Hypersensitivity Reaction of Tongue: Oral Adverse Effect of COVID-19 Vaccine: A Case Report

Coronavirus Disease-2019 (COVID-19) has introduced the new normal in this 21st century. This viral has caused a great infection storm in the recent past affecting more than half of the world population. Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) causes various symptoms from mild to severe. Mortality rate has been reported to be low, mostly associated with pre-existing medical history. Literature also states that mortality was high among those with poor immune surveillance. Based on the duration of symptoms, it has been classified into long COVID-19 and short COVID-19 to combat the outcome of the disease many vaccines were invented worldwide by various pharmaceutical companies and they helped a lot in controlling the severity of the disease. The vaccines effectively reduced the incidence of long COVID-19 and serious symptoms, thereby, reducing the death rate. Although the vaccines were very effective in control of serious complications of the infection, few patients had certain adverse reactions to the vaccines of both types' whole virus and viral-vector based vaccine. In the present case report, authors would like to document the delayed hypersensitivity reaction in the tongue as a potential Adverse Drug Reaction (ADR) postvaccination for SARS-CoV-2 infection in a 48-year-old female patient without any previous history of medical illness or drug allergy. The ADR was effectively controlled with systemic steroids and the symptoms were effectively controlled within a period of few months.

Dermatomyositis: severe acute respiratory syndrome coronavirus 2, an initiator or a trigger?

Dermatomyositis is an immune-mediated inflammatory myopathy. In adults, the common triggering factors for its onset include viral infections, malignancy, and drugs. The clinical manifestation of these group of disorders may be cutaneous, neurological, pulmonary, or a combination of all. The cutaneous manifestations are helpful in the early clinical diagnosis. The detection of myositis-specific autoantibodies serves as specific biomarkers for the diagnosis and helps in predicting the prognosis. We are presenting two cases of dermatomyositis, temporally related to the severe acute respiratory syndrome coronavirus 2 infection and vaccination. Copyright © 2022 Journal of the Egyptian Women's Dermatologic Society.

Three Cases of Disseminated Erythematous Papules with Elevated Serum Thymus and Activation-Regulated Chemokine Levels after COVID-19 Vaccination.

Case 1 was an 81-year-old man undergoing treatment for the nummular eczema of the lower leg. The day after being administered the first dose of a COVID-19 vaccine, the patient developed generalized pruritus, multiple serous papules, and erythema on the trunk, upper extremities, and palms, as well as worsening of pre-existing eczema on the lower legs. The serum TARC level of the patient was 1,383 pg/mL. After taking oral antihistamines and topical steroids for two weeks, the erythema faded, papules crusted, and serum TARC level normalized. Case 2 was a 22-year-old woman who had been treated with topical steroids for contact dermatitis by poultices on the ankles. On the same day as she received the second dose of COVID-19 vaccine, erythema with pruritus on the dorsum of the feet appeared and gradually expanded to papules and edematous erythema on the face, extremities, and trunk. The serum TARC level of the patient was 2,090 pg/mL. After taking 15 mg/day oral prednisolone and topical steroids for 10 days, overall erythema became hyperpigmented, and the erythema on the dorsum of the hands and fingers persisted for approximately 2 weeks and then became pigmented. Serum TARC level normalized after the skin rash reformed. Case 3 was a 74-year-old woman with a history of asthma. She received SBT/ABPC therapy for acute cholangitis for one week. Ten days after treatment, she received the first COVID-19 vaccination dose. Two days after vaccination, the patient became aware of pruritus on the extremities ipsilateral to the vaccination site, and small erythematous patches appeared all over the body in a disseminated pattern. Her serum TARC level was 3,862 pg/mL. After taking oral antihistamines and topical steroids for 3 weeks, the erythema completely faded, and the serum TARC level normalized. The DLST showed positive by SBT/ABPC, but the result of drug challenge test was negative. There have been no previous case reports of rash with a high TARC level after vaccination. In the future, it is necessary to accumulate patients with a high TARC level by vaccination and analyze the clinical and pathological trends including immunological mechanisms. Copyright © 2022 Osaka University Medical School. All rights reserved.

A case of morphea following the inactivated COVID-19 vaccine

Background: The emergence of the coronavirus disease (COVID-19) prompted pharmaceutical companies to develop effective vaccines to address the problem. While studies prove the vaccines are safe, rare systemic side effects remain possible. All types can cause various vaccine-related adverse reactions which are continuously being monitored. This paper aims to highlight new data on immunologic reactions to COVID-19 vaccines. Morphea demonstrated after COVID-19 vaccination is rare. Herein, we report a case of morphea that was most likely triggered by the immune response against inactivated COVID-19 vaccine. Method(s): A case of morphea was reviewed at the clinic in a tertiary hospital in the Philippines. Result(s): A 48 year old Japanese male had no underlying co-morbidities and no previous COVID-19 infection. He had his first dose of inactivated COVID-19 vaccine, coronaVac (sinovac) with no untoward reactions. After a month, he had his second dose. One week later, the patient started to have a red plaque on his upper back, palpable, tender on palpation and pruritic. Review of systems was unremarkable. The patient denied any insect bites or skin trauma. No medications applied or taken. No known allergies to food, medications or vaccines. He is a 32 pack years smoker. No family history of any autoimmune diseases. In five months, the skin lesion insidiously progressed, thickened and now spreading to the left side of the back. The patient sought consult with a dermatologist and rheumatologist. Physical examination revealed thickened skin and subcutaneous tissue on the upper back with post-inflammatory hyperpigmentation. Work-up showed normal complete blood count, normal chest x-ray, non-reactive Hepatitis B antigen. Antinuclear antibody (ANA) was positive with 1:80 titer and nuclear speckled pattern. Anti-double stranded DNA (anti-dsDNA), anti-smith, antinuclear ribonucleoprotein (anti-RNP), anti-SSA, anti-SSB and anti-Jo- 1 were all negative. The patient's skin biopsy to the reticular dermis showed findings that are consistent with Morphea. The patient was then started on Methotrexate. Conclusion(s): People should be educated about the possible outcomes of COVID-19 vaccines. One of these are immune-related diseases, such as morphea. The underlying mechanism of morphea is multifactorial but one hypothesis highlighted that the spike glycoprotein from vaccination drives these skin reactions. Other studies demonstrated molecular mimicry to viral epitopes. Discussing this cutaneous manifestation secondary to COVID-19 vaccine stressed the importance of this clinical condition, in order to provide a proper diagnosis and therapeutic management. Although there are novel case reports of morphea induced by COVID-19 mRNA vaccine, inactivated COVID-19 vaccine-related morphea has not been reported yet.

Generalized fixed drug eruption following Pfizer-BioNtech COVID-19 vaccination.

Fixed drug eruption is a cutaneous drug reaction which recurs at the same site when the individual is exposed to the causative drug, characterized by single or multiple round sharply demarcated erythematous-to-violaceous patches. Here, we report a patient with generalized non-bullous fixed drug eruption following mRNA-based Pfizer-BioNTech COVID-19 vaccine.

TUBERCULOUS PLEURAL EFFUSION MASQUERADING AS DRUG-INDUCED LUPUS

SESSION TITLE: Critical Care Presentations of TB SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: TNFα plays a pivotal role in inflammation and maintenance of immune response against tuberculosis. The use of TNF inhibitors (TNFi) is associated with a significant increase in the incidence of tuberculosis (TB). TNFi may cause drug-induced lupus (ATIL) presenting as constitutional symptoms, rashes, pericardial and pleural effusions with positive autoantibodies. We present a case of pleural TB masquerading as drug-induced lupus. CASE PRESENTATION: A 68y/o woman with a history of ulcerative colitis (on infliximab, mesalamine), hypertension, T2DM, CAD, complained of low-grade fever, rashes, left-sided chest pain, dyspnea, and arthralgias for two weeks. Chest pain- worse with inspiration and cough. She emigrated from India to the USA 40 years ago. Six months before infliximab therapy, Quantiferon gold was negative. Exam: faint hyperpigmentation over shins, minimal swelling of MCPs and ankles, dullness to percussion over the left chest with decreased breath sounds. Labs: CRP 101 mg/dL, Hb 10.8 iron deficient, rheumatoid factor and anti-CCP negative, ANA 1:40, dsDNA 1:640, a reminder of ENA negative, anti-histone negative, C3/C4 normal, UA bland, protein/Cr 0.4 mg/gm, negative blood cultures, SPEP and LDH normal. CXR: opacification of the left lung up to midfield. CT chest: moderate left and small right pleural effusions, enlarged mediastinal lymph nodes. COVID and Quantiferon: negative. Thoracentesis: 850 ml of exudative fluid (2 out of 3 Light's criteria), lymphocytic predominance (76% of 4148 nucleated cells), adenosine deaminase (ADA) 42 U/L, gram stain, culture, acid-fast and MTB PCR negative, cytology negative. Thoracoscopy with biopsy of the parietal pleura: necrotizing granulomatous pleuritis with acid-fast bacilli. Sensitivity: pan-sensitive M. tuberculosis. Sputum: negative for TB. She was discharged on RIPE treatment for reactivation of TB. DISCUSSION: The incidence of infliximab-induced lupus is approximately 0.19% and confirming the diagnosis is challenging. The immunogenicity of infliximab is high, 66% of patients develop positive ANA. Anti-histone antibodies are less commonly associated with ATIL as opposed to classic drug-induced lupus and dsDNA is positive in up to 90% of cases of ATIL. Renal involvement is rare. The diagnostic usefulness of ADA (over 40 U/L) in lymphocytic pleural effusions for the diagnosis of tuberculosis in an immunosuppressed individual is demonstrated here. In countries with low TB burden, such as the USA, the positive predictive value of ADA in pleural fluid declines but the negative predictive value remains high. CONCLUSIONS: Tuberculous pleuritis is not always easily diagnosed since AFB smears and sputum may remain negative. When ADA level in lymphocytic pleural fluid is not low thorough search for TB with thoracoscopy and biopsy is justified. Reference #1: Shovman O, Tamar S, Amital H, Watad A, Shoenfeld Y. Diverse patterns of anti-TNF-α-induced lupus: case series and review of the literature. Clin Rheumatol. 2018 Feb;37(2):563-568. Reference #2: Benucci, M., Gobbi, F. L., Fossi, F., Manfredi, M. & Del Rosso, A. (2005). Drug-Induced Lupus After Treatment With Infliximab in Rheumatoid Arthritis. JCR: Journal of Clinical Rheumatology, 11 (1), 47-49. Reference #3: Valdés L, San José ME, Pose A, Gude F, González-Barcala FJ, Alvarez-Dobaño JM, Sahn SA. Diagnosing tuberculous pleural effusion using clinical data and pleural fluid analysis A study of patients less than 40 years-old in an area with a high incidence of tuberculosis. Respir Med. 2010 Aug;104(8):1211-7. DISCLOSURES: No relevant relationships by Adam Adam No relevant relationships by Moses Bachan No relevant relationships by Chen Chao No relevant relationships by Zinobia Khan No relevant relationships by Milena Vukelic

SWEET SYNDROME IN ACUTE MYELOGENOUS LEUKEMIA- A CASE REPORT

CASE: Patient is a 63 y/o F with PMH of relapsed AML on treatment with Gilteritinib, Meniere's Disease, asthma, GERD, PRA positive, CKD Stage 3. She was on cycle 1 day + 20 of Gilteritinib when she presented with a neutropenic fever of 101.9. She reported congestion and headache. She was pan cultured and started on empiric Cefepime. Her blood cultures, COVID test and CXR were all negative for sources of infection. Eventually, Cefepime was stopped, and she was transited to PO Cefdinir and Cipro but redeveloped fevers and a maculopapular rash. Repeat pan-cultures were negative. Antibiotics were broadened to Merrem, Linezolid and Cresemba and her fevers improved. However, the rash continued to worsen. There was concern that nodular rash was secondary to infection or possible drug reaction from her antibiotics. Her rash showed no improvement with Benadryl or withholding drugs. She underwent skin punch biopsy before discharge. Biopsy showed florid superficial inflammation with benign ulcer that was highly suggestive of Sweet Syndrome given history of AML. IMPACT/DISCUSSION: Sweet syndrome (SS), or acute febrile neutrophilic dermatosis is a rare inflammatory condition characterized by painful cutaneous nodules and neutrophilic infiltrate in the dermis, in the absence of vasculitis. This syndrome is associated with malignancies with AML and MDS being the most reported. Malignancy associated Sweet Syndrome accounts for 15-20% of cases of SS. The atypical production of both pro-inflammatory cytokines (IL - 6, TNF - alpha) and signaling molecules demonstrated in AML is suspected to affect neutrophil function leasing to dermal clumping of the mature neutrophils. In our patient the fever presented prior to the rash with sudden onset of nodular as it has been commonly reported in literature review. Glucocorticoids, either topical or systemic, together with antibiotics and wound care, represent the mainstays of SS therapy. The rash heals without scarring if no ulcerations are present. The signs and symptoms of Sweet syndrome can mimic infection and be treated inaccurately, thus, it is important to make a correct diagnosis. Our patient's tissue cultures were negative for microorganisms. She was started on glucocorticoid with good response in regards to her rash but did have some scars and hyperpigmentation. Unfortunately due to her aggressive AML and complications patient elected to go to Hospice. CONCLUSION: When SS is established, the physician should keep a high index of suspicion to search underlying malignancies. Sweet Syndrome generally responds promptly to treatment with glucocorticoid.

SARS-COV-2 TREATMENT WITH HYDROXYCHLOROQUINE AND VITAMIN C: COMPARATIVE RETROSPECTIVE STUDY OF ORAL MUCOSAL CHANGES BY HEMATOLOGY TESTING DURING TWO PERIODS

Objectives. To compare two methods of COVID-19 treatment based on hematology test results and oral cavity manifestations. Materials and methods. The first part of the study included patients in the period from May to July 2020 with coronavirus infection;another part of the study was conducted in the period from August to October 2020. Two groups received different treatment: 1) with hydroxychloroquine and 2) with without hydroxychloroquine. Results. C-reactive protein was elevated in 173 (89%) in the hydroxychloroquine group and in 30 (81%) patients in group without hydroxychloroquine (p<.01). As well, INR, Quick prothrombin, D-dimer and neutrophils were statistically different. Hydroxychloroquine treatment showed a decrease in symptoms within 7-10 days while Vitamin C protocol demonstrated health improvements in 4-5 days. Patients from hydroxychloroquine group demonstrated pigmentation in the attached gingiva on both maxilla and mandibula (n=80;41.4%) and in hard palate (n=3;1.5%) Lentigo was revealed in 23 (10.8%) patients in both lips. None of the patients from the second group had any of manifestations. Conclusion. Oral changes are not primary in the oral cavity in COVID-19.

Partial breast irradiation with IORT using Xoft®. Experience at Catalan Institute of Oncology

Purpose or Objective external beam whole breast irradiation (WBI) for low-risk early-stage breast cancer patients after breast conserving surgery. We present the experience at our center treating patients with PBI using an IORT technic with Xoft® Axxent® Electronic Brachytherapy (eBx®) System®. Materials and Methods Between April 2019 and August 2021, 44 patients diagnosed with low-risk early-stage breast cancer who met international criteria for PBI, received IORT in a single fraction of 20 Gy to the tumor bed after lumpectomy. Toxicities and follow up were prospectively registered. Results 3 of the 44 initial patients were discarded for IORT due to non-compliance with the minimum safety distance (<1 cm) between the applicator and the skin. Of the remaining patients, 32/41 patients (78%) received a PBI, while 9/41 (22%) required adjuvant WBI due to adverse prognostic factors identified on the definitive biopsy. The most frequent risk factor was close resection margins (<2mm), present in 8/9 patients (88,8%). Two patients additionally presented sentinel node involvement and in 1 case no axillary sample was obtained. The most used IORT applicator was the 3-4 cm balloon, with most likely filling volumes between 30cc and 40 cc. For all treatments, the mean filling volume of the applicator was 45 cc and there were no complications during the irradiation procedure. Surgical bed seroma was the most common acute effect, observed in 29/41 patients (70,7%), although only 8/29 (27,5%) required drainage. We observed wound dehiscence in 7/41 cases (17%), inflammatory complications requiring antibiotics in 9/41 cases (19,5%), and 4/41 cases of hematoma (9,7%). Regarding late toxicity, at the time of the analysis it was only assessable for 37 patients. We observed low rates of local grade I fibrosis (21,6%) and only 1 case of tumor bed G2 fibrosis. Hyperpigmentation G1 was observed in 8,1% of patients and 10,8% presented occasional mild local discomfort. With median follow-up of 17.14 months (range 4-29 months), no relapses were observed, but 1 patient died from covid-19 pneumonia. Conclusion Intra operative PBI with Xoft® Axxent® Electronic Brachytherapy (eBx®) System® is a feasible approach to treat low-risk early-stage breast cancer patients. Our preliminary results show that it presents advantages over conventional WBI allowing for less toxic and shortened treatment courses while maintaining good local tumor control.

Shades of COVID-19 vaccine

SARS-CoV-2 infection is associated with a wide spectrum of skin manifestations and few may appear after immunization with vaccines expressing the SARS-CoV-2 spike protein. The COVID-19 pandemic has led to the rapid invention and approval of vaccines and, like any vaccination programme, reports of side-effects have begun to emerge. Though initial reports were about mild side-effects, reports of varied other moderate to severe side-effects have now started to emerge. Although these side-effects seem to be rare, the symptoms can be severe and data on them are scarce. We report a case of a 49-year-old woman with Fitzpatrick skin type VI developing coin-shaped well-defined, round to oval, erythematous to violaceous plaques with central dusky appearance along with vesicles and bullae on her right cheek, left cheek and left posterior thigh. This was seen a few days following each dose of AstraZeneca COVID vaccine but self-resolved in about 2 weeks with hyperpigmentation. There was no cutaneous disease elsewhere and no mucosal involvement. We considered a diagnosis of fixed drug eruption (FDE) based on history and clinical features. FDEs represent a cutaneous adverse drug reaction characterized clinically by the appearance of recurrent, quasiidentical, cutaneous eruptions in the same anatomical location on exposure and re-exposure to the offending drug.

Vitamin B12 deficiency in northern India tertiary care: Prevalence, risk factors and clinical characteristics.

Background: Vitamin B12 deficiency leads to a diversity of symptoms and affects many systems. It is often overlooked or sometimes even misdiagnosed in clinical practice. Aims and Objectives: The purposes of this study were to report the prevalence of vitamin B12 deficiency, the spectrum of clinical features and to draw attention to the possibility of rare hidden characteristics. Materials and Methods: This study was a multicenter, retrospective, and prospective conducted at a tertiary care teaching hospital and multispecialty hospital. All cases of vitamin B12 deficiency of either sex or age attending the Medicine Department were enrolled in this study from Aug 2015 to Dec 2020. Parenteral vitamin B12 was given, and cases were evaluated for the response on follow-up for more than three months. Results: Of 220 cases, 52.27% were males. Maximum cases were reported from the age group 50 to 65 years (27.27%) and belonged to urban areas (59.1%). The majority were strict vegetarian (86.36%). Among comorbidities, diabetes (20.91%) followed by malabsorption (10.45%) were most common. The cutaneous manifestations were revealed at 38.18%. The most frequent neurological manifestation was paraesthesia (98.18%). Head heaviness/ache was the most frequent (95%) psychiatric manifestation. Anemia was revealed in 87.73% of cases with 88.64% macrocytosis. Axonal sensorimotor (52.63%) neuropathy was a prevalent finding of NCV study. Conclusions: A high index of clinical suspicion is needed in cases with vague manifestations, especially in the pure vegetarian population. Early recognition can prevent further damage as most of its related disorders are generally reversible with treatment.

Cryptogenic Organizing Pneumonia Due to Mycoplasma

Introduction: Mycoplasma pneumoniae is a respiratory tract pathogen that most commonly causes acute bronchitis. Pneumonia is a less common manifestation. Herein we describe a patient who presented with COVID19 like symptoms after exposure but was later found to have Mycoplasma with cryptogenic organizing pneumonia (COP). Case Description: A 63-year-old lady presented to the emergency department with a cough with minimal sputum production and dyspnea for one week and a generalized itchy rash for four days. She had a recent travel history, exposure to a COVID-19 patient, and was unvaccinated against COVID-19. On admission, vitals were normal except for a heart rate of 121/min. On examination, she had a maculopapular rash involving the face, neck, back, palms, and soles (Fig A and B). Labs were significant for total leukocyte count of 12.9 X 103/ mm3, D-dimer of 1125 ng/mL which increased to 1635ng/mL in 24 hours, erythrocyte sedimentation rate of 38mm/h, and C-reactive peptide of 101.5mg/L. Chest x-ray revealed bilateral opacities worse on the right (Fig C). A CT pulmonary angiogram was negative for PE but showed bilateral peripheral opacities greater on the right side, suggesting COVID19 as the etiology (Fig D). But COVID19 PCR was negative. Due to the presence of diffuse rash, mycoplasma IgG antibodies were checked which were positive. During the hospital course, she became hypoxic requiring nasal cannula oxygenation. The patient underwent bronchoalveolar lavage (BAL) with transbronchial lung biopsy (TBLB) which revealed 60% eosinophils with COP. She was treated with IV methylprednisolone, IV ceftriaxone, and doxycycline. Her respiratory symptoms got better, and the rash significantly improved with residual hyperpigmentation. The patient was discharged on tapering doses of steroids and levofloxacin to complete 14 days of antibiotics. Discussion: Mycoplasma pneumoniae is known to cause atypical pneumonia most commonly in young children than in adolescents and adults. COP is rarely seen with it. Common dermatological manifestations include erythematous maculopapular rash, erythema multiforme. Our patient was an elderly female who presented with classic maculopapular rash and respiratory symptoms. The presence of rash and hypoxia prompted us to get BAL with TBLB which led to the diagnosis of COP and early initiation of steroids. Although open lung biopsy is considered the best approach for diagnosis, BAL with TBLB has a positive predictive value of around 95%. Symptomatic improvement in such patients is quite impressive with steroids with complete recovery in most of the patients. (Table Presented).

Multiple, Eruptive and Generalised Lobular Capillary Haemangiomas- A Rare Morphological Variant

Lobular Capillary Haemangioma or Pyogenic Granuloma (PG) is a common benign, vascular proliferative lesion, usually occurring at sites of preceding trauma. It is known to occur more commonly in children and young females. The most common presentation is a solitary lesion. Multiple, eruptive PG have been reported after antecedent burns, trauma and following retinoid therapy and as satellite lesions after treatment of a primary lesion. A 14-year-old female, without any co-morbidities presented with spontaneous onset of multiple, eruptive and generalised skin coloured papules and nodules over face, neck, upper chest and upper back. The lesions were eruptive in nature, involved the back, face and upper trunk over duration of 4 months. There was intermittent bleeding from the lesions after trivial trauma. Clinical diagnosis of lobular capillary haemangioma was confirmed by histopathology which showed lobules of variably dilated network of blood filled capillaries in the papillary dermis surrounded by typical epithelial collarette. The lesions were removed by Radiofrequency (RF) in subsequent sittings. This case report features an interesting and unusual morphological presentation of generalised eruptive lobular capillary haemangioma, which occurred de novo in a young female without any associated skin or systemic disease.

Primary Adrenal Insufficiency after COVID-19 Infection

Introduction: The clinical presentation of SARS-CoV-2 ranges greatly from asymptomatic disease to critical illness. The multisystemic effect of COVID-19 is becoming increasingly apparent, but its impact on the endocrine system, in particular, the hypothalamic adrenal axis has yet to be defined. Case Description: A 64-year-old woman with hypothyroidism and type 2 diabetes mellitus presented to the emergency room with a 1-week history of abdominal pain, nausea, and vomiting. The patient experienced an asymptomatic COVID-19 infection 5 months prior and reported an unintentional 30-lb weight loss since. She had been admitted several times at an outside hospital for hyponatremia where she never received exogenous steroids. Physical exam was notable for hypotension, epigastric tenderness, and hyperpigmentation of oral mucosa. Chemistry was significant for hyponatremia 117 mmol/L (135-145). Hyponatremia workup revealed a TSH of 0.33 mcIU/ml (0.35-4.00), free T4 1.4 ng/dl (0.6-1.7), serum osmoles 253 mOsm/kg (279-300), urine osmoles 324 mOsm/kg (300-900) and urine sodium 104 mmol/l consistent with hypotonic hyponatremia. Fluid restriction and salt tablets were initiated. Morning 8 AM cortisol returned low (2.6 μg/dl (ref: >18). A high-dose 250 mcg ACTH stimulation test followed;cortisol levels returned 2.3, 2.9, and 2.6 μg/dl (ref: >18) at baseline, 30, and 60 minutes, respectively. ACTH level was elevated to 1944 pg/ml (7.2-63.3), aldosterone was undetectable < 3.0 ng/dl (upright: 4.0-31.0), anti-21-hydroxylase antibody were positive (ref: neg). CT scan of the abdomen returned unremarkable for any adrenal pathologies. Fluid restriction and salt tablets were discontinued. Hypotension and hyponatremia resolved after initiation of Hydrocortisone IV 25 mg q8h. She was discharged on Hydrocortisone 30 mg daily and Fludrocortisone 0.05 mg daily. Discussion: This patient presented with hyponatremia and biochemical evidence of adrenal insufficiency confirmed by an abnormal stress cortisol response to a high-dose ACTH stimulation test. The markedly elevated ACTH level, inappropriately low aldosterone level, and the presence of anti-21-hydroxylase antibodies support the diagnosis of Addison's disease. Primary adrenal insufficiency (AI) after COVID-19 due to adrenal infarcts and hemorrhage have been documented, but the normal CT suggested that the etiology of AI, in this case, was not due to the aforementioned. This case is the first to suggest the onset of Addison’s disease in the COVID-19 sequelae.

Ectopic ACTH by Carcinoid Tumor Mimicking Nelson Syndrome in a Patient with Bilateral Adrenalectomy

Introduction: Nelson syndrome has been reported in up to 25% of adults after bilateral adrenalectomy (BLA) for Cushing’s disease (CD). It usually manifests as an expanding pituitary mass, rising adrenocorticotropic (ACTH) hormone levels and, in many patients, the development of hyperpigmentation. We review the clinical course of a patient with rising ACTH levels after BLA for presumed CD. Although the diagnosis of Nelson syndrome was considered, he was found 9 years after BLA to have an ectopic ACTH secreting bronchial carcinoid tumor as a cause for the elevated ACTH levels. Case Description: A 35 year old male was evaluated at another institution in 2010 after he presented with weight gain, new onset hypertension, muscle weakness with multiple falls, depression, irritability and emotional lability. He was diagnosed with CD and was referred to a university center where he underwent trans-sphenoidal pituitary surgery in May 2011. An adenoma was seen on frozen section but not on the final pathology. He developed transient symptoms of adrenal insufficiency on the second post-operative day. Because of persistent hypercortisolism he underwent BLA in November 2011. We started following him in 2012 and signs of hypercortisolism gradually resolved. He appeared euadrenal on hydrocortisone 10 mg am, 5 mg 12 noon and 5 mg 6 pm and fludrocortisone 0.05 mg daily. ACTH levels increased from 54 pg/ml (6-50) in 2012 to 1024 pg/ml in 2019. He had no hyperpigmentation and MRI of the pituitary from 2014-20 did not show a pituitary mass. During an evaluation for COVID-19 infection in May 2020, a chest x ray revealed a right lower lobe lung mass measuring 3.3 x 2.0 cm. He underwent right lower lobe lung lobectomy in July 2020 and pathology revealed a carcinoid tumor-spindle cell pattern which stained strongly positive for ACTH and weakly positive for chromogranin. ACTH levels after the surgery decreased to 16.3 pg/ml. Discussion: Some authors have suggested that Nelson syndrome be considered in patients with BLA who have one of the following: an expanding pituitary mass or ACTH levels >500 p/ml at 3 different time points after surgery. This case highlights the need to consider ectopic ACTH syndrome as another cause for rising ACTH levels after BLA for CD especially in those patients who are not found to have a discreet adenoma after pituitary surgery.

Clinicohaematological Patterns of Anemia and Correlation with Clinical Conditions in Children Aged 5 to 12 Years in Tertiary Care Centre

Objective: To classify the haematological pattern, severity of anemia in children 5-12 years age admitted and to find its correlation with the clinical conditions. Methods Crossectional study of 160 patients in two years was done. Patients satisfying the inclusion criteria were selected for study. Relevant clinical data were recorded in a structured proforma including detailed history was recorded with particular symptoms suggestive of anemia such as weakness and easily fatigability, breathlessness on exertion and pica. A thorough clinical examination of every child was done followed by routine investigations for anemia Results Patients between 7-8 year were found to be the most affected. Anemia was found to be more common in female children as compared to male children (F:M=1.13). Anemia is more common in undernourished child. Most common presenting symptoms were gastrointestinal including vomiting, diarrhea and pain abdomen. Most common sign was Pallor followed by other common signs included signs of dehydration associated with diarrhea, hepatosplenomegaly. microcytic hypochromic anemia was the most common morphological type of anemia and macrocytic anemia was the least common.Thalassemia cases were most common among hemolytic anemias. Iron Deficiency Anemia (Nutritional Anemia) was the most common etiology of anemia. Conclusion Dietary deficits affect children aged 5 to 12, creating financial, emotional, and psychological burden for patients and their families, as well as depleting critical national resources. As a result, screening for these illnesses, as well as early detection of anemia and related problems, is essential.

Follicular keratosis of the face in pediatric patients of color.

BACKGROUND/OBJECTIVES: Follicular keratosis (FK) is a poorly understood disorder presenting with multiple, grouped hyperkeratotic follicular papules typically affecting the chin or jawline. This study describes the clinical presentation, histopathology, management, and outcomes of a series of pediatric patients of color with FK of the face, thought to be related to rubbing or friction on the skin. METHODS: Retrospective review of 20 pediatric patients with FK of the face who presented to our pediatric dermatology practice between April 2019 and October 2021. RESULTS: Twenty patients (mean age 12.1 years, 13 females), all self-identified as Black/African American, were included. All presented with an initially asymptomatic, hyperpigmented patch containing multiple hyperkeratotic follicular papules, located on the cheek, chin, upper lip, and/or jawline. Five patients endorsed a history of rubbing the site. Nine patients had onset of the lesions during the COVID-19 pandemic. Treatments included topical vitamin D analogs, corticosteroids, and/or retinoids. Topical vitamin D analogs and retinoids improved the texture and hyperpigmentation of the follicular lesions in only four patients, while topical corticosteroids had no effect. Histopathological examination of two patients revealed multiple dilated follicles containing keratinized material and associated with a sparse dermal inflammatory infiltrate in one patient and granulomatous inflammation within the dermis in the other. CONCLUSIONS: In our cohort of pediatric patients with FK, patients of color were preferentially affected, and all cases were associated with hyperpigmentation. Some patients presented during the COVID-19 pandemic suggesting that friction from facial mask wearing may have induced or exacerbated this uncommon condition.

The potential role of UV and blue light from the sun, artificial lighting, and electronic devices in melanogenesis and oxidative stress.

Our exposure to blue light from artificial sources such as indoor lights (mainly light-emitting diodes [LEDs]) and electronic devices (e.g., smartphones, computer monitors, and television screens), has increased in recent years, particularly during the recent coronavirus disease 2019 lockdown. This radiation has been associated to skin damage across its potential in generating reactive oxygen species in both the epidermis and the dermis, skin water imbalances and of potential activating melanin production. These circumstances make it important to determine whether current blue light exposure levels under artificial illumination and electronic devices exposure can cause the previously indicated disorders as compared to solar UV and visible radiation in a typical summer day. Blue light accounted for 25% of the sun's rays, approximately 30% of radiation emitted by electronic devices, and approximately from 6% to 40% of that emitted by indoor lights. The reference equations showed that the sun was the main source of effective irradiance for immediate and persistent pigmentation as well as for potential oxidative stress in our skin. Effective blue light exposure to artificial devices is significantly lower than the solar contribution. However, its contribution must be considered as accumulative dose effect, and especially in people with hypersensitivity promoting skin hyperpigmentation.

Colchicine-induced fixed drug eruption with first reported positive patch test

Case Report Background : Fixed drug eruption (FDE) is a rare delayed hypersensitivity reaction which is often misdiagnosed. Colchicine is a drug used for gout prophylaxis known to regulate multiple inflammatory pathways. Since 1996 only one case of colchicine-associated FDE has been reported. Case-presentation : A 58-year old man presented at the clinic with recurrent erythematous lesions on the right arm, hand, thighs, chest, and genitals which followed residual hyperpigmentation. First clinical presentation was in 2018 and upon subsequent episodes the lesions appeared on the same skin sites following a tendency to engage larger skin surface and new spots occurred. The patient reported on-demand treatment with colchicine, metamizole, paracetamol, diclofenac for gout arthritis, and acetylsalicylic acid/vitamine C, for Covid-19 prophylaxis. Epicutaneous patch tests with European standard series was performed on healthy skin, and patch testing with colchicine, paracetamol, diclofenac and metamizole was performed on lesional skin. Results were interpreted as positive for: nickel (++), peruvian balm (++), propolis (++), and colchicine (+). The patient did not report intake of food and drugs containing nickel, nor any consumption of honey and propolis-containing products. The patient's history, clinical presentation, and the positive colchicine patch test helped establish the diagnosis of colchicine-induced FDE. Conclusion : We report the second case of colchicine-induced FDE diagnosed for the first time by epicutaneous patch testing on lesional skin. Proper diagnosis might help evade further complications, and the need for oral challenge tests which could be associated with detrimental effects.

Oral manifestations in a patient with a history of asymptomatic COVID-19: Case report.

The pandemic situation has led to public health measures that have forced patients with and without the SARS-CoV-2 virus to remain isolated and take steps to prevent the spread. Many of these patients have been unable to attend the control of medical-dental services, which in many cases complicates their situation. This study reports on the oral manifestations of an asymptomatic COVID-19 patient treated interdisciplinary by teleconsultation due to the sudden appearance of lesions in the oral mucosa. Lesions are diagnosed, therapeutic measures are taken, and improvement is shown. This case shows that the problems that arise in the oral mucosa in patients with suspected or confirmed SARS-CoV-2 infection can be monitored through interdisciplinary teleconsultation during the pandemic with the support of information technology currently available worldwide. It also decreases the risk of transmission of SARS-Cov-2 between patients and health professionals.