Comparison between organismal staining on histology and tissue culture in the diagnosis of cutaneous infection: A retrospective study.

BACKGROUND: In instances of suspected cutaneous infection, the standard of care includes obtaining skin biopsy specimens for histology and tissue culture. Few studies have compared the clinical utility of each test. OBJECTIVE: To assess the concordance of results between tissue culture and histology, as well as the clinicopathologic features that may influence the diagnostic yield of each test. METHODS: A retrospective review of all patients who underwent skin biopsy for histology and tissue culture at New York University from 2013 through 2018. RESULTS: Of 179 patients, 10% had positive concordance, 21% had positive tissue culture only, and 7% had positive histology only. We calculated a kappa correlation coefficient of 0.25 between histology and tissue culture (reference, 0.21-0.39 indicates minimal agreement). Histology exhibited higher sensitivity in detecting fungi, whereas tissue culture was more sensitive in identifying Gram-negative bacteria. Antimicrobial use before biopsy led to significantly fewer positive cultures (37.5% vs 71%; P = .023) in patients ultimately diagnosed with infection. LIMITATIONS: This study was conducted at a single institution, thereby restricting its broad applicability. The lack of a validated criterion standard to diagnose infection also limits interpretation of the results. CONCLUSION: Tissue culture and histopathology often yield discordant results. Dermatologists should recognize specific limitations, yet high clinical utility in special circumstances, of tests when approaching cases of suspected infection.

Anti-MDA5-Positive Dermatomyositis Presenting as Fever of Unknown Origin.

Dermatomyositis is a chronic systemic autoimmune disease characterized by inflammatory infiltrates in the skin and muscle. The wide variability in clinical and serologic presentation poses a diagnostic challenge for the internist. Appreciation of the clinical variants of dermatomyositis allows for expedient diagnosis and avoidance of diagnostic error. We illustrate these challenges with the case of a 51-year-old Vietnamese-American man who initially presented with fever of unknown origin in the absence of overt skin and muscle manifestations. The diagnosis of dermatomyositis was not evident on several clinical encounters due to the absence of these hallmark symptoms. We review the variable clinical manifestations of a subtype of dermatomyositis associated with an autoantibody against melanoma differentiation-associated protein 5 (anti-MDA5) and suggest consideration of dermatomyositis as a diagnosis in patients presenting with systemic illness and markedly elevated ferritin, even in the absence of elevated muscle enzymes and classic autoantibodies.

A potential role for the dermatologist in the physical transformation of transgender people: A survey of attitudes and practices within the transgender community.

BACKGROUND: There are an estimated 700,000 or more transgender people in the United States, however their dermatologic needs are not fully established in the medical literature. Unique needs relate to hormone therapy, prior surgeries, and other aspects of physical transitioning. OBJECTIVES: By examining attitudes and practices of transgender individuals, we aimed to identify areas for which dermatologists could contribute to their physical transformation. METHODS: This cross-sectional study used an anonymous online survey, distributed via lesbian, gay, bisexual, and transgender organizations; social media; and at targeted locations and events. RESULTS: A total of 327 people completed the survey (63% men, 29% women, 9% other). Most transgender women indicated that their face was most imperative to have changed, whereas men noted their chest, in turn influencing procedures. Of women's facial procedures, hair removal predominated, followed by surgery then injectables, mostly performed by plastic surgeons. Hormone-induced facial effects varied, usually taking over 2 years for maximal effect. When choosing procedures, money was the major barrier and good aesthetic outcome the primary concern. Participants did not think that facial procedures necessitate the currently accepted prerequisites for chest and genital surgery. LIMITATIONS: This study has limited size and convenience sampling. CONCLUSION: Dermatologists could contribute to the physical transformation of transgender patients through noninvasive procedures.

Aberrant lymphatic drainage and risk for melanoma recurrence after negative sentinel node biopsy in middle-aged and older men.

BACKGROUND: Aberrant lymphatic drainage is believed to contribute to the high recurrence rate of head and neck melanomas. The purpose of this study was to identify the clinical significance of unexpected lymphatic drainage patterns. METHODS: A single institution retrospective analysis was performed of middle-aged and older men (mean age, 66.2 years; range, 41-87 years) who underwent successful lymphoscintigraphy with sentinel lymph node biopsy (SLNB) from 1997 through 2012. Node status, distribution, and recurrence were assessed comparing patients with expected and unexpected drainage patterns. RESULTS: Sixty-six patients were identified with 55.8 months median follow-up (range, 5.6-206.1 months). Unexpected sentinel lymph node drainage was associated with multiple basin drainage (p < .01) and greater recurrence after negative SLNB (p = .03). Both groups had similar anatomic distribution, sentinel lymph node sampling, histopathologic characteristics, follow-up, and survival. CONCLUSION: Lymphatic drainage differing from expected patterns is associated with greater recurrence after negative SLNB in middle-aged and older men. © 2015 Wiley Periodicals, Inc. Head Neck 38: E754-E760, 2016.

Dermatomyositis, clinically presenting with cutaneous ulcers, with histopathologic evidence of perforating collagenosis.

Dermatomyositis is a systemic, autoimmune diseasewith a variety of clinical features that often includemyositis and characteristic cutaneous findings. Asubset of patients with dermatomyositis developcutaneous ulcers, often in the setting of vasculitis orvasculopathy. We present a case of dermatomyositiswith cutaneous ulcers that show perforatingcollagenosis on histopathologic examination.Acquired reactive perforating collagenosistypically occurs in the setting of diabetes mellitus,chronic renal failure, and other pruritic conditions,and this case represents a rare association withdermatomyositis, which may ultimately be helpful inelucidating the pathophysiology of this perforatingdisorder.

Prevalence and treatment patterns of psoriatic arthritis in the UK.

OBJECTIVES: The objectives of this study were to determine the prevalence of PsA in The Health Improvement Network (THIN), a large population-based medical records database in the UK, to examine factors associated with prevalent PsA among patients with psoriasis and to describe the use of DMARDs in patients with PsA. METHODS: Two cohorts were derived from THIN to examine the prevalence of PsA in a cross-sectional study among all patients aged 18-90 years and among a subcohort of 4900 psoriasis patients aged 45-65 years. Prescription codes were used to describe therapies after the diagnosis of PsA. Associations for prevalent PsA among psoriasis patients were assessed using logistic regression analysis. RESULTS: Among 4.8 million patients in THIN between the ages of 18 and 90 years, 9045 patients had at least one medical code for PsA, giving an overall prevalence of 0.19% (95% CI 0.19%, 0.19%). Of those patients, 45.9% with PsA have been prescribed DMARDs. Among the 4064 confirmed psoriasis patients, the prevalence of PsA was 8.6% (95% CI 7.7%, 9.5%). PsA was more prevalent among patients with severe psoriasis [odds ratio (OR) 3.34; 95% CI 2.40, 4.65], obesity (OR 1.77; 95% CI 1.30, 2.41) and duration of psoriasis for ≥10 years (OR 7.42; 95% CI 3.86, 14.25) in the fully adjusted model. CONCLUSION: The prevalence of PsA in THIN is consistent with previous population-based estimates. Limitations include a definition of PsA based on a diagnostic code rather than Classification Criteria for Psoriatic Arthritis (CASPAR) criteria. Given the large population of PsA patients, THIN is an important resource for the study of PsA.

Increased risk of diabetes mellitus and likelihood of receiving diabetes mellitus treatment in patients with psoriasis.

OBJECTIVE: To assess the risk of incident diabetes mellitus (DM) in patients with psoriasis and to evaluate DM treatment patterns among patients with psoriasis and incident DM. DESIGN: Population-based cohort study. SETTING: United Kingdom-based electronic medical records. PATIENTS: We matched 108 132 patients with psoriasis aged 18 to 90 years with 430 716 unexposed patients based on practice and time of visit. For our nested study, only patients who developed incident DM during our study time were included. MAIN OUTCOME MEASURES: Incident DM and adjusted risk of pharmacotherapy among those with incident DM. RESULTS: The fully adjusted hazard ratios (95% CIs) for incident DM were 1.14 (95% CI, 1.10-1.18), 1.11 (95% CI, 1.07-1.15), and 1.46 (95% CI, 1.30-1.65) in the overall, mild, and severe psoriasis groups, respectively. Among those with incident DM and severe psoriasis, the adjusted risk for receiving DM pharmacotherapy was 1.55 (95% CI, 1.15-2.10). CONCLUSIONS: Our results suggest that psoriasis is an independent risk factor for the development of type 2 DM in a dose-dependent manner, and that patients with severe psoriasis who develop DM are more likely to receive systemic diabetic therapies in comparison with patients with DM but without psoriasis.

Prevalence of metabolic syndrome in patients with psoriasis: a population-based study in the United Kingdom.

Increasing epidemiological evidence suggests independent associations between psoriasis and cardiovascular and metabolic disease. Our objective was to test the hypothesis that directly assessed psoriasis severity relates to the prevalence of metabolic syndrome and its components. A population-based, cross-sectional study was undertaken using computerized medical records from the Health Improvement Network Study population including individuals in the age group of 45-65 years with psoriasis and practice-matched controls. The diagnosis and extent of psoriasis were determined using provider-based questionnaires. Metabolic syndrome was defined using the National Cholesterol Education Program Adult Treatment Panel III criteria. A total of 44,715 individuals were included: 4,065 with psoriasis and 40,650 controls. In all, 2,044 participants had mild psoriasis (2% body surface area (BSA)), 1,377 had moderate psoriasis (3-10% BSA), and 475 had severe psoriasis (>10% BSA). Psoriasis was associated with metabolic syndrome, adjusted odds ratio (adj. OR 1.41, 95% confidence interval (CI) 1.31-1.51), varying in a "dose-response" manner, from mild (adj. OR 1.22, 95% CI 1.11-1.35) to severe psoriasis (adj. OR 1.98, 95% CI 1.62-2.43). Psoriasis is associated with metabolic syndrome and the association increases with increasing disease severity. Furthermore, associations with obesity, hypertriglyceridemia, and hyperglycemia increase with increasing disease severity independently of other metabolic syndrome components. These findings suggest that screening for metabolic disease should be considered for psoriasis, especially when it is severe.

Assessing long-term drug safety: lessons (re) learned from raptiva.

Efalizumab was approved for moderate to severe psoriasis in 2003 based on studies in approximately 2700 patients, of whom only 218 were exposed to the drug for more than 1 year. In 2009, after more than 46,000 patients were exposed to efalizumab, the drug was withdrawn from the market after 3 confirmed and 1 suspected case of progressive multifocal leukoencephalopathy (PML) were spontaneously reported. As PML is very rare, it is extremely unlikely that the 4 reported cases were due to chance and given that PML occurs primarily in patients who are immunosuppressed, the association is likely causal. The identification of PML as a serious, but statistically rare risk of efalizumab demonstrates the strengths and weaknesses of the current drug approval and pharmacovigilance processes for fully measuring the safety of a drug. Patients and clinicians need to be aware of the relative completeness and limitations of existing safety data of a drug when selecting a treatment.