Beware the Unexpected Infection: Disseminated Varicella Zoster Virus Mimicking A Drug Eruption.

Adverse cutaneous reactions to medications are not uncommon and may resemble viral infection and vice versa, complicating diagnosis. We describe the case of a 79-year-old male with cholangiocarcinoma with liver and presumed lung metastasis who presented with abdominal pain and was admitted with ileitis with partial small bowel obstruction. He had a widespread papulovesicular rash with hemorrhagic center, mostly on his face, chest, and back. The rash was initially thought to be a drug eruption, but was eventually diagnosed via dermatopathological examination as disseminated varicella zoster virus (VZV) infection. Steroid treatment was discontinued, and airborne precautions were initiated. Polymerase chain reaction for VZV was obtained and intravenous acyclovir treatment was begun. This case of VZV, initially suspected to be an adverse drug reaction, highlights the importance of early identification of a highly infectious lesion and the importance of early infection control measures, given the implications of exposure to VZV for health care personnel.

Painful scrotal dermatitis secondary to topical 5-fluorouracil.

5-Fluorouracil (5-FU) is an antineoplastic agent that is used topically to treat actinic keratoses. Although topical 5-FU frequently causes irritant contact dermatitis at the site of application, distant skin reactions are rare and could relate to accidental transfer or systemic absorption of the drug. We present a patient who developed a painful scrotal dermatitis after applying the topical cream to actinic keratoses on his chest. Upon discontinuation of topical 5-FU, the reaction resolved over a four-week period with oral prednisone and topical betamethasone ointment. The patient was re-challenged with topical 5-FU one year later and again developed scrotal pain and erythema similar to the initial reaction. Scrotal dermatitis is a rare adverse effect of topical 5-FU therapy that can be associated with significant distress and disruption of daily activities.

Prevalence of scratching during examination among patients with scabies and among patients with other pruritic dermatoses.

BACKGROUND: Scabies is a parasitic skin disease. Its clinical diagnosis may be challenging. METHODS: In a prospective observational study, we enrolled all consecutive patients ≥16 years of age with a presumptive diagnosis of scabies and all patients ≥16 years of age with a diffuse itchy dermatosis lasting for more than 1 week. We investigated whether patients with scabies were more prone to scratch themselves during the consultation than patients with other pruritic dermatoses. RESULTS: We observed that a significant proportion of patients (25/62, 40%) with scabies had to scratch while talking or being examined. This clinical sign was less frequently noticed in patients with pruritic dermatoses of other origins (26/196, 13%) (P < 0.001). CONCLUSIONS: The observation of a patient scratching himself during the consultation should prompt serious consideration of scabies. This easily observable clinical sign may be especially useful in low-resource settings, where scabies is known to be very prevalent.

Eritema multiforme inducido por hidroxicloroquina en paciente con COVID-19 / Hydroxychloroquine-induced erythema multiforme in a patient with COVID-19

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Herpes associated erythema multiforme: A retrospective study.

BACKGROUND: Erythema multiforme (EM), an acute dermatologic condition frequently encountered in the Emergency Department, classically presents with a targetoid rash. We reviewed all recent EM cases seen at the LAC-USC County Hospital in order to ascertain the proportion of Herpes associated EM (HAEM) cases and to inform the diagnostic workup of these patients. METHODS: ICD-9 and ICD-10 codes were used to extract a list of EM cases at our institution from 2013 to 2019. Two non-blinded abstractors screened records to confirm an EM diagnosis and entered patient data utilizing a standardized data abstraction form. Cohen's kappa statistic was used to measure inter-rater reliability on various variables. Kappa (κ) values ranged from 0.803 to 1.0. RESULTS: 70 pediatric and 56 adult EM patients were included in the study. A likely etiology was ascribed to 63% of pediatric and adult EM cases. Pediatric EM was most commonly attributed to upper respiratory infection (URI) (n = 23; 33%), Mycoplasma pneumoniae infection (n = 5; 7%), and medications (n = 4; 6%). Adult EM was most commonly attributed to HSV infection (n = 11; 20%), medications (n = 5; 9%), URIs (n = 4; 7%), and other infections (n = 4; 7%). CONCLUSION: HSV-1/2 serologic testing should be considered in most EM patients to potentially prevent repeated ED visits. In EM cases not clearly attributable to herpes or drug exposure, physicians can consider further workup: Mycoplasma serology, nasal PCR, and a respiratory viral panel in pediatric patients. Identification of an etiologic cause may suggest a different treatment approach and prevent mislabeling of medication allergies in patient charts.

[Lichenoid drug eruption with antituberculosis drugs associated with an anonychia]. / Toxidermie lichénoïde aux antituberculeux associée à une anonychie.

INTRODUCTION: Lichenoid cutaneous reactions to antituberculosis drugs are rare. Herein we report a new case. PATIENTS AND METHODS: A 41-year-old patient was seen for a profuse and pruriginous rash occurring 2 weeks after administration of rifampicin and isoniazid for pulmonary tuberculosis. Dermatological examination revealed polymorphic erythemato-squamous plaques with lichenoid, psoriatic and eczematous features, associated with cheilitis, erosions on the cheeks and diffuse onychodystrophy. The skin biopsy confirmed a lichenoid reaction. The pharmacovigilance investigation incriminated isoniazid and rifampicin. The patient was treated with topical corticosteroids and UVB phototherapy. The outcome involved complete regression of the eruption but with secondary anonychia. DISCUSSION: Antituberculosis drugs including isoniazid and rifampicin are known to induce lichenoid reactions. It is difficult to distinguish the results from lichen planus. The clinical polymorphism of the rash as well as the patient's drug intake militate in favour of a diagnosis of lichenoid reaction. Widespread ungual involvement, which is extremely rare, warranted early management in order to avert irreversible anonychia.

[Hemorrhagic bullous dermatosis (HBD): A rare side-effect of heparins]. / Dermatose bulleuse hémorragique (DBH) : un effet indésirable rare des héparines.

BACKGROUND: Bullous haemorrhagic dermatosis (BHD) induced by heparin is a rare and benign side effect of which we report two cases. PATIENTS AND METHODS: Case 1: an 81-year-old man presented haemorrhagic bullae on the limbs and trunk 7 days after starting enoxaparin. The laboratory haemostasis assessment was normal. A diagnosis was made of BHD induced by enoxaparin and the patient's treatment was switched to apixaban, resulting in a favourable outcome with resolution of the lesions within 15 days. Case 2: a 71-year-old woman hospitalised for pulmonary embolism was given tinzaparin. At two months of treatment, haemorrhagic bullae were observed on her forearms at distance from the injection sites. A diagnosis of BHD induced by tinzaparin was made. Treatment with tinzaparin was continued and the lesions resolved within 15 days. DISCUSSION: Heparin-induced BHD is a rare entity initially described in 2006. Ninety-five cases of heparin-induced BHD have been reported. It is characterized by multiple haemorrhagic bullae at a distance from the injection sites. Time to onset of lesions after heparin initiation ranges from 24h to 4 months. Laboratory assessment should be routinely performed to rule out any haemostasis disorders. Lesions subside within 15 days whether heparin is continued or withdrawn. CONCLUSION: Heparin-induced BHD is a rare but benign side effect of heparins. In the absence of recommendations, therapeutic management should be adapted to the individual situation.

Successful Treatment of Allopurinol-Induced Severe Skin Reactions with Double Filtration Plasmapheresis: A Case Report.

Severe cutaneous adverse reactions (SCAR) are uncommon and acute and frequently represent a drug reaction. For years, allopurinol use has remained the highest risk factor for SCARs worldwide. There are multiple risk factors for allopurinol-induced SCARs, including genetic and non-genetic factors. Renal failure has been found to be an important factor resulting in allopurinol-induced SCARs with greater severity and poorer prognosis. An 80-year-old female was admitted to our hospital after administration of allopurinol in December 2018. She developed erythaematous skin of the epidermis of the hips, which rapidly extended over the trunk and limbs, resulting in itching and flaking. The presumptive diagnosis was a drug-induced SCAR. Despite treatment with glucocorticoids and kidney support therapy, the skin lesions extended over the entire body. Fortunately, the progression of pruritic erythema was stopped by double-filtration plasmapheresis (DFPP). DFPP was discontinued after the signs of skin inflammation were no longer visible. Her skin, but not kidney function, recovered after 10 days of hospitalization. She tolerated DFPP well without development of any severe complications. We present here a case of allopurinol-induced SCAR, which was successfully treated with DFPP.

Clinicopathologic overlap of psoriasis, eczema, and psoriasiform dermatoses: A retrospective study of T helper type 2 and 17 subsets, interleukin 36, and ß-defensin 2 in spongiotic psoriasiform dermatitis, sebopsoriasis, and tumor necrosis factor α inhibitor-associated dermatitis.

BACKGROUND: T helper (Th) type 17 and Th2 cells mediate psoriasis and eczema, respectively. Some dermatoses exhibit overlapping clinicopathologic features, and their immunopathology is relatively unexplored. OBJECTIVE: To determine whether Th17 and Th2 subsets and interleukin (IL) 36 and ß-defensin 2 (BD-2) markers of IL-17 signaling expression can discriminate between biopsy samples of psoriasis and eczematous/spongiotic dermatitis and to use those markers to immunophenotype cases with clinicopathologic overlap. METHODS: A retrospective study was performed on biopsy samples of psoriasis, eczema/spongiotic dermatitis, sebopsoriasis, tumor necrosis factor α inhibitor-associated psoriasiform dermatitis, and ambiguous cases diagnosed as spongiotic psoriasiform dermatitis. Dual CD4/GATA3 and CD4/RORC, IL-36, and BD-2 immunohistochemistry was performed. RESULTS: IL-36 and BD-2 were strongly expressed in biopsy samples of psoriasis compared with eczema/spongiotic dermatitis. No significant differences were observed in the percentages of Th2 and Th17 cells between disease types. Strong expression of IL-36 and BD-2 was observed in a subset of spongiotic psoriasiform dermatitis, sebopsoriasis, and tumor necrosis factor α inhibitor-associated psoriasiform dermatitis biopsy samples. LIMITATIONS: This was an exploratory study with a small sample size. No multiple testing adjustment was done. Clinical follow-up was limited. CONCLUSIONS: In cases with clinicopathologic overlap between psoriasis and spongiotic dermatitis, IL-36, and to a lesser extent BD-2, may be used to assess for a psoriasis-like/IL-17 phenotype, which could inform therapeutic clinical decisions.

Managing dermatologic changes of targeted cancer therapy.

Failure to control these dermatologic changes can lead to lower dosages of cancer agents or an interrupted course of Tx. These steps can help you to head off trouble.

Mucocutaneous manifestations of human immunodeficiency virus (HIV) infection in children in relation to the degree of immunosuppression.

BACKGROUND: Human immunodeficiency virus (HIV) infection in children is becoming a common occurrence. Worldwide, limited studies have been done on the mucocutaneous manifestations in HIV-positive children. The aim of our study was to analyze the spectrum of mucocutaneous manifestations of pediatric HIV infection and correlate to degree of immunosuppression. MATERIAL AND METHODS: One hundred and sixty-five children under 18 years with HIV, who presented to the departments of dermatology and pediatrics, were examined for mucocutaneous manifestations. Patients were classified into four groups of immunodeficiency such as normal, mild, advanced, and severe, based on NACO guidelines of immunosuppression. The most recent CD4 count (within 6 months of study period) was considered. RESULTS: One hundred and sixty-five patients were examined, and skin manifestations were seen in 100 (61%) of them.The highest incidence of mucocutaneous manifestations was in 6-10 age group. Papular pruritic eruptions (PPE) (16%) was the most common condition, with highest prevalence in severe CD4 category (38%). Molluscum contagiosum (MC) (10%) was the most common infectious condition, with highest prevalence in advanced CD4 category (14%). Severe cutaneous adverse reactions (SCAR) caused by nevirapine were seen in three children. The percentage of skin manifestations was highest in the advanced (107%) and severe (100%) CD4 category. There was no significant difference in manifestations between those who were on antiretroviral therapy (ART) and those not. CONCLUSION: The percentage of skin manifestations increased with degree of CD4 depletion. PPE was found to be the hallmark of severe immunosuppression. However, opportunistic infections did not correlate with severity of immunodeficiency.

Estudio clínico-histopatológico de las eritrodermias en un hospital universitario: 14 años de experiencia / Clinical-histopathological study of erythroderma in a university hospital: 14 years of experience

INTRODUCCIÓN: La eritrodermia es un síndrome inflamatorio cutáneo infrecuente caracterizado por compromiso eritematoso generalizado y descamación, de más del 90% de superficie cutánea total. OBJETIVO: Caracterizar clínica e histopatológicamente a los pacientes con eritrodermia en un hospital universitario chileno. METODOLOGÍA: Estudio retrospectivo, realizado en el Hospital Clínico Universidad de Chile, basado en revisión de fichas clínicas e informes histopatológicos de pacientes con eritrodermia, entre 2005 y 2018. Se evaluó edad, sexo y variables clínicas (co-morbilidades, síntomas, días de evolución, ingreso hospitalario, informe histopatológico, diagnóstico y evolución). RESULTADOS: Total de 28 pacientes, 18 hombres (64%), edad promedio 59 años. Causa más frecuente de eritrodermia fue dermatosis pre-exis-tentes, con 15 casos (54%), que incluyen: psoriasis 9 (32%), dermatitis de contacto 3 (11%), PRP 2 (7%), dermatitis atópica 1 (4%). A estas le siguen: reacción adversa medicamentosa 6 (21%), idiopática 6 (21%) y Síndrome de Sezary 1 (4%). CONCLUSIÓN: El presente estudio corresponde a la primera serie de eritrodermias realizada en Chile. Destacan las dermatosis preexistentes como la principal causa, lo que se correlaciona con la literatura.

INTRODUCTION: Erythroderma is an infrequent cutaneous inflammatory disorder characterized by generalized erythematous compromise and desquamation, of more than 90% of total cutaneous surface. OBJECTIVE: Clinical and histopathological cha-racterization of patients with erythroderma in a Chilean university hospital. METHODOLOGY: Retrospective study, performed at the University of Chile Clinical Hospital, based on review of clinical records and histopatho-logical reports of patients with erythroderma, between 2005 and 2018. Age, sex and clinical variables were evaluated (co-morbidities, symp-toms, days of evolution, hospital admission, histopathological report, diagnosis and evolu-tion). RESULTS: A total of 28 patients, 18 were men (64%), average age 59 years. Most frequent cause of erythroderma was pre-existing dermatosis, with 13 cases (52%), which included: psoriasis 9 (32%), contact dermatitis 3 (11%), PRP 2 (7%), atopic dermatitis 1 (4%). These are followed by adverse drug eruption 6 (21%), idiopathic 6 (21%) and Sezary syndrome 1 (4%). CONCLUSION: The present study corresponds to the first series of erythrodermas performed in Chile. The pre-existing dermatoses were the main cause of erythroderma, which coincides with other reports.

Un caso de poroqueratosis diseminada eruptiva en un paciente oncológico tratado con trastuzumab y exemestano: ¿fenómeno asociado al cáncer o inducido por fármacos? / A Case of Eruptive Disseminated Porokeratosis in a Cancer Patient after Trastuzumab and Exemestane Treatment: Cancer Related or Drug Induced Phenomenon?

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