Livedo reticularis y dengue

Se presenta a un varón de 40 años, residente en la ciudad de Lima, sin viajes recientes, con fiebre, malestar general, cefalea y diarrea. Acudió al Servicio de Emergencia y los exámenes auxilares mostraron leucopenia y trombocitopenia leve. Los estudios para Epstein-Barr, hepatitis B, toxoplasma, rubéola, citomegalovirus, herpes 1 y 2 y COVID-19 fueron negativos. Los anticuerpos IgM y IgG para dengue fueron negativos, y la proteína NS1 fue positiva. El paciente fue diagnosticado con dengue y solo recibió paracetamol. En el seguimiento, en el séptimo día de enfermedad, se le halló afebril y con lesiones dérmicas tipo livedo reticularis en los miembros, principalmente. Se resalta este inusual patrón cutáneo en dengue.

We present the case of a 40-year-old male, resident of Lima city, with no recent travels, with fever, general malaise, headache and diarrhea. He went to the Emergency Department and auxiliary tests showed leukopenia and mild thrombocytopenia. Studies for Epstein-Barr, hepatitis B, toxoplasma, rubella, CMV, herpes 1-2 and COVID-19 were negative. IgM and IgG antibodies for dengue were negative and NS1 protein was positive. He was diagnosed with dengue. He only received paracetamol. On follow-up, on the seventh day of illness, he was found afebrile and with livedo reticularis type dermal lesions on the limbs, mainly. This unusual cutaneous pattern in dengue is highlighted.

COVID-19 presenting as an exanthematic disease: a case report

Abstract Coronavirus disease (COVID-19) is caused by SARS-CoV-2 and has spread rapidly and caused a global pandemic. Knowledge about clinical and laboratory manifestations in the pediatric population is necessary to guide and monitor such patients. A 3-year-old female patient diagnosed with COVID-19 presented with high fever. After defervescence, she experienced a maculopapular rash that worsened by the sixth day of the disease with self-limited evolution without relevant laboratory changes. The identification of rashes in children with COVID-19 is an unusual and important condition that must be recognized in view of the high transmissibility shown.

Stevens-Johnson syndrome and toxic epidermal necrolysis: a review

Stevens Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are considered a single entity with variability in the extent of the lesions, characterized by erythema multiforme that may involve mucosa. Severe cutaneous reactions secondary to medications are classified according to the area of epidermal detachment. The activation of cytotoxic T cells and macrophages is mediated mainly by IL-2 and interferon gamma secreted by Th1 lymphocytes, and the activation of eosinophils and B lymphocytes in IgE is mediated by secreted IL-4, IL-5, IL-10 and IL13 by B lymphocytes. The topography of SJS is predominantly central, affecting the trunk and sometimes a generalized dissemination is shown that affects a body surface area of less than 10%, characterized by irregular violaceous erythematous macules of target shooting, which can form confluent blisters. TEN is characterized by a skin detachment greater than 30% of the body surface, whose predominant lesion is diffuse erythema with individual macules, which give rise to detachment surfaces greater than 5 cm. The treatment is symptomatic, nonspecific, and aimed at avoiding complications, carried out in specialized intensive care units, due to ignorance of the pathogenesis. Integral management with different therapeutic alternatives can represent a crucial part in the multisystemic management of SJS and TEN.

Fiebre manchada de evolución fatal en la provincia de Salta / Fatal spotted fever in Salta province

Describimos el caso de un varón de 17 años oriundo de la ciudad de Salta quien, 10 días después de visitar una zona rural de la provincia homónima, ingresó a nuestro hospital por convulsiones febriles. Durante la internación presentó exantema seguido de disfunción orgánica múltiple, la que evolucionó rápidamente hacia shock séptico irreversible y muerte a las 48 horas de su admisión. El diagnóstico serológico -altos títulos de IgM e IgG anti-Rickettsia spp. por inmunofluorescencia indirecta- arribó post mortem. Las rickettsiosis del grupo de las fiebres manchadas son transmitidas por garrapatas, tienen distribución global y en varios países continúan siendo subdiagnosticadas debido a una baja sospecha clínica. En las provincias del noroeste argentino se agrega la carencia de un laboratorio regional capacitado para efectuar el diagnóstico etiológico. Esta limitación es crítica porque en esa región del país ya ha sido documentada la presencia de las formas graves de la enfermedad, usualmente debidas a R. rickettsii. Dado que las fiebres manchadas se presentan como sindromes febriles inespecíficos y los componentes del ciclo enzoótico están presentes en vastas áreas geográficas, incluso en algunas aún no consideradas endémicas para rickettsiosis, su diagnóstico nunca debe ser subestimado. Con el tratamiento antibiótico adecuado instaurado en tiempo oportuno, el pronóstico de este grupo de enfermedades potencialmente mortales mejora en forma drástica.

We describe the case of a 17-year-old male patient living in Salta city who, 10 days after visiting a rural area in Salta province, was hospitalized for febrile seizures. Shortly after admission, he developed an exanthema followed by a multiple organ dysfunction that evolved to irreversible septic shock followed by death 48 hours after admission. Serological diagnosis -high IgM and IgG anti-Rickettsia spp. antibody titres as detected by indirect immunofluorescence- arrived post mortem. Spotted fever group rickettsioses are tick-borne diseases distributed worldwide and continue being under diagnosed in several countries mainly due to a low clinical suspicion. In the north-western provinces of Argentina there is also the limitation of not counting with a regional laboratory to perform the etiological diagnosis. This is crucial because the severe forms of the disease, which are commonly caused by R. rickettsii, have been already documented in the region. Given that spotted fevers have broadly unspecific febrile presentations and the components of the enzootic cycle are present even in geographic areas not yet considered to be endemic for tick borne diseases, their diagnosis should not be underestimated. If the adequate antibiotic treatment is administered timely, the prognosis of this group of life-threatening diseases improves drastically.

Manifestation and therapies of EGFRI-induced dermatological toxicities / 中国肿瘤临床

In the past decades, the advent of molecular targeted agents has been a considerable breakthrough for cancer patients, ex-cept for traditional operation, chemotherapy, and radiotherapy. As a novel therapeutic method, molecular targeting treatment is im-portant in the field of medical oncology, in which epidermal growth factor receptor inhibitors (EGFRIs) have been widely used as target-ed agents. Dermatological toxicities are the common side effects associated with the EGFRIs. Diarrhea, weakness, and pneumonia can be observed. EGFRI-induced dermatological toxicities may disrupt the health-related quality of life and cause anticancer treatment dose adjustments or discontinuance. The dermatological toxicities mainly involve rash acneiform, pruritus, xerosis, paronychia, hair change, and skin hypersensitivity. Treatment recommendations from guidelines include antibiotics, corticosteroids, and antihista-mines, but their clinical therapeutic efficacy have not been proven. Therefore, oncologists and dermatologists are investigating effec-tive medication. This article reviews the advances in the study of the clinical manifestations and drug therapies of EGFRI-induced der-matological toxicities to provide reference for clinical practitioners.

Earlier treatment improves the chances of complete relief from postherpetic neuralgia

BACKGROUND: As herpes zoster progresses via postherpetic neuralgia (PHN) to well-established PHN, it presents its recalcitrant nature to the treatment. At this point, the well-established PHN is fixed as a non-treatable, but manageable chronic painful neuropathic disorder. This study evaluated the incidence of complete relief from PHN according to PHN duration at their first visit, and the other factors influencing it. METHODS: A retrospective chart review was performed on patients with PHN at a university-based pain clinic over 7 years. The responders were defined as patients who had complete relief from pain after 1 year of active treatment. Age, sex, PHN duration at their first visit, dermatomal distribution, and underlying disorders were compared in the responder and non-responder groups. Responders were also compared according to these factors. RESULTS: Among 117 PHN patients (M/F = 48/69), 35 patients (29.9%) had complete relief from PHN. Mean ages were 64.3 ± 10.6 and 66.9 ± 10.7 years, numbers of male to female patients were 11/24 and 37/45, and mean durations of PHN at their first visit were 8.5 ± 6.3 and 15.3 ± 10.7 months in the responder and non- responder groups, respectively. In addition, PHN patients who visited the clinic before 9 months showed a better result. Dermatomal distribution and underlying disorders did not show significant differences. CONCLUSIONS: Almost 30% of PHN patients received complete relief. Those who sought treatment in a pain clinic before 9 months received a better result.

Association of GSTT1 and GSTM1 polymorphisms in South Indian Epilepsy Patients.

Experimental studies suggest that oxidative stress is one of the contributing factors in the onset of epileptic seizures. Glutathione S-transferases (GSTs) are able to conjugate electrophilic compounds, and thus possess neuroprotective role by removing exogenous and endogenous oxidants, detoxifying therapeutic drugs, environmental toxins through conjugation with glutathione (GSH). Several studies from different ethnic groups showed that polymorphisms of the GST gene have been associated with Epilepsy. In the present study, we investigated the association of GST polymorphism in the South Indian epilepsy patients population. A total 371 samples (110 cases and 261 controls) were genotyped for the GST1 and GSTM1 polymorphism by multiplex PCR method. We observed a significant association of GSTT1 null polymorphism in patients with epilepsy. The frequency of the GSTT1 null genotype was found to be significantly higher in cases (35.45 %) than the controls (18.39 %) (OR: 2.44, 95%CI: 1.4-4.02, P <0.0001). In contrast, the frequency of the GSTM1 null variant was significantly lower in cases (11.81%) than controls (32.95%) (OR: 0.27, 95%CI: 0.14-0.51, P <0.001) indicating a protective role. These results indicated that individuals who have GSTT1 null variant are at higher risk for developing seizure than those of GSTT1 wild genotype. On the other hand, individuals carrying GSTM1 null variant showed protective role against seizure. Further, these two null variants did not show any significant association with antiepileptic drug-induced skin rash.

Rash in a foreign worker

Hookworm-related cutaneous larva migrans (HrCLM) is a zoonosis which is endemic in many subtropic and tropical countries including Malaysia. We report a case of a 40-year old plantation worker who presented with a pruritic rash on his abdomen. It is important for clinicians to diagnose and treat HrCLM promptly as this condition results in considerable morbidity when treatment is delayed.

Severe Skin Lesions or Arthritis May be Associated with Coronary Artery Lesions in Kawasaki Disease

PURPOSE: Kawasaki disease (KD) shows a variety of clinical signs of multi-system involvement, including clinical diagnostic criteria. It is unknown that the severity of the clinical signs is associated with the risk of coronary artery lesions (CALs). We wanted to evaluate clinical characteristics and the risk of CALs in the patient groups who had severe skin lesions or those with arthritis. METHODS: We retrospectively reviewed the medical records of 220 KD patients who were treated with intravenous immunoglobulin (IVIG). We compared clinical and laboratory data between the group with severe skin lesions (n=52) and those with mild or no skin lesions (n=168), and between the group with arthritis (n=6) and those without arthritis (n=214). RESULTS: The mean age of total patients was 2.23±1.87 years of age, and the male-to-female ratio was 1.5:1 (138/82). Among 220 patients, 52 patients had CALs (23.6%), and 29 patients (13.2%) showed incomplete KD. The patients with CALs had a higher mean age, longer total fever duration, and higher rate of IVIG non-responsiveness. The patient group with severe skin lesions showed a higher mean age (P<0.001), more prolonged fever duration (P=0.041), higher frequency of CALs (P=0.033), higher WBC, neutrophil, and neutrophil-to-lymphocyte ratio levels, compared to the patient group without severe skin lesions. The patients with arthritis had a tendency of further treatment with methylprednisolone or infliximab. CONCLUSIONS: The frequency of CALs was higher in patient group with severe skin lesions. Our results suggest that the intensity of clinical signs of KD such as skin rash, cervical lymphadenopathy and possibly arthritis may be associated the risk of CALs.

A Case of Local and Generalized Skin Adverse Reactions after Pneumococcal Vaccination / 대한피부과학회지

Pneumococcus is the most frequently encountered causative pathogen in community-acquired pneumonia in elderly patients. The pneumococcal polysaccharide vaccine (PPV23) is widely used for preventing pneumococcal diseases in adults. PPV23 is relatively safe; however, some cutaneous adverse reactions, including localized mild inflammation associated with erythema, a sensation of heat, and tenderness, have been reported. Systemic reactions such as myalgia, arthralgia, and headache have also been reported, though severe adverse reactions are rare. In the Korean literature, a case of localized toxic reaction near the injection site after pneumococcal conjugate vaccine (PCV13) administration was previously reported. However, there are no published reports of a generalized skin rash after PPV23. Herein, we report a case of PPV23-induced generalized skin rash on the face, neck, upper trunk, and both arms with a local adverse reaction at the injection site after vaccination.

Sulfasalazine Induced DRESS Syndrome: A Review of Case Reports.

Introduction: Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) is designated as a lethal adverse drug effect with characteristic sign and symptoms such as skin rashes, fever, leukocytosis with eosinophilia or atypical lymphocytes, lymph node enlargement, and liver or renal dysfunction. Incidences of the DRESS range from 1/1000-1/10,000 drug exposures and are associated with a mortality rate of 10%. Pathogenesis of DRESS relates to an abnormal immune response in a genetically vulnerable individual, i.e. presence of human leukocyte antigen (HLA)*5801 and HLA-B* 5701 genotype and slow acetylation metabolic pathways. Methods: 48 cases were associated with the “Sulfasalazine-induced DRESS syndrome” reported between January 1990- March 2015 in PubMed-MEDLINE and HighWire Press. The “RegiSCAR” scoring system was used to analyze the case reports. Using this system, cases were classified into 4 categories as “no”, “possible, “probable” and “definite”. Results: The vast majority of cases were classified as “probable/definite” DRESS cases (83%). Hypereosinophilia, atypical lymphocytes and fever were significantly associated with “probable/ definite” DRESS cases. Liver involvement and skin rash was described in almost all of the cases, including “possible cases”. DRESS was found fatal in two cases. Conclusion: Awareness of DRESS is essential for diagnosis with the presence of skin rash, liver involvement, fever, hyper eosinophilia and lymphadenopathy. Early identification, followed by a prompt withdrawal of the culprit drug is the most essential measure to avoid disease evolution and to restore wellness.

Adult Onset Stills Disease: A Case Report.

Adult onset still’s disease (AOSD) is a rare inflammatory disorder of unknown etiology. Because of lack of a defined diagnostic test the diagnosis of AOSD can only be made after excluding infectious, malignant, and autoimmune diseases. A 21-year-old female patient was admitted in our hospital with intermittent high-grade fever, polyarthritis and rash. On further history, examination and laboratory investigation she was found to be fulfilling all the Yamaguchi criteria for AOSD. All other causes consisting of acute or chronic infections, hematological malignancies, and other rheumatic disorders were excluded by laboratory investigations. Patient was treated as AOSD with non-steroidal anti-inflammatory drugs and steroids and is completely free of symptoms.

Maculopapular skin rash due to amoxicillin tri-hydrate hypersensitivity reaction: a case report.

Amoxicillin tri-hydrate (AMT) is a commonly used penicillin group of antibacterial agent to combat various bacterial infections. Penicillin group of drugs are known to cause cutaneous drug eruptions as a hypersensitivity reaction. Most of the time, these eruptions are mild in nature, however, sometimes they represent the early manifestation of rare and severe drug-induced cutaneous reactions, such as; Stevens–Johnson syndrome and toxic epidermal necrolysis. Here, we report a case of maculopapular skin rash developed due to AMT hypersensitivity reaction in a 48-year-old Indian male patient. Pheniramine maleate, hydrocortisone and skin protecting lotion were prescribed to manage the situation. This case is being reported to emphasize the need for reporting of drug induced complications and their management procedures.

Febrile Illness with Skin Rashes / 감염과화학요법

Skin rashes that appear during febrile illnesses are in fact caused by various infectious diseases. Since infectious exanthematous diseases range from mild infections that disappear naturally to severe infectious diseases, focus on and basic knowledge of these diseases is very important. But, these include non-infectious diseases, so that comprehensive knowledge of these other diseases is required. Usually, early diagnostic testing for a febrile illness with a rash is inefficient. For clinical diagnosis of diseases accompanied by skin rash and fever, a complete history must be taken, including recent travel, contact with animals, medications, and exposure to forests and other natural environments. In addition, time of onset of symptoms and the characteristics of the rash itself (morphology, location, distribution) could be helpful in the clinical diagnosis. It is also critical to understand the patient's history of specific underlying diseases. However, diagnostic basic tests could be helpful in diagnosis if they are repeated and the clinical course is monitored. Generally, skin rashes are nonspecific and self-limited. Therefore, it could be clinically meaningful as a characteristic diagnostic finding in a very small subset of specific diseases.

Clinical experience on use of oral EGFR-TKIs as first-line treatment of advanced NSCLC from a tertiary care centre in North India and implications of skin rash.

Background. Limited data are available from India on treatment outcomes with oral epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) in newly diagnosed non-small cell lung cancer (NSCLC). We studied the demographic profile and treatment outcomes of patients with NSCLC, receiving first-line treatment with oral EGFR-TKIs. Methods. Retrospective study of newly diagnosed NSCLC patients treated with oral EGFR-TKIs over a 4-year period at a tertiary care institute in North India. Results. Of 76 patients studied, females and non-smokers constituted 32.9% and 48.7%, respectively. Majority of patients had adenocarcinoma (59.2%), stage IV (64.5%) disease and Karnofsky performance status <70 (74.5%). Gefitinib was the most frequently used EGFR-TKI (92.1%). Most common indication for the use of EGFR-TKIs was poor performance status (65.8%). Among assessable patients, disease control and progressive disease were evident in 66% and 34%, respectively. Most common side effects were skin rash (17%) and diarrhoea (10.6%). Patients with and without skin rash differed significantly in relation to objective response to treatment (100% versus 23.1%) and overall survival (median not reached versus 178 days). On multivariate logistic regression analysis, malignant pleural effusion was associated with occurrence of rash (odds ratio=0.19; 95% confidence interval = 0.04-0.95; p=0.04). Conclusions. Oral EGFR-TKIs appear to be useful for the treatment of clinically selected patients with advanced NSCLC. Occurrence of skin rash was independently associated with treatment response and better survival in the current study.

Absence of HLA-B*1502 and HLA-A*3101 Alleles in 9 Korean Patients With Antiepileptic Drug-Induced Skin Rash: A Preliminary Study

There have been a number of studies about correlations between HLA genotypes in various ethnic groups and occurrence of various cutaneous adverse drug reactions, ranging in intensity from mild to severe, caused by antiepileptic drugs (AEDs). This is the first report analyzing the HLA genotypes of 9 Korean patients with skin rashes induced by various AEDs. The AEDs that induced skin rash were lamotrigine (n=3), carbamazepine (n=3), oxcarbazepine (n=1), phenobarbital (n=1), and phenytoin (n=1). None of the patients' HLA genotypes was either HLA-B*1502 or HLA-A*3101. Based on these series of cases, AED-induced skin rash can occur independently of HLA-B*1502 or HLA-A*3101 genotypes in the Korean patients.

Acute Onset Methimazole-Induced Arthralgia and Skin Rash / 대한갑상선학회지

Methimazole, a type of thionamide, is used to treat hyperthyroidism. Several adverse effects of thionamides have been reported. The representative minor adverse effects are arthralgia, skin rash, and gastric intolerance. Methimazole is reported to induce 1-6% of arthralgia cases. These patients begin to suffer from arthralgia from 1 month to 2 years after methimazole treatment. Here, we present a patient with acute onset methimazole-induced arthralgia and skin rash. At 2 days after starting methimazole treatment, a 57-year-old female developed arthralgia and a skin rash on her right leg, which subsequently spread to her left leg and right arm, and she stopped taking the medication. The patient was admitted to the rheumatology department of Ulsan University Hospital, where laboratory tests and a skin biopsy were performed to ascertain whether she had a rheumatic disorder. The skin biopsy revealed nonspecific inflammation. At 2 days after stopping methimazole treatment, the arthralgia and skin rashes had improved and methimazole treatment was recommenced. However, the same symptoms developed within 1 day. Therefore, methimazole treatment was again stopped and the symptoms disappeared.

Muscle Weakness in a Patient with History of Poliomyelitis: A Differential Diagnosis for Post-polio Syndrome (PPS) and Dermatomyositis

Dermatomyositis (DM) is an idiopathic inflammatory myopathy, characterized by inflammation of the proximal skeletal muscles and typical skin manifestations, which results in symmetric muscle weakness. A 43-year-old man was presented with skin rash and left leg weakness, and he had a history of poliomyelitis. Initially, he was diagnosed as having post-polio syndrome (PPS) due to unilateral muscle weakness and a result of an the electromyography (EMG), which had shown patterns of PPS. After 4 months with conservative therapy for PPS, weakness of bilateral upper arms had developed and skin rashes on his entire body had aggravated and progressed. He was diagnosed as having dermatomyositis, based on elevated muscle enzyme levels, typical skin rashes, and typical EMG findings, which indicated muscle disease. When a patient with previous poliomyelitis has a newly developed muscle weakness or pain, we should consider various possible causes other than PPS.

Self medicated Combiflam induced acute dermatological drug reaction.

A 30 year old female took a single tablet of Combiflam (ibuprofen 400mg + paracetamol 325mg) for backache following which she noticed maculopapular rashes with generalized facial and lip swelling with generalized itching. Subsequently patient was treated with antihistaminic and steroids and she responded well. The causality assessment according to Naranjo casualty assessment scale come under “Probable” category of adverse drug reaction. According to World Health Organization-Uppsala Monitoring Centre causality assessment scale it falls under “Probable/Likely” category. According to Hartweig and Siegel severity assessment scale it was level 3 and moderate adverse drug reaction. This is a rare adverse effect of combiflam with the incidence less than 0.1%. The awareness of the health care personnel to this widely used drug on its rare adverse effect is necessary.

Lamotrigine Induced Severe Cutaneous Reaction.

Antiepileptic drugs are used commonly by physicians, neurologist and neurosurgeons in Nepal. Lamotrigine is an effective antiepileptic drug used as an add-on and monotherapy for a variety of seizure types in both adults and children. Rashes due to AED including SJS and hypersensitivity syndrome leading to hospitalization occur in approximately 0.33% of adults and 0.8% in children. Reactions due to LTG alone occur in around 5.7% of cases. We report probably the first case of this reaction in a 12-year old girl with a brief discussion on its etiology and management.