(-4) and p=0.003). TC was correlated with CRP. HDL-C and its subfractions were correlated with CRP and TG levels. HDL subparticle percentages were also correlated with age. CONCLUSIONS: Our findings of a reduction of HDL-C and HDL2 subpopulation and an increase HDL3 subclass and a higher LDL-C/HDL-C ratio may be considered as important predictors of cardiovascular events in BD patients.

[Evaluation of small bowel involvement in Crohn's disease by small- bowel videocapsule endoscopy: a prospective comparative study with computed-tomography enteroclysis and small bowel radiography]. / Évaluation de l'atteinte du grêle de la maladie de Crohn par vidéocapsule endoscopique : étude prospective et comparative avec le transit du grêle et l'entéroscanner.

BACKGROUND: Small-bowel videocapsule endoscopy (VCE) is a new technique in evaluation of intestinal involvement in several pathologies. Crohn's disease affects principally terminal ileum. Small bowel involvement in Crohn's disease is not well estimated by endoscopic and radiologic conventional techniques. AIMS: To evaluate the performances of VCE in detection of asymptomatic proximal small bowel lesions in consecutive patients with Crohn's disease with terminal ileal involvement, to compare the results of VCE to small bowel radiography and CT-enteroclysis and to determine the therapeutic impact of VCE in these patients. METHODS: A prospective study which included Crohn's disease patients with distal ileal involvement, based on radiological or endoscopic findings. We performed in all patients small bowel radiography, CT enteroclysis and VCE. Proximal involvement was characterized by presence of aphtoid, superficial or deep ulcerations in the jejunum or the proximal ileum. RESULTS: We studied 20 patients (12 men, mean age 31.6 years). VCE confirmed the distal ileal involvement in all patients. Significative proximal lesions was observed in nine patients (jejunum only: one case, jejunum and ileum: six cases and proximal ileum: two cases), in most cases aphtoid or superficial lesions. Deep ulcerations were observed in two patients. Small bowel radiography showed proximal ileal lesions in only two patients, and CT-enteroclysis in only one patient. Treatment by azathioprine was prescribed in two patients with severe and extended small bowel lesions in VCE examination. CONCLUSION: VCE is more accurate than radiologic techniques in detection of small bowel lesions in Crohn's disease. In cases of severe and extended small bowel involvement, VCE can conduct to changes of therapeutic approach.

[Rosai -Dorfman disease: a two cases report]. / La maladie de Rosai ­ Dorfman : a propos de deux observations.

BACKGROUND: Rosai-Dorfman disease (RDD) is a benign lymphoproliferatif disorder characterized by cervical lymphadenopathies with a consistent risk of airways' compression and esthetical prejudice. Extra nodal localizations are also described. AIM: To report two pediatric cases of RDD. CASES: the first case concerned a patient with a prolonged nodal involvement of RDD. Remission seems to be natural although it coincided with a sulfaméthoxazole- triméthoprime therapy. The second case illustrated an extranodal form of RDD localized in soft tissue and paranasal sinus with extension to nasal cavity which were corticodependant. CONCLUSION: RDD is usually a benign disorder. Particular localizations, lack of effective therapy and the high risk of recurrence are important issues in this rare affection.