Bowel-Associated Dermatosis-Arthritis Syndrome: A Case Report.

Introduction: Gastric bypass surgery is an effective surgical intervention for morbid obesity. However, it is not without risk. Gastric bypass surgery may produce malabsorptive or surgical complications, which can result in nutritional deficiencies as well as syndromes related to bacterial overgrowth in the blind loops of the bowel. Case Presentation: Severe nutritional deficiencies may occur due to patient noncompliance with the prescribed regimen, or arise secondary to malabsorptive or mechanical surgical complications. We describe a case of a 37-year-old female who underwent gastric bypass surgery and experienced a recalcitrant eczematous eruption with sporadic subcutaneous, purulent nodules which completely resolved after the reversal of her bariatric procedure. Conclusion: Since 2001, the number of morbidly obese patients who have undergone bariatric surgery has been increasing. As a result, clinicians can expect to more frequently encounter complications that can result from these procedures.

Presentations of Cutaneous Disease in Various Skin Pigmentations: Acne Vulgaris - Comedonal Acne.

Description Acne vulgaris is a common inflammatory skin condition of the pilosebaceous unit in adolescents and young adults and is primarily characterized by the presence of open and closed comedones. In patients of various skin pigmentations, skin-colored comedones may be difficult to appreciate and lead to incorrect or delayed diagnosis of acne. To aid in the identification of acne vulgaris in patients of various skin pigmentations, we present comedonal acne in different skin types and commonly encountered differential diagnoses. With its significant volume and burden of disease, acne vulgaris should be correctly identified in various skin pigmentations by primary care clinicians for the initiation of appropriate management.

Complete Clearance of Pustular Psoriasis After A Single Dose of Risankizumab.

Introduction: Psoriasis is a chronic, multifactorial, inflammatory skin disease with several subtypes, including pustular psoriasis. Pustular psoriasis is characterized by pustules forming lakes of pus on the skin. Pro-inflammatory pathways, such as the interleukin (IL)-17/IL-23 axis, have been shown to play a significant role in the pathogenesis of psoriasis. Biologic therapies directed towards these pro-inflammatory pathways have effectively treated plaque psoriasis, but fewer treatments have shown similar efficacy for pustular psoriasis. Case Presentation: We present a 45-year-old Black female who presented to the dermatology clinic with generalized pustular psoriasis affecting approximately 70% of her body surface area. She also noted joint stiffness and pain that was worse after inactivity. Her disease did not respond to previous treatment, which was using adalimumab for 6 months. She also had no response to a 3-month course of apremilast.Two weeks after receiving her first dose of risankizumab, she had complete clearance of her pustular psoriasis, affecting 0% of her body surface area. She also noted significant improvement in her joint pain. Conclusions: There is little data regarding the efficacy of IL-23 inhibitors in treating generalized pustular psoriasis. To date, our case is the only reported instance in the literature showing rapid clearance of pustular psoriasis after 1 injection of risankizumab. This case illustrates that IL-23 inhibitors play an essential role in the rapid clearance of pustular psoriasis.

Resolved Peristomal Erosive Papulonodular Dermatitis Mimicking Nevoid Hyperkeratosis of the Nipple and Areola.

Introduction: Nevoid hyperkeratosis of the nipple and areola (NHKNA) is a rare cutaneous entity with a distinct clinical and histological presentation. The type II form of this condition can result from various dermatoses, such as irritant contact dermatitis. Erosive papulonodular dermatitis is a chronic irritant dermatitis that often occurs in areas of occlusion and maceration, such as peristomal skin. Pseudoverrucous papules and nodules are a variant of erosive papulonodular dermatitis and have a non-specific histologic pattern of reactive hyperplasia. Case Presentation: We present a case of a patient with resolved peristomal erosive papulonodular dermatitis who presented status-post ileostomy reversal with clinical and histologic findings classically seen in NHKNA. Conclusion: In type II NHKNA, treatment of the primary dermatosis typically leads to resolutions. In the case of our patient, removal of the offending agent via colostomy reversal and barrier protection led to the resolution of the lesions.

Presentations of Cutaneous Disease in Various Skin Pigmentations: Inverse Psoriasis.

Description Inverse psoriasis is a clinical variant of psoriasis involving flexural or intertriginous areas of the body. Inverse psoriasis may be present in 3 to 36% of psoriasis patients. Lesions are clinically characterized as smooth, well-demarcated, erythematous plaques (raised, >1 cm) without the typical silvery scales of classic psoriasis. Differential diagnosis includes tinea infection, candidiasis, seborrheic dermatitis, or bacterial streptococcal infection. The clinical images in this review focus on identifying inverse psoriasis along the full spectrum of skin tones.

Presentations of Cutaneous Disease in Various Skin Pigmentations: Cutaneous Abscesses.

Description Cutaneous abscesses are collections of pus resulting from skin and soft tissue bacterial infections. They clinically exhibit the four cardinal inflammatory signs of pain, warmth, swelling, and erythema. In patients with darkly pigmented skin, classically-associated erythema may be challenging to appreciate and can lead to missed or delayed diagnosis. We compare abscess presentations in different skin types. Recognition of varying presentations of cutaneous abscesses in diverse skin colors will help clinicians utilize additional clues to identify and diagnose this entity correctly.

Delayed Diagnosis of Klippel-Trénaunay Syndrome in a 23-year-old African American Male.

Description Klippel-Trénaunay syndrome is a rare genetic disorder that typically presents as a triad of symptoms consisting of venous malformations (varicosities), capillary malformations (port-wine stain), and limb overgrowth. We followed a 23-year-old African American male with a past medical history of peripheral vascular disease, who was visiting the dermatology clinic for a persistent skin lesion on his thigh. During physical examinations, we noted a subtle port-wine stain on his right leg, right leg hypertrophy, and peripheral vascular disease. Skin findings were difficult to observe on his darker skin tone, Fitzpatrick skin type VI, which may have led to the delayed diagnosis of Klippel-Trénaunay syndrome. The lesion of concern was removed during a follow-up visit and was consistent with an angiokeratoma. Our patient had not suffered any serious complications from his new diagnosis of Klippel-Trénaunay syndrome; however, there was a concern for thrombotic events.

Presentations of Cutaneous Disease in Various Skin Pigmentations: An Introduction.

Description Dermatological disease has historically been dependent on photography as a primary modality for education. Previously, photographs used for medical education were representative of the regional patient populations at that time; however, they have not proportionally reflected the rapidly changing demographics in the United States. Education on the diagnosis of cutaneous disease has, therefore, primarily relied on photographs of lighter skin tones. There is a need for a better representation of darker skin tones in dermatologic medical education. This article introduces a clinical series that highlights dermatological diseases in various skin pigmentations, which are commonly seen in the primary care office. The goal is to improve the diagnostic accuracy of primary care clinicians and to compare how certain cutaneous diseases may vary in appearance depending on the individuals' Fitzpatrick skin type.

Presentations of Cutaneous Disease in Various Skin Pigmentations: Plaque Psoriasis.

Description Recent studies estimate that more than 8 million Americans have psoriasis. The prevalence of psoriasis in African Americans is 1.5% compared to 3.6% of Caucasians. Psoriasis is likely to be underdiagnosed among African Americans and other individuals with darker pigmented skin due to variations in clinical presentation in addition to disease distribution and severity. We present images of psoriasis vulgaris in a variety of Fitzpatrick skin types. Differences in the biology of skin pigmentation may explain the clinical masking of erythema in darker-skinned individuals. Recognition of this important difference will help clinicians utilize additional clues to identify and diagnose this entity correctly.

Pleomorphic Dermal Sarcoma: A Clinical and Histopathologic Emulator of Atypical Fibroxanthoma, but Different Biologic Behavior.

Description Pleomorphic dermal sarcoma (PDS) can clinically and histopathologically mimic atypical fibroxanthoma (AFX). However, it has a more aggressive clinical course with a higher recurrence rate and metastatic potential. This case presentation aims to report a rapidly-growing, exophytic, 4 cm tumor following a non-diagnostic shave biopsy 2 months prior and to highlight distinctive features between PDS and AFX needed to make the correct diagnosis. Like AFX, PDS occurs on the sun-damaged skin of the elderly, usually on the head and neck. Also, like AFX, PDS histopathologically consists of sheets or fascicles of epithelioid and/or spindle-shaped cells, often with multinucleation, pleomorphism, and numerous mitotic figures. Immunohistochemistry cannot distinguish PDS from AFX but is used to exclude other malignancies. PDS can be distinguished from AFX by size (PDS is usually >2.0 cm) and by the presence of more aggressive histopathologic features, such as subcutaneous involvement, perineural and/or lymphovascular invasion, and necrosis. PDS is a rare entity not well documented in the literature with confusing, misleading, and changing nomenclature. PDS is a diagnosis of exclusion made after complete excision of the tumor with the aid of histopathology and immunohistochemistry.

Linear Cutaneous Lupus Erythematosus Following Blaschko's Lines on the Scalp: Additional Cases and Review of the Literature.

Description Alopecia of the scalp has various causes and presentations. However, linear alopecia is unusual and lupus erythematosus presenting as linear alopecia is exceedingly rare. To date, there have been 16 documented cases of linear alopecia diagnosed as chronic cutaneous lupus erythematosus occurring in a linear configuration following Blaschko's lines. We report 2 additional cases and review the clinical and histologic features along with treatment. This Blaschkoid linear variant of cutaneous lupus erythematosus has distinct clinical and histologic characteristics that set it apart from other causes of alopecia and from classic forms of cutaneous lupus. These distinct features include a linear configuration, a younger age of presentation, a disproportionate number of Asians affected, and a paucity of cases with systemic involvement. Histologically, the lesions are characterized by prominent mucin in the dermis and subcutaneous tissues. Blaschkoid linear lupus of the scalp is sufficiently distinctive to suggest the diagnosis on histology alone, in the appropriate clinical context. The most common and successful treatments included systemic and/or combination treatment with oral hydroxychloroquine, oral steroids, and/or intralesional steroids.

Acyclovir-Resistant Anogenital Herpes Simplex Virus in an HIV Patient With Pseudoepitheliomatous Hyperplasia Resembling Squamous Cell Carcinoma.

Background: Herpes simplex virus (HSV) is a common infection. However, it may present atypically when patients are immunocompromised, such as with slowly expanding, long-lasting ulcerative or hypertrophic lesions. The histopathologic finding of pseudoepitheliomatous hyperplasia (PEH) can occur in a variety of situations where there is chronic inflammation and can be seen in patients with chronic HSV. Atypical presentations of HSV, particularly hypertrophic lesions with histopathologic findings of PEH, can be misinterpreted as squamous cell carcinoma, create difficulty in diagnosis and hinder appropriate treatment. Case Description: We report a case of a 59-year-old female with a past medical history of human immunodeficiency virus (HIV), who presented at a dermatology clinic with multiple exophytic ulcerations of varying sizes in the perianal region. The patient was diagnosed with HSV and was started on valacyclovir. Over a several-year period, the patient had multiple recurrences of her HSV lesions with persistent vulvodynia despite prophylactic treatment with valacyclovir. Specimens were collected for culture and sensitivities, which revealed acyclovir resistance. The patient's lesions were biopsied due to concern for possible malignancy. Biopsies revealed prominent PEH. The patient had improvement of her HSV with saucerization, topical imiquimod, and increased doses of prophylactic valacyclovir. Conclusion: Atypical, chronic presentations of HSV are common in immunocompromised patients. Hypertrophic HSV is the least common clinical presentation and can be mistaken for squamous cell carcinoma, creating difficulty in diagnosis. Due to concerns for malignancy, our patient's lesions were biopsied, which revealed prominent PEH. While PEH is benign, it can be misdiagnosed as squamous cell carcinoma on histopathology, particularly when there is clinical suspicion for malignancy. In these cases, the clinician needs to alert the pathologist to the immunosuppressed status of the patient. Detailed evaluation for infectious causes, such as HSV, can avoid misinterpretation and potential surgical and oncological overtreatment.

Congenital Giant Juvenile Xanthogranuloma, Let It Be.

Description Juvenile xanthogranuloma (JXG) is a rare type of non-Langerhans cell histiocytosis. JXGs are benign and have a self-limiting course generally lasting 6 months to 3 years, with some reported durations longer than 6 years. We present a rarer congenital giant variant, defined as lesions with a diameter larger than 2 cm. It is uncertain if the natural history of giant xanthogranulomas is similar to the usual JXG. We followed a 5-month-old patient with a 3.5 cm in diameter, histopathologically-confirmed, congenital, giant JXG located on the right side of her upper back. The patient was seen every 6 months for 2.5 years. At 1 year of age, the lesion had decreased in size, lightened in color, and was less firm. At 1.5 years old, the lesion had flattened. By 3 years old, the lesion had resolved but left a hyperpigmented patch with a scar at the punch biopsy site. Our case represents a congenital giant JXG that was biopsied to confirm the diagnosis and then monitored until resolution. This case supports the clinical course of giant JXG not being affected by the larger lesion size and that aggressive treatments or procedures are not warranted.

Incidence of Endemic Human Cutaneous Leishmaniasis in the United States.

Importance: Leishmaniasis is recognized as an endemic human disease in Africa, the Middle East, Asia, and South America. Yet despite case reports of endemic human leishmaniasis in the United States, and well-documented occurrences of disease in various animal vectors and reservoirs, the endemicity of leishmaniasis in North America has not yet been established. Moreover, leishmaniasis is not a federally reportable disease in the United States. Clinical awareness of endemic disease therefore remains low, with North American physicians considering leishmaniasis a tropical disease. Objective: To assess the endemicity of human leishmaniasis in the United States. Design, Setting, and Participants: This cross-sectional multicenter observational study reviewed cases of human leishmaniasis occurring in the United States from 2007 through 2017. Previously diagnosed, deidentified cases of leishmaniasis were reported by the institutions of the authors and acknowledged contributors, as well as the Texas Department of State Health Services. Cases of leishmaniasis were identified by searching by disease name (leishmaniasis) or International Classification of Diseases, 9th and 10th Revisions diagnosis codes in the respective laboratory information systems. Exposures: Via examination of deidentified demographics, cases of leishmaniasis were classified as one of the following: (1) documentation of no history of travel outside of the United States within 10 years; (2) positive history of travel outside of the United States within 10 years; or (3) unknown or no documentation of travel history. Main Outcomes and Measures: Cases of leishmaniasis were considered endemic if identified in patients with documentation of no travel history outside of the United States within 10 years. Results: Of the 69 novel cases of human cutaneous leishmaniasis identified in this study, 41 (59%) were endemic; the median age at diagnosis was 61 years (range, 3-89 years), and 28 (68%) of the endemic cases occurred in female patients. Twenty-two (32%) cases had documentation of Leishmania speciation performed by polymerase chain reaction, and in 100% of these cases the infectious organism was identified as Leishmania mexicana. Conclusions and Relevance: Human cutaneous leishmaniasis is endemic in the United States, and, at least regionally, is acquired endemically more frequently than it is via travel. Our data argue in favor of making leishmaniasis a federally reportable disease and may have substantial implications on North American public health initiatives, with climate models predicting the number of citizens exposed to leishmaniasis will double by 2080.

Insight into Natural History of Congenital Vitiligo: A Case Report of a 23-Year-Old with Stable Congenital Vitiligo.

Vitiligo is a disorder of skin pigmentation. It affects approximately 1% of the world's population. Vitiligo occurs equally between the sexes with no racial predilections. The majority of cases are acquired and arise between the second and third decades of life. Acquired vitiligo has an unpredictable clinical course. Congenital vitiligo is rare with few reported cases. Due to the rarity of congenital vitiligo, little is known about the clinical course. For patients with acquired or congenital vitiligo, the psychosocial burden can have a profound impact on quality of life. The unknown course of congenital vitiligo can exacerbate the feelings of distress and embarrassment. We report of a case of congenital vitiligo that has been stable for 23 years. The patient had no associated autoimmune disease. The pathogenesis of congenital vitiligo is unknown. This case may be useful to assist clinicians caring for newborns with congenital vitiligo in reassuring parents.

Perianal Comedones: A Rare Incidental Finding.

Comedones occur when an overproliferation of keratinocytes blocks sebum secretion in a pilosebaceous duct. Comedones have multiple possible etiologies and contributing factors. While comedones are common to acne, they are also seen in occupational exposures and are associated with certain syndromes. We describe a particularly rare case of comedones at the perianus that is not associated with any known exposure or disease and is a rare incidental finding.

Mortality hazard and survival after tuberculosis treatment.

OBJECTIVES: We compared mortality among tuberculosis (TB) survivors and a similar population. METHODS: We used local health authority records from 3 US sites to identify 3853 persons who completed adequate treatment of TB and 7282 individuals diagnosed with latent TB infection 1993 to 2002. We then retrospectively observed mortality after 6 to 16 years of observation. We ascertained vital status as of December 31, 2008, using the Centers for Disease Control and Prevention's National Death Index. We analyzed mortality rates, hazards, and associations using Cox regression. RESULTS: We traced 11 135 individuals over 119 772 person-years of observation. We found more all-cause deaths (20.7% vs 3.1%) among posttreatment TB patients than among the comparison group, an adjusted average excess of 7.6 deaths per 1000 person-years (8.8 vs 1.2; P < .001). Mortality among posttreatment TB patients varied with observable factors such as race, site of disease, HIV status, and birth country. CONCLUSIONS: Fully treated TB is still associated with substantial mortality risk. Cure as currently understood may be insufficient protection against TB-associated mortality in the years after treatment, and TB prevention may be a valuable opportunity to modify this risk.

Treatment for preventing tuberculosis in children and adolescents: a randomized clinical trial of a 3-month, 12-dose regimen of a combination of rifapentine and isoniazid.

IMPORTANCE: Three months of a once-weekly combination of rifapentine and isoniazid for treatment of latent tuberculosis infection is safe and effective for persons 12 years or older. Published data for children are limited. OBJECTIVES: To compare treatment safety and assess noninferiority treatment effectiveness of combination therapy with rifapentine and isoniazid vs 9 months of isoniazid treatment for latent tuberculosis infection in children. DESIGN, SETTING, AND PARTICIPANTS: A pediatric cohort nested within a randomized, open-label clinical trial conducted from June 11, 2001, through December 17, 2010, with follow-up through September 5, 2013, in 29 study sites in the United States, Canada, Brazil, Hong Kong (China), and Spain. Participants were children (aged 2-17 years) who were eligible for treatment of latent tuberculosis infection. INTERVENTIONS: Twelve once-weekly doses of the combination drugs, given with supervision by a health care professional, for 3 months vs 270 daily doses of isoniazid, without supervision by a health care professional, for 9 months. MAIN OUTCOMES AND MEASURES: We compared rates of treatment discontinuation because of adverse events (AEs), toxicity grades 1 to 4, and deaths from any cause. The equivalence margin for the comparison of AE-related discontinuation rates was 5%. Tuberculosis disease diagnosed within 33 months of enrollment was the main end point for testing effectiveness. The noninferiority margin was 0.75%. RESULTS: Of 1058 children enrolled, 905 were eligible for evaluation of effectiveness. Of 471 in the combination-therapy group, 415 (88.1%) completed treatment vs 351 of 434 (80.9%) in the isoniazid-only group (P = .003). The 95% CI for the difference in rates of discontinuation attributed to an AE was -2.6 to 0.1, which was within the equivalence range. In the safety population, 3 of 539 participants (0.6%) who took the combination drugs had a grade 3 AE vs 1 of 493 (0.2%) who received isoniazid only. Neither arm had any hepatotoxicity, grade 4 AEs, or treatment-attributed death. None of the 471 in the combination-therapy group developed tuberculosis vs 3 of 434 (cumulative rate, 0.74%) in the isoniazid-only group, for a difference of -0.74% and an upper bound of the 95% CI of the difference of +0.32%, which met the noninferiority criterion. CONCLUSIONS AND RELEVANCE: Treatment with the combination of rifapentine and isoniazid was as effective as isoniazid-only treatment for the prevention of tuberculosis in children aged 2 to 17 years. The combination-therapy group had a higher treatment completion rate than did the isoniazid-only group and was safe. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00023452.