Cutaneous signs of selected cardiovascular disorders: A narrative review.

Cardiovascular diseases are the leading cause of mortality and morbidity globally. Clinicians must know cutaneous signs of cardiovascular disease, including petechiae, macules, purpura, lentigines, and rashes. Although cutaneous manifestations of diseases like infectious endocarditis and acute rheumatic fever are well established, there is an indispensable need to evaluate other important cardiovascular diseases accompanied by cutaneous signs. Moreover, discussing the latest management strategies in this regard is equally imperative. This review discusses distinctive skin findings that help narrow the diagnosis of cardiovascular diseases and recommendations on appropriate treatment.

Association Between Early Patient Characteristics and IgE-Mediated Allergy in the Perioperative Setting.

BACKGROUND: Early recognition of perioperative anaphylaxis, a life-threatening, usually IgE-mediated, immediate hypersensitivity, is essential, but bedside diagnosis is not always straightforward because clinical presentation may vary. OBJECTIVES: To describe early characteristics of perioperative immediate hypersensitivity, with special attention to cutaneous phenotypes, and identify risk factors for IgE-mediated allergy. METHODS: We retrospectively analyzed data from adults with suspected perioperative immediate hypersensitivity who were investigated in two academic medical centers. Multivariable logistic regression was conducted to evaluate associations among patient, clinical, and paraclinical characteristics and IgE-mediated allergy. RESULTS: Of 145 enrolled patients, 99 (68.3%) and 46 (31.7%) were respectively categorized in the IgE-mediated allergy and non-allergy groups. Cutaneous vasoconstriction phenotype (pallor, piloerection, thelerethism, and sweating with or without cyanosis) occurring within minutes (or even 1 minute) of drug exposure was strongly associated with IgE-mediated allergy (adjusted odds ratio [aOR] = 28.02; 95% CI, 4.41-305.18). IgE-mediated allergy was always life-threatening in this setting. Other early factors associated with allergy were low end-tidal carbon dioxide 25 mm Hg or less (aOR = 5.45; 95% CI, 2.39-26.45), low mean arterial pressure 60 mm Hg or less (aOR = 3.82; 95% CI, 1.28-17.31), and early cutaneous vasodilation (erythema, urticaria, and/or angioedema) (aOR = 2.78; 95% CI, 0.73-20.54). Late cutaneous vasodilation after restoration of hemodynamics corroborated the diagnosis of allergy (aOR = 23.67; 95% CI, 4.94-205.09). The best-fit model including three readily available variables (cutaneous phenotype involving the three modalities [reference lack of cutaneous signs], low mean arterial pressure, and low end-tidal carbon dioxide) had an area under the curve of 0.91. CONCLUSIONS: Cutaneous vasoconstriction phenotype is associated with the strongest risk of life-threatening allergy and thus may be regarded as pathognomonic of perioperative IgE-mediated anaphylaxis.

Detection of Frank's sign in the dental setting: A population-based cohort study.

BACKGROUND: In 1973, Saunders T. Frank described the diagonal earlobe crease (DELC) as a potential marker of cardiovascular disease. However, this anatomical finding is not routinely examined. The aim of this study was to assess the presence of this crease in the general population attending a dental setting and describe its anatomical variations to be able to categorize it as a physical sign. METHODOLOGY: A study group of 1050 white adults were selected, as participants in the framework of the "A Estrada Study of Glycation and Inflammation" (AEGIS), a cross-sectional, population-based descriptive study of a representative sample of the general adult population of the municipality of A Estrada (Pontevedra, Spain). Each participant's age, sex, and preferred head position when sleeping were recorded. Both earlobes were visually inspected and the anatomical variables of the crease were recorded (unilateral or bilateral, length, depth, and presence of secondary creases). The relationship between the study variables was analyzed using the chi-squared test, Student's t-test, the analysis of variance (ANOVA), and the nonparametric tests of Mann-Whitney and Kruskal-Wallis. RESULTS: The DELC was observed in 65.2% of the participants. In 71.5% of the cases, the sign was complete (occupying the space from the tragus to the posterior edge of the earlobe); in 56.9% of the cases, the sign was bilateral; in 45.1% of the cases it was deep; and in the 43.6% of the cases, accessory creases were identified. Neither sex nor the habitual head position when sleeping were related to the prevalence or characteristics of the DELC. The prevalence, extent and depth of Frank's sign increased significantly with age (p < .001). CONCLUSION: The prevalence of the DELC increases significantly with age, and its morphological characteristics are accentuated. This finding, therefore, gains special relevance as a marker of potential cardiovascular disease when observed in young adults.

Manifestaciones cutáneas comunes de las principales enfermedades hepáticas / Common cutaneous manifestations of major liver diseases

Las enfermedades hepáticas presentan múltiples manifestaciones sistémicas, entre las cuales se destacan los hallazgos en piel, siendo los más comunes el prurito y la ictericia; así mismo, se pueden encontrar angiomas en araña, eritema palmar, xantomas, vasculitis y cambios en anexos. Este artículo tiene como objetivo describir los principales signos y síntomas cutáneos en las enfermedades hepáticas para brindar herramientas semiológicas al clínico en su práctica diaria

Liver disease present multiple systemic manifestations, among which skin findings stand out, being the most common pruritus and jaundice. Other findings can also be manifested like spider angiomas, palmar erythema, xanthomas, vasculitis and changes in skin appendages. The objective of this article is to describe the main skin signs and symptoms of liver diseases to provide semiological tools to the physician in his daily practice.

La piel como reflejo de trastornos hepáticos subyacentes / The skin as a reflection of underlying liver disorders

La piel es el órgano más grande y visible del cuerpo humano; en ella se pueden reflejar diversos hallazgos de enfermedades sistémicas, incluidas las hepatopatías crónicas y agudas, las cuales se asocian a múltiples lesiones dermatológicas como principal manifestación extrahepática. Las manifestaciones cutáneas son comunes pero inespecíficas y pueden encontrarse en diferentes enfermedades; por lo tanto, la piel funciona como una ventana a nuestra salud general, de ahí que el examen clínico de la piel, las uñas y el cabello pueda permitir el reconocimiento adecuado, el diagnóstico y tratamiento temprano de las enfermedades hepáticas y la mejoría de la calidad y esperanza de vida de los pacientes afectados.

La piel es el órgano más grande y visible del cuerpo humano; en ella se pueden reflejar diversos hallazgos de enfermedades sistémicas, incluidas las hepatopatías crónicas y agudas, las cuales se asocian a múltiples lesiones dermatológicas como principal manifestación extrahepática. Las manifestaciones cutáneas son comunes pero inespecíficas y pueden encontrarse en diferentes enfermedades; por lo tanto, la piel funciona como una ventana a nuestra salud general, de ahí que el examen clínico de la piel, las uñas y el cabello pueda permitir el reconocimiento adecuado, el diagnóstico y tratamiento temprano de las enfermedades hepáticas y la mejoría de la calidad y esperanza de vida de los pacientes afectados.

[Immunoglobulin A vasculitis]. / Immunglobulin-A-Vaskulitis.

The immune-mediated small vessel vasculitis is known as Schoenlein-Henoch purpura predominantly from pediatrics and in these cases occurs more frequently after infections of the upper airways. In adults, immunoglobulin A (IgA) vasculitis often proceeds more severely und recurrently with the classical tetrad of skin manifestations in the sense of leukocytoclastic vasculitis, joint affection, gastrointestinal involvement and IgA nephritis, in contrast to the mostly mild and self-limiting course in children. The background of this systemic vasculitis with formation of IgA immune complexes is considered to be an altered glycosylation of IgA, as this causes the exposure of binding sites for autoantibodies so that an immune complex reaction can be elicited. This ultimately leads to perivascular deposition of IgA and a further activation of neutrophils. Groundbreaking in the diagnostics is the histological detection of leukocytoclastic vasculitis and in cases of renal manifestations a kidney biopsy with characteristic deposits of immune complexes, which cannot be clearly differentiated from IgA nephropathy. The treatment is aimed at the respective manifestation and is mostly based on consensus recommendations due to the lack of randomized studies. In addition to immunosuppressive medication, in the presence of a chronic kidney disease general nephroprotection is becoming increasingly more important also by inhibition of sodium-glucose transporter 2 (SGLT2). The type and extent of kidney involvement and also rare cardiac manifestations are the main determinants of the prognosis. Continuous medical accompaniment of those affected is necessary due to the possible progression of the disease and the risk of recurrence.

Transient abdominal telangiectasia of the newborn: Four new cases with abdominal distension.

Transient abdominal telangiectasia of the newborn (TATN) is a recently described entity. The majority of cases had no specific clinical context or trigger identified, but a minority occurred in the clinical context of transient increased intraabdominal pressure. We report four additional cases of TATN, all in the presence of transient abdominal distension, further supporting the causative relationship of abdominal distension to TATN.

Knowledge, attitude, and practice regarding COVID-19 skin manifestations among doctors working at Khartoum dermatology and venereology teaching Hospital, 2021

Background: COVID-19 is a global pandemic caused by SARS_COV2. The symptoms of covid-19 include: fever, dyspnea, fatigue, a recent loss of smell and taste, sore throat, cough, and cutaneous lesions. In addition, some skin manifestations were reported to be associated with COVID-19. Methods: The study design is a descriptive cross-sectional hospital-based study. The study aimed to evaluate the level of knowledge and practice about skin manifestations of COVID-19 among doctors working at Khartoum dermatology and venereology teaching hospital. A self-administrated questionnaire was used for data collection after an informed consent was taken. Results: Among 140 doctors working in the dermatology and venereology teaching hospital, 75.7% of the doctors had knowledge that COVID-19 can present with skin manifestations. The study results showed that about half of the participants have poor knowledge about COVID-19 skin manifestations while 25% have no knowledge, and that 35 (25%) doctors have good knowledge. From a total of 140 doctors; 46.4% reported that when patients present with COVID-19 skin lesions, they will isolate them in separate rooms and call the epidemiology center, whereas, 61 doctors (43.6%) did not know if they have a protocol for COVID-19 suspected cases. This study reported a significant association between job category and level of knowledge toward COVID-19 skin manifestations measured by Chi-square test, the P-value was 0.003 (significant at 0.05), and the same significant association was found between the year of rotation and knowledge. Conclusion: Half of the doctors covered by this study had poor knowledge about COVID-19 skin manifestations, and therefore, educating doctors in dermatology hospitals about skin manifestations of COVID-19 is recommended, besides clear and precise guidelines and protocols for diagnosis and management.

Acute Onset Rheumatoid Vasculitis With Polyarthritis and Erythema: A Case Report.

We present the case of a woman in her 70s who was diagnosed with rheumatoid vasculitis (RV) after initially presenting with systemic joint pain and erythema. RV, a rare complication of rheumatoid arthritis, involves inflammation of blood vessels, leading to various skin manifestations. The patient's complaints included fever, generalized joint pain, and skin manifestations that initially resembled erythema multiforme. However, a skin biopsy revealed vasculitis, which guided the RV diagnosis. Although rheumatoid arthritis primarily affects the joints, systemic implications such as RV can arise in rare cases. This case underscores the importance of a holistic and meticulous diagnostic approach, especially in older patients, as early detection and treatment are crucial for managing disease progression and associated complications. Collaborative care involving multidisciplinary teams is vital to achieving optimal outcomes in complex cases.

A Challenging Case of Metastatic Crohn's Disease Without Gastrointestinal Manifestations.

Metastatic Crohn's disease (MCD) is a rare cutaneous manifestation of Crohn's Disease (CD), defined as non-caseating, granulomatous skin lesions non-contiguous with the gastrointestinal (GI) tract. Most patients with MCD either have concomitant classic manifestations of CD or develop them within a few months to years. We report a case of MCD without known involvement of the GI tract, after more than three years from diagnosis. After failure or intolerance to several conventional treatments, including oral corticosteroids and azathioprine, adalimumab was initiated with a good response.  Diagnosis of cutaneous CD is made by a combination of clinical and histopathological findings. Therapeutic options include topical, intralesional, and systemic corticosteroids as well as topical and systemic immunosuppressants and immunomodulators. Surgical excision may be considered for refractory cases.

Cutaneous Ovarian Carcinoma Metastases: Case Report and Literature Review.

Metastatic cutaneous ovarian carcinoma is a rare diagnosis with a poor prognosis. Cutaneous manifestations are variable in size and morphology. We report a woman presenting with cutaneous ovarian metastases mimicking reticulated dermatoses. Our patient presented with a four-month history of a mildly pruritic eruption in the setting of stage IV ovarian adenocarcinoma, for which she was undergoing carboplatin, doxorubicin, and bevacizumab chemotherapy. On exam, she had erythematous, indurated papules and plaques involving the right flank and breast, as well as a reticulated erythematous patch on the lower abdomen. Cutaneous ovarian metastases have varied presentations. Our case highlights an uncommon manifestation of ovarian metastases and reviews the prior literature.

An atypical presentation of COVID-19: Hidden risk for seniors to misdiagnose.

The outbreak of coronavirus disease (COVID-19) was announced as a pandemic by the World Health Organization in March 2020. Clinical manifestations include cough, fever, dyspnea, myalgia, and loss of sense of smell and taste. Less common extrapulmonary signs and symptoms such as cutaneous manifestations, diarrhea, confusion, functional decline have been reported in the literature. Older patients with multiple comorbidities are at a greater risk for severe disease and death and are vulnerable to atypical presentations due to changes in organ systems, multimorbidity, cognitive impairment, and sensory disturbances. In this case, a 77-year-old patient diagnosed with COVID-19 pneumonia presented with atypically acute urticaria with angioedema was reported. Although there were no typical signs of the disease, such as cough or shortness of breath, the patient's laboratory values, and chest imaging were compatible with COVID-19. Therefore, the diagnosis of COVID-19 should be considered in older patients presenting with subtle signs or cutaneous manifestations.

Application of cold atmospheric microwave plasma as an adjunct therapy for wound healing in dogs and cats.

BACKGROUND: Cold atmospheric plasma is a novel innovative approach for wound care, and it is currently underrepresented in veterinary medicine. OBJECTIVES: To investigate the efficacy and safety of using cold atmospheric microwave plasma (CAMP) as an adjunct therapy for wound healing in dogs and cats. METHODS: Wound healing outcomes were retrospectively analyzed using clinical records of client-owned dogs and cats who were first managed through standard wound care alone (pre-CAMP period) and subsequently via CAMP therapy (CAMP period). The degree of wound healing was estimated based on wound size and a modified wound scoring system. RESULTS: Of the 27 acute and chronic wounds included in the analysis, 81.48% showed complete healing after the administration of CAMP as an adjunct therapy to standard care. Most wounds achieved complete healing in < 5 weeks. Compared with the pre-CAMP period, the rate of wound healing significantly increased every week in the CAMP period in terms of in wound size (first week, p < 0.001; second week, p = 0.012; third week, p < 0.001) and wound score (first week, p < 0.001; second week, p < 0.001; third week, p = 0.001). No adverse events were noted except for mild discomfort and transient erythema. CONCLUSIONS: CAMP is a well-tolerated therapeutic option with immense potential to support the treatment of wounds of diverse etiology in small animal practice. Further research is warranted to establish specific criteria for CAMP treatment according to wound characteristics.

EGFR inhibitors: clinical aspects, risk factors and biomarkers for acneiform eruptions and other mucosal and cutaneous adverse effects

Abstract The frequency of the use of drugs that act on the epidermal growth factor receptor (EGFR) is increasing, with the consequent onset of cutaneous toxicity, specifically acneiform eruption. The authors extensively review the topic, focusing on describing how these drugs can affect the skin and its appendages, that is, the pathophysiology that encompasses the cutaneous toxicity related to the use of EGFR inhibitors. In addition, it was possible to list the risk factors that may be associated with adverse effects of these drugs. Based on this recent knowledge, the authors expect to aid in the management of patients who are more vulnerable to toxicity, reduce morbidities, and improve the quality of life of patients undergoing treatment with EGFR inhibitors. Other issues related to the toxicity of EGFR inhibitors, such as the clinical aspects of the acneiform eruption grades, and other different types of cutaneous and mucosal reactions, are also included in the article.

Sporadic late onset nemaline myopathy with concurrent dermatological symptoms responding to immunosuppressive treatment.

BACKGROUND: Sporadic late onset nemaline myopathy is a rare, progressive muscle disease, presenting in adulthood, mainly affecting proximal limb and bulbar muscles. Muscle biopsies show characteristic nemaline rods. The putative mechanism is considered immune-related. Other manifestations aside from neuromuscular symptoms have not been described previously. CASE PRESENTATION: We present a case with atypical sporadic late onset nemaline myopathy (SLONM) of a non-HIV, non-MGUS subtype, where skin manifestations preceded neuromuscular symptoms, and a residual thymus with the histology of thymic follicular hyperplasia was detected during the diagnostic workup. Thorough dermatological investigations could not explain the skin presentations. Muscle biopsy revealed variation in fiber diameter, ragged-red and COX-negative fibers associated with discrete fibrosis. Electron microscopy detected atrophic muscle fibres with disorganization of the myofibrils, nemaline rods and abnormal mitochondria. Single-fiber EMG suggested signs of a neuromuscular transmission defect, EMG showed signs of myopathy. Analyses of antibodies associated with myasthenia gravis were negative. The patient showed improvement after intravenous immunoglobulin treatment regarding both the skin and the muscle symptoms. CONCLUSIONS: Our case highlights the heterogeneity of SLONM with its varied spectrum of presentation. A unique combination of dermatological symptoms and SLONM could be seen with skin lesions as primary presenting symptoms. An association can be considered between the different manifestations, presumably based on immune etiology, where immunosuppressive therapy has been beneficial.

What the skin of 341 premature newborns says - a transversal study.

OBJECTIVES: Determine the frequency of dermatological diagnoses in preterm newborns up to 28 days of life and associated perinatal factors. METHOD: a cross-sectional analytical study with a convenience sample and prospective data collection, was conducted between November 2017 and August 2019. Overall, 341 preterm newborns who had been admitted to a University hospital - including those admitted to the Neonatal Intensive Care Unit - were evaluated. RESULTS: 61 (17.9%) had less than 32 weeks gestational age (GA), with a mean GA and birth weight of 33.9 ± 2.8 weeks and 2107.8 ± 679.8g (465 to 4230g), respectively. The median age at the time of evaluation was 2.9 days (4 h to 27 days). The frequency of dermatological diagnoses was 100% and 98.5% of the sample had two or more, with an average of 4.67+1.53 dermatoses for each newborn. The 10 most frequent diagnoses were lanugo (85.9%), salmon patch (72.4%), sebaceous hyperplasia (68.6%), physiological desquamation (54.8%), dermal melanocytosis (38.7%), Epstein pearls (37.2%), milia (32.2%), traumatic skin lesions (24%), toxic erythema (16.7%), and contact dermatitis (5%). Those with GA< 28 weeks showed more traumatic injuries and abrasions, whereas those with ≥ 28 weeks had physiological changes more frequently, and those with GA between 34-366/7 weeks, had transient changes. CONCLUSION: Dermatological diagnoses were frequent in our sample and those with higher GA showed a higher frequency of physiological (lanugo and salmon patch) and transient changes (toxic erythema and miliaria). Traumatic lesions and contact dermatitis were among the 10 most frequent injuries, reinforcing the need to effectively implement neonatal skin care protocols, especially in preterm.

Pyoderma Gangrenosum as a Presenting Feature of Takayasu Arteritis.

Takayasu arteritis (TA) is a large vessel vasculitis that involves the aorta and its major branches. The disease has a female preponderance, and it presents with a wide variety of symptoms including skin manifestations, mainly ulcerative nodules, pyoderma gangrenosum, and erythema nodosum-like lesions. We report a case of a 50-year-old female who presented to the outpatient department with multiple ulcerative lesions over both upper extremities and chest. On physical examination, the patient had pulseless upper limbs. Laboratory investigations revealed positive antinuclear antibodies (ANA) and raised inflammatory markers. CT angiography of the aorta showed thickened aortic arch with the obliterated lumen of the left common carotid and left subclavian arteries. A biopsy of the skin lesion revealed surface ulceration and densely inflamed granulation tissue with a fibroblastic proliferation of deeper tissues. The patient had three out of six features of the American College of Rheumatology 1990 (ACR-1990) criteria for the classification of TA and was diagnosed with TA associated with pyoderma gangrenosum. The patient was managed with steroids and immunosuppressants along with gentle wound debridement with grafting of skin wounds. Since TA has varying presentations, its diagnosis is often challenging and requires a combined approach including clinical signs and symptoms, as well as laboratory and radiological workup. The disease also requires long-term follow-up due to its remitting and relapsing course.