Comparison of low-dose meglumine antimoniate/ allopurinol combination therapy with full dose meglumine antimoniate alone in the treatment of cutaneous leishmaniasis - a randomized controlled trial

Objective: To compare the efficacy and safety of meglumine antimoniate 20 mg/kg/day with combination of meglumine antimoniate 10 mg/kg/day and allopurinol 20 mg/kg/day

Methods: A multi-center single blind randomized controlled trial was conducted. Soldiers over 18 years of age having parasitologically proven cutaneous leishmaniasis requiring systemic therapy, willing for admission to hospital for the study and regular follow up visits in outdoor, and consenting not to use any other treatment for cutaneous leishmaniasis while in study were included. On entry into the study patients were randomly assigned to either group A or group B using a random number table. Group A patients were given meglumine antimoniate 20 mg/kg/day/intramuscular till clinical resolution or for 28 days maximum. Group B patients were given intramuscular meglumine antimoniate 10mg/kg/day along with allopurinol 20 mg/kg/day/per oral till clinical resolution or for a maximum of 28 days. The ulcer and induration areas were recorded separately for each patient. Time to healing was recorded and compared among the two groups

Results: A total of 324 patients were included in the study. Group A had 151 [46.6%] patients while 173 [53.4%] were in group B. Three hundred and six patients completed the study and 18 dropped out due to various complications, 9 belonging to each group. Lesion size at baseline in group A was 29.7+16.4 mm, while in group B it was 28+15.8 mm [p=0.35]. Lesion size at the end of treatment period was 1.5+3.4 mm in group A and 0.9+2.6 mm in group B [p=0.07]. Lesion size at the end of follow-up period was 0.1+0.9 mm in group A and 0.03+0.4 mm in group B [p=0.40]. A total of 109 adverse effects were seen, 60 in group A and 49 in group B [p=0.05]

Conclusion: Low-dose meglumine antimoniate/allopurinol combination is equally effective and safe as compared to full dose meglumine antimoniate treatment

Zosteriform cutaneous leiomyoma: a rare cutaneous neoplasm

Cutaneous leiomyomas are firm, round to oval, skin-coloured to brownish papules and nodules that may present as a solitary, few discrete or multiple clustered lesions. Different uncommon patterns of multiple leiomyoma distribution have been noted as bilateral, symmetrical, linear, zosteriform, or dermatomal-like arrangement. One such rare presentation was seen in a 23-year-old patient who presented with zosteriform skin coloured, occasionally painful cutaneous lesions over left shoulder region. Histopathology confirmed the diagnosis of cutaneous leiomyoma. He was symptomatically managed with non-steroidal anti-inflammatory agents and topical capcicum cream. Case is reported here due to rare occurrence of this benign cutaneous neoplasm in an atypical pattern and on uncommon site

Clinico-epidemiological pattern of cutaneous leishmaniasis in armed forces personnel fighting war against terrorism in Khyber Pakhtunkhwa Province and FATA regions

Cutaneous leishmaniasis [CL] is endemic in various regions of Khyber Pakhtunkhwa [KPK] province and Federally Administered Areas [FATA]. Troops deployed in these regions are at an increased risk of acquiring the disease as compared to the native population. To determine clinical and epidemiological pattern of CL in armed forces personnel serving in endemic areas of CL in KPK and FATA. This observational/descriptive study was conducted at CMH, Peshawar from January, 2010 to June, 2010. All patients of any age reporting in skin outdoor with clinical diagnosis of CL were enrolled in the study and all were subjected to skin slit smears for Leishman-Donovan [LD] bodies and skin biopsies were also taken in all cases to observe histopathological features. Patients in whom clinical diagnosis was not supported by laboratory diagnosis, were excluded. Clinical and epidemiological data was recorded and finally analyzed by using descriptive statistics. Out of 172 initially enrolled cases, 2 were excluded from the study as their clinical diagnosis was not supported by laboratory findings. All patients were young males [deployed armed forces personnel]. Their ages ranged from 18 to 43 [mean age: 27.4 years]. Number of lesions ranged from 1-11. Multiple lesions were seen in 41.2% cases only. Size of lesions ranged from 1-13 cm. 70.6% of lesions were seen on upper and lower limbs followed by head and neck region 27.6%, and trunk and abdomen 1.8%. Morphological patterns seen were crusted plaques, psoriasiform plaques, nonhealing ulcers, erythematous infiltrated nodules and papules. Majority of the cases were from the regular army units deployed in the areas in recent past [71.8%] as compared to 28.2% of native troops of Frontier Corps [FC]: 3% deployment of regular troops against 0.5% of FC troops. CL is common in soldiers serving in KPK province and FATA regions of Pakistan. Armed forces personnel who moved from central Punjab and deployed in these areas for operations against terrorists are at much higher risk of acquiring the disease as compared to the native troops. This risk can be decreased by implementing effective precautionary measures and education of the soldiers

Mucosal lichen planus simultaneously involving oral mucosa, conjunctiva and larynx

Lichen planus is an autoimmune disease that typically involves skin and the mucosa of the mouth and genitalia. The involvement of conjunctival and laryngeal is rare. A young patient presented with hoarseness of voice, oral ulcerative lesions and symblephron. Mucosal biopsies [buccal mucosa and supraglottic area] revealed the diagnosis of lichen planus and he was managed accordingly. Although oral lichen planus is frequently reported but simultaneous involvement of oral, ocular and laryngeal mucosa has not been reported earlier

Churg-strauss syndrome: a rare systemic vasculitis

Churg-Strauss syndrome is a rare diffuse small/medium sized vessel vasculitis that is almost invariably accompanied by severe asthma. The cause is unknown, but its characteristic histological findings and association with asthma distinguish it from other vasculitides. We report here a middle aged lady who presented with sudden onset of vasculitic skin lesions in association with long standing asthma. Skin biopsy and serology revealed diagnosis of Churg-Strauss syndrome. She was successfully managed with oral prednisolone

Malignant acanthosis nigricans: an early diagnostic clue

Acanthosis nigricans [AN] is characterized by velvety, hyperpigmented, verrucous, symmetric and occasionally pruritic plaques along with papillomatous lesions which have a special predilection for neck, axillae, groin, umbilicus and mucosal regions. Rarely, it presents as a paraneoplastic syndrome and prompts a thorough search for an internal malignancy. We present here a case of malignant acanthosis nigricans seen in an elderly patient who was found to have underlying adenocarcinoma of the lower end of esophagus. After diagnosing associated malignancy, he was referred for further evaluation and subsequent surgical resection of tumour

Clinical spectrum of nasal leishmaniasis in muzaffarabad

To determine the frequency of nasal leishmaniasis and the presentation of disease involving nose as well as nasal mucosa in patients reporting from the Muzaffarabad district of Azad Jammu and Kashmir [AJK]. Study Design: Case series. Place and Duration of Study: Combined Military Hospital, Muzaffarabad, from January 2006 to May 2008. Methodology: All patients belonging to Muzaffarabad district of AJK, clinically suggestive of Cutaneous Leishmaniasis [CL] and supported by laboratory diagnosis were registered. Diagnosis was made on the basis of clinical characteristics of the lesions, laboratory demonstration of leishmania trophozoite bodies on skin smears or skin biopsies and therapeutic trials. Those having lesions primarily on nose, irrespective of age and gender were included in the study. All those cases with primary lesion elsewhere over face and secondarily involving nose [by extension of primary lesion] were excluded. Various demographical features of the patients and clinical patterns of the lesions were recorded in all cases and subsequently categorized accordingly. Results: Seventy three out of 252 [29%] cases of nasal leishmaniasis were encountered. Male to female ratio was 43:30. Fifty five had solitary lesions which were restricted only to nose in 51 patients. Morphological patterns included psoriasiform [30], furunculoid [8], nodular [13], lupoid [8], mucocutaneous [4], rhinophymous [3], erysipeloid [1], basal cell carcinoma-like [1], discoid lupus erythematosis-like [1], mutilating [2], verruciform [1] and keloidal [1]. Conclusion: Nose was a common site of involvement in CL, where the disease can present in various forms. In endemic areas, CL should be included in the differential diagnosis of all nasal lesions

Frequency and antimicrobial susceptibility pattern of methicillin resistant Staphylococcus aureus

To determine the frequency of methicillin resistant Staphylococcus aureus and its antimicrobial susceptibility pattern in patients reporting to Combined Military Hospital [CMH], Pano Aqil. A non-interventional, cross-sectional study. Pathology Laboratory, Combined Military Hospital [CMH], Pano Aqil, from December 2005 to January 2008. Strains of Staphylococcus aureus were isolated from a variety of clinical specimens. Standard methodology, using modified Kirby-Bauer disk diffusion method, was adopted for antibiotic sensitivity test. The MIC of oxacillin and vancomycin was performed by E-strips, for MRSA isolates and isolates revealing vancomycin resistance on disk diffusion. A total of 195 hospital and 42 community acquired isolates were tested. Forty-seven [19.8%] non-duplicate strains were found to be methicillin resistant Staphylococcus aureus [MRSA]; methicillin resistance did not differ among hospital strains [n=42] as compared to community ones [n=5, p=0.1555]. No isolates from the community and hospital acquired showed resistance to vancomycin. Community and hospital acquired isolates revealed higher resistance against penicillin and doxycycline than against ciprofloxacin, erythromycin, gentamicin and chloramphenicol. However, resistance against these antibiotics did not differ significantly among community and hospital acquired isolates. Increase in prevalence of MRSA is impending in future, appealing preventive measures to be adopted. However, Staphylococcus aureus resistant to vancomycin was not observed

Microscopic polyangiitis: a rare ANCA-associated small- vessel vasculitis

Microscopic Polyangiitis [MPA] is an autoimmune disease characterized by pauci-immune, necrotizing, small-vessel vasculitis without clinical or pathological evidence of necrotizing granulomatous inflammation. Because many different organ systems may be involved, a wide range of symptoms are possible in MPA. Cutaneous involvement is not frequent. We describe a young girl who presented with multiple vasculitic skin lesions along with arthralgia and after the onset of illness it took 4 years for appropriate diagnosis and management of the disease

Familial dysbetalipoproteinemia: a potentially fatal disorder

Familial dysbetalipoproteinemia is an inherited disorder in which both cholesterol and triglycerides are elevated in the plasma of the blood, which pre-disposes people to coronary artery disease and peripheral vascular disease. We report two young boys with multiple cutaneous xanthomas and grossly abnormal serum cholesterol and triglycerides. Two of the family members had died of cardiovascular accidents in young age and rest of the family members had deranged lipid profile. Patients were managed with lipid lowering drugs and fat restriction diet. All family members were counseled and advised regular exercise and follow-up

Gronblad-Standberg syndrome: a case report and review of literature

Gronblad-Strandberg syndrome is a rare congenital hereditary dysplasic disorder of the connective tissue, characterized by a progressive abnormal mineralization and dystrophic calcification of elastic tissue and collagen. The term Gronblad-Strandberg syndrome is used when angioid streaks in eye occur in association with pseudoxanthoma elasticum [PXE] of skin. We report a young patient having characteristic skin and eye manifestations of the syndrome. He was evaluated thoroughly regarding extent and potential systemic complications of the disease and was counseled accordingly. Since dermatologists are generally not familiar with historical background and ocular findings of the disease, a brief review of these two aspects is also made

Pigmentary skin disorders in black Africans of Sierra Leon

Eighty percent of the world`s population consists of individuals with pigmented skin. Darker skin differs from Caucasian skin in its reactivity and disease presentation. The purpose of the study was to see the prevalence of disorders of pigmentation in black Africans of eastern province of Sierra Leone and to compare the differences with other ethnic populations. The study was carried out in eastern province [Kenema] of Sierra Leone from Nov, 2004 to Oct, 2005. It was an observational/descriptive study. Local black patients of all age groups presenting in dermatology out patient department of Pak Field Hospital [established as a part of UN peacekeeping mission in Sierra Leone] were included. After clinical history and physical examination, laboratory investigations were carried out when indicated. Skin diseases were broadly classified into two major categories i.e. pigmentary and non pigmentary. Non-black settlers in the area and UN troops were not included in the study. Data was recorded and analyzed by Microsoft Excel. A total of 3011 patients belonging to different local tribes having a variety of skin disorders were seen during the study period. Patients were of all ages and both sexes ranging from I month to 73 years of age. Sex ratio was almost equal. The pigmentary skin disorders were seen in 228 [7.6%] patients and most prevalent disorders were post inflammatory hyper and hypopigmentation, followed by melasma, vitiligo and albinism. Pigmentary disorders in blacks are not infrequent and can be of significant concern

Onchocerciasis: a review of a filarial disease of significant importance for dermatologists and ophthalmolodists

Onchocerciasis is a common, chronic, multisystemic disease caused by the nematode Onchocerca volvulus. The disease characteristically includes dermatologic, lymphatic, ophthalmologic, and systemic manifestations. It is transmitted to humans by a bite from the intermediate host, the black fly [Simulium damnosum]. It is endemic in Western and Central Africa and approximately 95% of all infected people live in these regions. Onchocerciasis has been associated with a high incidence of detrimental effects on socioeconomic development and public health in endemic areas. We, here in Asia, hardly see any case of this disease but due to globalization, frequent international traveling and deployment of military troops from Asian countries [as a part of UN forces] in endemic African countries. We should expect such diseases in our region also and should have a high index of suspicion. Here is a review of this troublesome filarial disease with emphasis of its clinical spectrum, so that dermatologists, ophthalmologis ts and physicians in our region would be able to keep this disease in mind as a differential diagnosis of some unusual case of dermatitis, blindness or arthritis etc. Patients described in this article are author`s own collection during one year stay in Sierra Leone [an endemic country of West Africa for the disease]

Hypohidrotic ectodermal dysplasia: a case report and literature review

Ectodermal dysplasia is a rare hereditary disorder involving two or more of the ectodermal structures, which include the skin, hair, nails, teeth, mucus and sweat glands. Different combination of defects may give rise to variable phenotypes of this syndromic disorder. We present a nine years old boy having dental, skin and sweat glands defect. A brief review of literature is also presented

Dermatological disorders related to cultural practices in black africans of Sierra Leone

To describe various skin manifestations directly or indirectly related to the prevalent cultural practices in the local community of black Africans of Sierra Leone. Eastern province [Kenema] of Sierra Leone from November 2004 to October 2005. Local black patients of all age groups presenting in Dermatology Outpatient department of Pak Field Hospital [established as a part of UN peacekeeping mission in Sierra Leone] were included. After clinical history and physical examination, lesions were photographed. Laboratory investigations were carried out when indicated. Skin diseases were broadly classified into two major categories i.e. related to cultural practices and not related to cultural practices. Non-black settlers in the area and UN troops were excluded. Data was recorded and analyzed by Microsoft Excel. A total of 3011 patients belonging to different local tribes having a variety of skin disorders were seen during the study period. Patients ranged from 1 month to 73 years of age with almost equal gender ratio. Vast majority were from very low socioeconomic group. Skin manifestations related to cultural practices were seen in more than 20% patients and most prevalent were alopecia and hypertrophic scars followed by pomade acne, pseudofolliculitis and contact dermatitis. Prevalent cultural practices in black Africans do play a role in causation of various skin disorders. For a dermatologist, it becomes imperative to be cognizant of the signs and symptoms associated with these practices for proper diagnosis and appropriate treatment

Blaschkolinear dermatoses - an overview of interesting patterned dermatological disorders

A large number of congenital/nevoid and acquired skin diseases on the human skin and mucosae assume a characteristic morphological pattern following the Blaschko lines. This pattern recognition is important for dermatologists so as to have an idea about the etiopathogenesis as well as to categorize various such disorders. This article is an attempt to overview and classify a variety of blaschkold disorders described so far in the literature