Cutaneous malakoplakia in an HIV-positive patient.

Malakoplakia is an uncommon granulomatous infectious disease that is found primarily in the genitourinary tract, but may rarely involve the skin. We report a case of cutaneous malakoplakia in an HIV-positive patient diagnosed on the basis of Michaelis-Gutman bodies. The patient presented with ulcers, draining sinuses and tender papules and nodules mainly on perigenital area, buttocks and right thigh.

Acanthosis nigricans: a dermatologic marker of metabolic disease.

Most patients with acanthosis nigricans have either clinical or subclinical insulin resistance. We undertook a study to estimate the insulin sensitivity of a group of patients referred from the dermatologist with biopsy proven acanthosis nigricans. Thirty-six patients were evaluated in the Endocrinology clinic. Plasma glucose and serum Insulin levels were estimated after a 75 gms oral glucose load (OGTT). An intravenous Insulin Tolerance Test (ITT) was performed with measurement of Glucose Disposal Rate (GDR). There were 28 females and 8 males (M:F--3.5:1; mean age 26.3+/-1.7 years) in the study. 25/36 patients were morbidly obese (BMI--36.0 +/- 1.2 Kg/m2) with an abnormal body fat distribution (WH ratio--0.9 +/ - 0.02). One patient had generalized lipoatrophy. 16/36 patients with acanthosis nigricans had IGT or overt diabetes and all had highly significant hyperinsulinemia (AUCI = 20825 +/ 1287.7 vs. 6340.0 +/- 984.2 mIU/ml/hr in controls, p < 0.0005). The GDR in patients with acanthosis nigricans was reduced (-0.66 +/- 0.07) compared to controls (-0.39 +/- 0.08; p < 0.01). There was a significant positive correlation between indices of adiposity and insulin resistance in subjects with impaired tolerance.

A study of insulin resistance in subjects with acanthosis nigricans.

AIM: To study the prevalence of insulin resistance (IR) and its sequelae in patients with acanthosis. METHODOLOGY: Thirty six patients (28 females; eight males) with biopsy proven acanthosis nigricans and eight controls were evaluated for insulin sensitivity (IS) by estimating (a) the glucose and insulin responses to a 75 gm glucose load (Oral glucose tolerance test-OGTT), (b) the glucose disposal rate (GDR) during an intravenous insulin tolerance test (ITT). Serum androgen levels (testosterone--Te, androstenedione--ASD, Dehydro-epiandrosterone sulphate--DHEAS) were estimated in the basal state and 60 min after a bolus of insulin. Thyroid function tests (tri-iodo-thyronine--T3, thyroxine--T4, thyroid stimulating hormone--TSH) were performed in all subjects. RESULTS: The acanthotic population, overall had insignificant hyperglycemia (Area under curve of glucose--AUC-G : 17,745.5 +/- 847.5 v/s 11,051.3 +/- 274.5 mg/dl/min) and hyperinsulinemia (Area under curve of insulin -AUC-I: 20,825.2 +/- 1,287.7 v/s 6,340.1 +/- 984.2 microlU/ml/min) compared to controls during OGTT. Eight patients with acanthosis nigricans had impaired glucose tolerance and eight had overt diabetes using WHO criteria. 69.4% of the acanthotic subjects were obese and 13.9% (5/36) were hypertensive. Thyroid dysfunction was present in three (one had hypothyroidism and two had thyrotoxicosis). Reproductive disorders--menstrual irregularity (46.5%), amenorrhea (21.4%), hirsuitism (21.4%) and infertility (3.6%) was encountered in a significant number of acanthotics. Acanthotics overall had statistically higher levels of androgens; Te (females)--0.74 +/- 0.09 v/s 0.27 +/- 0.09 ng/ml (p < 0.005), ASD--1.8 +/- 0.21 v/s 0.94 +/- 0.2 ng/ml (p < 0.005) and DHEAS--1,880.8 +/- 216.3 v/s 772.8 +/- 210.4 ng/ml (p < 0.005). An elevated DHEAS correlated positively to body mass index (BMI) and android obesity. Serum Te levels correlated positively with GDR. Serum insulin levels increased progressively with obesity and acanthosis. Serum insulin was associated with progressive worsening of hyperandrogenism (as seen in non-obese controls, non-obese and obese acanthotics). CONCLUSIONS: Subjects with acanthosis nigricans should be screened for insulin resistance and its clinical and metabolic sequelae. Thyroid dysfunction should be sought in these subjects as it can be easily treated.

Candid-B cream in the treatment of candidiasis with inflammatory dermatoses--National Study Group.

Physicians (n = 84) across the country prescribed candid-B cream (clotrimazole 1% + beclomethasone dipropionate 0.025%) on 822 patients suffering from candidiasis with inflammatory diseases to evaluate the efficacy and safety of the combination. The results showed reduction in severity was more than 80% for all symptoms/signs except scaling and lichenification where the reduction was 76.05% and 66.03% respectively. Only one patient complained of adverse reaction. So in the treatment of coexisting candidiasis and inflammatory dermatoses the combination of clotrimazole 1% + beclomethasone 0.025% (candid-B cream) was found to be highly effective.

A comparison of systemic photochemotherapy with 8-methoxypsoralen (8-MOP) and with trimethylpsoralen (TMP) in vitiligo.

Oral 8-MOP and TMP were compared in the PUVA therapy for vitiligo. Group A (25 cases) was initiated on 0.3 mg/kg of 8-MOP with 1/2 Joule/cm2 of UVA and weekly increments of 1/2 Joule/ cm2 and Group B was started on 0.6 mg/kg of TMP with 1 Joule/cm2 of UVA and weekly increments of 1 Joule/cm2. Therapy was given thrice a week. Repigmentation was evaluated by using a 0-6 scale. At the end of 60 sittings, on acceptable cosmetic response was seen over the face, neck and upper extremities in both groups, while trunk and lower extremities showed lesser response. 8-MOP gave earlier response, needing a lower cumulative UVA dose i.e. 75 J/cm2 as compared to TMP i.e. 106 J/cm2. Phototoxicity was seen more often with 8-MOP. In conclusion, in Indians, 8-MOP is the drug of choice in PUVA therapy of vitiligo provided precautions against phototoxicity are adequate.

Proteus syndrome.

A 2½-year-old male child born of a nonconsanguineous marriage with high parental age presented with macrodactyly, dysmorphic features, large disfiguring lipomas, small fibromas, a linear verrucous epidermal naevus and lymphangioma circumscriptum. X-ray of hand revealed macrodystrophia lipomatosa progressiva. A lipoma and lymphangioma circumscriptum were confirmed by histopathology. The cosmetically disfiguring lipomas were excised. This is the first case report from India with the characteristic macrodactyly. This could possibly be the first case of report of a mutational disorder following intake of carbimazole during pregnancy.

Flexural planar xanthomas: report of four cases.

Four patients with primary hyperlipoproteinemia, Frederickson's type IIb, were observed to have symmetrical planar xanthomas affecting flexures: finger webs, antecubital and popliteal fossae, axillae, and intergluteal cleft. Other types of xanthomas were also present and serum lipid electrophoresis showed type IIb pattern. We draw attention to the peculiar pattern of symmetrical planar xanthomatosis hitherto described only with type III disease and some forms of normolipemic xanthomatoses.

Cutaneous vasculitis with peripheral neuropathy.

a 40-year-old male patient presented with cutaneous vasculitis affecting both lower legs without any evidence of systemic involvement and a bilateral sensory neuropathy affecting both lateral popliteal nerves. Treatment with oral prednisolone resulted in healing of the cutaneous lesions but the sensory loss persisted.

Comparison of topical methenamine, glutaraldehyde and tap water Iontophoresis for palmoplantar hyperhidrosis.

Sixty patients with palmo-plantar hyperhidrosis were studied to compare the efficacy and safety of topical methenamine in the treatment of palmo-plantar hyperhidrosis with established therapies like glutaraldehyde and tap water iontophoresis. Patients were randomly allocated to 3 treatment groups: topical Methenamine (10%) solution, topical Glutaraldehyde (5% for palms and 10% for soles) and tap water iontophoresis. Hyperhidrosis was graded into 4 grades. The total duration of therapy was 4 weeks for all the 3 groups. Patients were followed up weekly for 4 weeks and 2 weeks after completion of therapy. Response to therapy was evaluated by the change in the grade of hyperhidrosis. Side-effects like irritation and pigmentation were looked for at every follow up. Wilcoxon's rank sum test was used for comparison between changes in grading of 2 groups. It showed that methenamine is superior to tap water iontophoresis and acts faster than glutaraldehyde. Fewer side effects were noted with mether amine.

Endocrine profiles in six patients with acanthosis nigricans.

Six women (age range 17-38 years), who presented to the dermatology services with biopsy-proven acanthosis nigricans of variable duration were evaluated to rule out endocrine diseases. Menstrual abnormalities (5/6 patients), pallid striae (4/6 patients), hirsutism (4/6 patients) and acne vulgaris (2/6 patients) were found on physical examination. All the patients had body mass indices in the obese (> 27 kg/m2) range, and in association we found ovarian hyperthecosis, PCOD, premature ovarian failure, glucose intolerance and hyperprolactinaemia in the above six patients. The importance of appropriate endocrinal evaluation in patients with biopsy-proven acanthosis nigricans is emphasized.

Urticaria-pigmentosa-like lesions in acute lymphoblastic leukaemia (2 cases).

Two males aged 12 and 38 years presented with widespread severely pruritic blackish spots for 15 days. Widespread slate-grey patches and erythematous hyperpigmented plaques were observed with a positive Darier's sign. There were associated neck swellings, abdominal pain, anorexia, weight loss and bleeding gums in both. Peripheral blood and bone marrow showed blast cells, anaemia and thrombocytopenia. Cell surface markers confirmed the presence of acute lymphoblastic leukaemia. Skin biopsy showed an infiltrate of lymphoblasts as well as mast cells. Partial response was noted with cytotoxic therapy in 1 patient. Thus lesions mimicking urticaria pigmentosa may be the presenting sign of acute lymphoblastic leukaemia.

Alagille syndrome. A case report.

A 5-year-old physically and mentally retarded female child born of non-consanguineous parents, who had had disseminated skin lesions for 4 1/2 years, is presented. She had persistent neonatal jaundice associated with clay-coloured stools and generalized pruritus which receded by the age of 2 years. Examination revealed characteristic facies, moderate hepatosplenomegaly, cardiac murmur and widespread smooth yellow papules and nodules on ears, trunk, bony prominences and palms. Ophthalmic examination revealed corneal opacities. Liver function tests and lipidogram were abnormal. A diagnosis of Watson-Alagille Syndrome was made on the basis of characteristic facies, xanthomatosis and cholestatic jaundice.

Dermatomyositis with Calcinosis Cutis Universalis.

An eleven year old child with dermatomyositis and calcinosis cutis universalis is presented. She showed heliotrope bloating of eyelids, Gottrons sign, proximal muscle wasting with contractures and extensive areas of calcification over the shoulder, pelvic girdles and proximal extremities. The dignosis was confirmed by biochemical and histopatholo "cal studies as 91 well as electromyography. High doses of steroids and supportive measures made the patient ambulatory.

Doxycycline in the Treatment :uncomplicated Gonorrohea.

Gonorrhoea constitutes nine per cent of the sexually transmitted diseases seen at the department of Dermatology and Venereology, Nair Hospital, Bombay. Fifty cases of uncomplicated males were treated with doxycycline 200mgs iv on the first day and 100 mgs, iv for 2 more - a total of 400 mgs doxycycline. Smears for gonococci and blood V D R L were treatment. The cases were reviewed every week for a period 3 weeks. Three cases showed a positive serology and 44 cases responded well to therapy giving a success rate of 88%. Side effects were minimal.