A Rare Case of Multidrug-Resistant Lupus Vulgaris with a Mixed Pattern of Resistance - A Long Journey to Diagnosis and Treatment.

An 18-year-old male presented with a single round to oval well-defined irregular erythematous plaque 10 cm × 6 cm, with a verrucous surface, central atrophy, and crusting at the periphery on the right knee of one-year duration. The patient had received ATT (anti-tubercular treatment) twice in the past without any improvement. MGIT (mycobacteria growth indicator tube) and CBNAAT (Cartridge-based nucleic acid amplification test) were performed, and drug sensitivity testing was done, which led to a diagnosis of multidrug resistance (MDR) with a mixed pattern. The management of cutaneous tuberculosis (TB) is becoming difficult due to an increase in resistance to category-I ATT. Patients harboring MDR and extensively drug-resistant (XDR) strains present a fearsome challenge for the clinician. A cure is possible with early identification of resistance and the use of an appropriate regimen.

Clinical and histopathological aspects of lichenoid dermatitis in patients of retroviral diseases.

Context: Lichen planus (LP) is known to be associated with viral infections such as hepatitis B and C, but its association with HIV is rarely reported. Lichenoid drug eruptions have been implicated as the side effects of anti-retroviral therapy. Aims and Objectives: The aim of this study is to study demographics, clinical, histological, and immunological profile of the HIV patients presenting with lichenoid dermatitis. Subjects and Methods: HIV patients presenting with LP such as lesions were evaluated with complete history and physical examination. Demographic profile of patients was studied with features such as age, sex, duration of disease, distribution of the lesions, CD4 count, concomitant medications, associated comorbidities, and response to the treatment. Results: Twenty-one HIV patients presenting with LP such as lesions were studied. Of these, 20 patients had LP and one patient had lichenoid drug reaction. The age of the patient ranged from 40 to 60 years with no sex predilection. The duration of lesions ranged from 15 days to 7 years. Eleven patients had simultaneous cutaneous and oral involvement, five patients had only oral involvement and four patients of LP and one patient of lichenoid drug reaction had only cutaneous lesions. All the patients were on antiretroviral therapy, mainly on lamivudine, zidovudine, and nevirapine. Almost all the patients had CD4 count of more than 250 at the time of presentation. One patient was diagnosed to have lupus erythematosus and LP overlap. Patients were treated with oral medications such as corticosteroids, methotrexate, and dapsone and topical medications such as corticosteroids and calcineurin inhibitors. Conclusions: The appearance of LP such as lesions in HIV patients is a rare occurrence with 11 cases of LP reported till date. Our case series of 20 patients will throw light on possible etiology and difficulties in the management of LP such as lesions in HIV patients.

Presence and the roles of IL-9/Th9 axis in vitiligo.

Immune dysregulation is critical in vitiligo pathogenesis. Although the presence and roles of numerous CD4+ T-cell subsets have been described, the presence of Th9 cells and more importantly, roles of IL-9 on melanocyte functions are not explored yet. Here, we quantified the T helper cell subsets including Th9 cells in vitiligo patients by multicolor flowcytometry. There was an increased frequency of skin-homing (CLA+ ) and systemic (CLA- ) Th9 cells in vitiligo patients compared to healthy donors. However, there was no difference in Th9 cell frequency in vitiligo patients with early and chronic disease. There was negligible IL-9 receptor (IL-9R) expression on human primary melanocytes (HPMs); however, IFNγ upregulated IL-9R expression on HPMs. Functionally, IL-9/IL-9R signaling reduced the production of IFNγ-induced toxic reactive oxygen species (ROS) in HPMs. There was no effect of IL-9 on expression of genes responsible for melanosome formation (MART1, TYRP1, and DCT), melanin synthesis (TYR), and melanocyte-inducing transcription factor (MITF) in HPMs. In conclusion, this study identifies the presence of Th9 cells in vitiligo and their roles in reducing the oxidative stress of melanocytes, which might be useful in designing effective therapeutics.

Management of Rhinophyma with Radio Frequency: Case Series of Three Patients.

Rhinophyma is the most common form of phymatous rosacea, typically seen in men. It may appear de novo (without preceding inflammatory changes) or occur in patients with preexisting papulopustular rosacea. It is characterized by slow, bulbous, reddish-purple, painless enlargement of lower two-third of nose with rugose peau d'orange surface resulting from the enlargement of the sebaceous glands and subcutaneous tissue, which does not resolve spontaneously. Though benign, it causes lot of cosmetic and psychological concern. Commonly used treatment modalities include debulking by surgical excision, electrosurgery, carbon dioxide laser ablation, cryosurgery, or dermabrasion. Here we report a case series of three patients with Grade 3 rosacea as per National Rosacea Society grading, treated by radio frequency with good improvement.

Nodulo-ulcerative and erythrodermic secondary syphilis in human immunodeficiency virus-infected individuals.

Syphilis and human immunodeficiency virus (HIV) infections are both transmitted sexually. Co-infection of HIV and syphilis alters the course of both diseases. Clinical presentation of syphilis in patients of HIV may be atypical. HIV-infected individuals are at risk of developing lues maligna, which is characterized by nodulo-ulcerative lesions associated with severe constitutional symptoms. Erythroderma secondary to generalized papulo-squamous lesions of secondary syphilis is also uncommon. Here we report two cases of atypical presentations of secondary syphilis in HIV-positive patients.

A Study of Clinicopathological Correlation of Periorbital Hyperpigmentation.

CONTEXT: "Dark circles" are esthetic concerns that can affect individuals of any age, gender, or race. They can be familial, physiological, or associated with various medical illnesses. AIM: To study the clinicopathological correlation of periorbital hyperpigmentation. PATIENTS AND METHODS: Fifty patients affected with periorbital melanosis (POM) were enrolled for the study after obtaining informed consent. Details regarding history, demographic data, and physical examination of POM were recorded, and a 2-mm punch skin biopsy was taken from the affected skin under local anesthesia and stained with hematoxylin and eosin (H and E), Fontana Masson (Melanin), Perls Prussian blue (Hemosiderin). RESULTS: Twenty-three (46%) patients with POM had history of chronic illness before developing POM; 18% patients were atopic, 16% had jaundice, 18% had associated pigmentary demarcation lines (PDL) of type F and G, 8% had acanthosis nigricans, 22% patients had anemia, 16% patients gave positive family history of POM, and menstrual irregularity was seen in 16%. Histopathology revealed dermal melanin deposition with melanophages along with predominantly increased epidermal melanin and melanin in vellus follicular epithelium. Prussian blue for hemosiderin was negative in all cases. CONCLUSIONS: The study has elicited the multifactorial origin of POM; females are affected more than males. Dermal melanin deposition is a constant feature. Hemosiderin is not found in POM. Increased pigmentation of the vellus follicular epithelium is a feature of POM.