Diagnostic Utility of Direct Immunofluorescence on Paraffin-Embedded Skin Biopsy Samples for the Diagnosis of Autoimmune Vesiculobullous Lesions.

Background Autoimmune vesiculobullous diseases (AIBDs) are a group of diseases characterized by blisters of the skin/mucosa due to the presence of circulating autoantibodies against antigens in the epidermis or the dermo-epidermal junction. Direct immunofluorescence (DIF) for immunoglobulin (Ig)G, IgC3, and IgA on fresh-frozen tissue is the gold standard diagnostic test for AIBDs. However, DIF in the absence of frozen tissue is challenging for the diagnosis of AIBDs. This study aimed to analyze the practical utility of DIF using paraffin-embedded skin biopsy rather than fresh frozen tissue for the diagnosis of AIBDs. Methodology This cross-sectional comparative study included 30 cases of AIBDs. DIF for IgG and IgA was performed on paraffin-embedded tissue (PE-DIF) after proteinase digestion on histopathologically confirmed 15 pemphigus vulgaris (PV), three pemphigus foliaceous (PF), four bullous pemphigoid (BP), three dermatitis herpetiformis (DH), three subcorneal pustular dermatosis (SCPD), and one case each of linear IgA disease and pemphigoid gestationis (PG). PE-DIF staining pattern was compared with the DIF on fresh frozen tissue (FF-DIF). Results All cases of PV and PF showed an intercellular IgG chicken wire staining pattern similar to FF-DIF. However, background staining was more intense in PV cases while less intense in PF cases. Three BP cases showed linear IgG staining in PE-DIF. DH, SCPD, linear IgA disease, and PG cases did not show IgG positivity. Out of three DH cases, two cases showed granular IgA positivity while linear IgA positivity along the basement membrane was seen in a single case of linear IgA disease. Negative IgG staining was observed in SCPD. Immunofluorescence in PE-DIF was rapidly deteriorating than in FF-DIF. Conclusions DIF done on paraffin-embedded tissue can be used as a supplement and salvage technique with histopathology for the diagnosis of AIBDs, particularly when a cryostat facility for frozen tissue is not available and the patient is unable to undergo a second biopsy procedure.

Unraveling the Enigma of Perforating Itches: A Comprehensive Report of Reactive Perforating Collagenosis in Three Patients.

Reactive perforating collagenosis (RPC) is a rare dermatosis where dermal connective tissue erupts through the epidermis, resulting in diverse clinical manifestations such as umbilicated papules with crusting and excoriated nodules with central puncta. Associated with systemic disorders like diabetes mellitus, chronic kidney diseases, and autoimmune conditions, RPC's pathogenesis involves abnormal collagen metabolism, immune dysfunction, genetic predisposition, and environmental triggers. Histopathological examination reveals vertically oriented shallow cup-shaped invaginations containing degenerated collagen fibers, aiding diagnosis. Treatment includes managing underlying causes and utilizing options like topical corticoids, retinoids, and phototherapy, with a possibility of spontaneous regression and recurrence. This case report highlights the significance of considering RPC in patients with characteristic skin lesions and severe itching, emphasizing early recognition and accurate diagnosis to optimize patient care. Continued research and collaboration are crucial for improving outcomes in individuals affected by RPC.

A Psittacine bite and subcutaneous basidiobolomycosis: A case with a therapeutic challenge.

Basidiobolus ranarum is a saprophyte that can be found in soil, rotting vegetables, and frogs' digestive tracts. Clinically, basidiobolomycosis presents as a persistent infection of subcutaneous tissue affecting the trunk and extremities in an immunocompetent host. We describe a case of subcutaneous basidiobolomycosis in a 56-year-old immunocompetent woman farmer by occupation residing at remote part of central India. This study highlights the traumatic implantation and zoonotic potential of fungal species. Clinical suspicion of fungal etiology and timely mycology laboratory diagnostic support is key to address such cases. This case is documented to emphasize the problems of compliance to treatment specially in remote and poor patients challenging the treatment with complete cure. 2012 Elsevier Ltd. All rights reserved.

Role of cytopathology in diagnosing phaeohyphomycosis masquerading as nerve abscess in a lepromatous leprosy patient: A case report.

INTRODUCTION AND IMPORTANCE: Phaeohyphomycosis is a rare fungal infection primarily affecting immunocompromised individuals. Its clinical manifestations are diverse, and diagnosis can be challenging, particularly when lesions mimic other conditions. CASE PRESENTATION: A 66-year-old male, with a history of irregular leprosy treatment and prolonged steroid use, presented with symptoms suggestive of a nerve abscess. On examination, cystic swellings were observed on the left thumb and leg. Histopathological examination and fine needle aspiration cytology (FNAC) revealed melanized hyphae, leading to a final diagnosis of phaeohyphomycosis. The patient was treated with oral itraconazole, leading to regression in lesion size. CLINICAL DISCUSSION: Leprosy patients on long-term steroids are especially susceptible. The pathogenicity of these fungi in immunocompetent people is believed to be due to melanin in their cell walls, which defends against host defenses. Diagnosis involves histopathological examinations, staining, and fungal culture. Treatment involves surgical excision and antifungal drugs. If untreated, it can lead to severe complications including fatal brain infections. CONCLUSION: This case highlights the unusual presentation of phaeohyphomycosis mimicking a nerve abscess in a leprosy patient. It underscores the importance of a high degree of clinical suspicion in diagnosing such rare infections, particularly in immunocompromised individuals. It also emphasizes the value of FNAC in reaching a definitive diagnosis. Prompt diagnosis and appropriate treatment are essential to prevent potentially serious outcomes.

Atypical Hansen's Disease Mimicking Xanthogranuloma: Role of Cytology.

Fine needle aspiration cytology is a simple, safe, and effective technique that can be used in the diagnosis of cutaneous diseases. Here, we present a case of Hansen's disease with an erythematous dermal nodule mimicking xanthogranuloma clinically. In our scenario, since leprosy is considered eliminated in India, the presentation of patients with classical signs and symptoms is becoming rare. Atypical manifestation of leprosy is increasing day by day, so it is necessary to have a high suspicion of leprosy in every case.

Update in the Uses of Chalazion Clamp in Dermatological Procedure Revisited.

Chalazion clamp has a distal tip with a flat oval plate; other side has a ring-like structure and forceps-like handle. Handle has a thumbscrew, which can be tightened and released so as to achieve the required pressure. Available in various sizes. Used mainly in ophthalmological procedures primarily. Used in dermatology by modifying its technique and creating an adequate hemostasis in various diagnostic and interventional procedures. In the previous article chalazion clamp was used for preparing SSS for ear lobule, so this article revisited the uses of chalazion clamp in dermatology and extended use in the preparation of adequate blanching while preparing SSS from the peripheral tissue site.

Topical steroid containing combinations: Burden of adverse effects and why the recent regulatory action may not be enough.

OBJECTIVES AND METHODS: In September 2018, the government of India banned 328 fixed dose combinations (FDCs), 24 of which are combinations containing topical steroids. To assess what impact can be expected from this regulatory action, we analyzed reports of adverse drug events due to topical corticosteroids at a hospital-based pharmacovigilance center between January 2017 and August 2018. RESULTS: Among 34 different steroid-containing FDCs responsible for 485 reports of ADEs with topical steroids, only three preparations, accounting for 50.10% of ADEs, come under the umbrella of the recent ban. Clobetasone propionate (68.87%) and betamethasone (28.45%) were the corticosteroids most frequently associated with adverse events. Most of the steroid preparations (87.84%) had been bought without a prescription for the treatment of dermatophytoses (76.70%). Males (77.73%) were predominantly affected, and nearly half (47.43%) of the patients were between 21 and 30 years of age. Skin atrophy (50.10%), striae (25.54%), and hypopigmentation (19.79%) were the major ADEs. CONCLUSION: Nearly half of the cutaneous adverse effects were due to topical steroid combinations which are still widely available over the counter.

An old entity, a new trigger: Post COVID-19 vaccine pityriasis rubra pilaris.

BACKGROUND: Pityriasis rubra pilaris (PRP) is a rare, acquired, chronic papulosquamous dermatosis which can occur in all ages. PRP can be associated with infection, autoimmunity, drugs and malignancies, and can be idiopathic. OBJECTIVE: PRP following vaccination has been rarely described in the literature. To the best of our knowledge, we report the first case of PRP two weeks following COVID-19 vaccination (Covishield). CASE REPORT: A 72-year-old male presented to the outpatient dermatology department at All India Institute of Medical Sciences - Bhopal with minimally pruritic superficial plaques since one week. The patient was vaccinated against COVID-19 with Covishield two weeks earlier. The lesions developed as erythematous scaly follicular papules and plaques over axilla that rapidly spread to the trunk in the following weeks and involved palms and soles as well as thickening and fissuring. The clinical features suggested PRP. The histopathology showed epidermal acanthosis with hypergranulosis alternating with parakeratosis and orthokeratosis with broad rete ridges with follicular plugging. The patient had started taking topical corticosteroids and emollients, which proved effective. There was no recurrence after receiving a second dose on follow-up. CONCLUSION: In patients presenting with new onset PRP in this COVID-19 era, the possibility of vaccine as a trigger should be taken into consideration, and further dosing should be carefully monitored in view of possible recurrence.

Cutaneous mastocytosis-Conglomerate of diagnostic tools: A report of four cases.

Mast cells are naturally distributed in the dermis, respiratory, gastrointestinal/genitourinary mucosa, adjacent to blood vessels, lymphatics, and peripheral nerves. The most common site for the abnormal accumulation of mast cells is the skin, which is known as cutaneous mastocytosis. We report four cases of cutaneous mastocytosis with erythematous maculopapular to bullous lesion along with a positive Darier sign. Skin biopsy, with special stains like Toluidine blue, Giemsa stain, immunohistochemistry (IHC) for CD117, and serum tryptase level correlations were done. Mastocytosis can affect only the cutaneous sites or involve multiple organs. It is most common in infancy with varied clinical presentations, thus requiring a high index of suspicion with histopathological correlation. Although the prognosis is good, there remains a risk of sudden mast cell degranulation due to triggering agents and subsequent collapse.

Unilateral lymphoedema of lower limb: an unusual presenting feature of hidden tuberculosis verrucosa cutis of foot.

A 42-year-old Indian farmer presented with gradually progressive swelling of the right lower limb for the last 20 years. There were few verrucous plaques over the right foot for the same duration. Those plaques were initially ignored and mistaken as lymphoedema-induced secondary changes by primary care physicians. Histopathology of the skin lesion showed pseudoepitheliomatous hyperplasia with upper dermal granulomatous infiltrate and a diagnosis of tuberculosis verrucosa cutis was suspected. Subsequently, the lesions as well as lymphoedema improved significantly with antitubercular therapy.

Association of Antimicrobial Susceptibility and Treatment Outcome in Acne Vulgaris Patients: A Pilot Study.

Purpose Cutibacterium acnes ( C. acnes ) is an emerging pathogen that is highly resistant to antibiotics and is capable of causing persistent infections that are difficult to treat. Methods & Materials Acne vulgaris patients visiting dermatology OPD of our tertiary care hospital during the study period of 2 months were recruited. Skin swabs were collected, and the sample was processed on 5% sheep-blood agar for anaerobic culture by the GasPak method. Isolates were identified by the standard biochemical test. Antimicrobial susceptibility testing was performed for clinically relevant antibiotics by the E-strip method. The clinical response was evaluated after 1-month follow-up to the prescribed antibiotics. Results Minocycline, doxycycline, ceftriaxone, and tetracycline were the most effective antibiotics. Nonsusceptibility to clindamycin and erythromycin were observed in 11.9% and 31% isolates, respectively, with 9.5% isolates being nonsusceptible to both. For none of the antibiotics we found significant difference in the proportion of susceptible and nonsusceptible isolates between mild, moderate, and severe grades of acne vulgaris. For none of the antibiotic regimens, significant difference was observed between nonresponders and responders. Twenty-seven patients received clindamycin and among them 16 of 19 responders and 6 of 8 nonresponders yielded growth of clindamycin-susceptible isolates ( p = 0.57). Conclusion We observed significant prevalence of resistant strains of C. acnes among patients with acne vulgaris. No association was observed between in vitro susceptibility results and treatment outcome.

A Rare Case of Foveal Hypoplasia With Dyschromatosis Universalis.

Foveal hypopalsia (FH) is typically seen in association with diseases like albinism and aniridia, and familial FH (FFH) is very rare. The authors present a case of unique association of FH with dyschromatosis universalis hereditaria (DUH). Family members of this patient had history of nystagmus and dermal pigmentary anomalies, suggesting that this may represent FFH with DUH in X-linked pattern. The authors also discuss the role of pigment anomalies in manifesting as this combination. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:192-195.].