Congenital miliaria crystallina in a neonate of a COVID- 19 positive mother

Introduction: Miliaria crystallina occurring during neonatal period is one of the differential diagnosis for vesiculopustular lesions in that age group. Congenital miliaria crystallina is a rare condition developing due to various causes. Case Report: An otherwise well, term female neonate born by caesarean section presented with generalised clear fluid filled vesicles over the trunk, upper limbs, face and scalp at birth. Mother was COVID-19 positive with fever and cough for 1 week. Otherwise she had an unremarkable antenatal, sexual history and examination. The vesicles were located on normal looking skin and ruptured easily on rubbing. Palms, soles and mucosae were normal. Tzanck smear from the vesicles showed a few deformed keratinocytes only. Venereal Disease Research Laboratory test in dilution for both mother and child was non-reactive. Baby's RT-PCR came negative. She fared well on follow up, the vesicles started to desquamate on the second day and completely disappeared on the third day. Mother's COVID-19 symptoms also subsided after child birth. A final diagnosis of congenital miliaria crystallina was made based on the characteristics of the vesicles. Discussion(s): Miliaria crystallina is triggered by environmental temperature and humidity. Congenital cases are associated with maternal febrile illnesses. However, there are reports of it occurring in newborns of mothers without fever in whom other factors are involved. This is the first report of congenital miliaria crystallina occurring in a neonate born to a COVID-19 positive mother. Conclusion(s): This case report highlights the importance of recognizing this benign self-limiting condition so as to avoid unnecessary investigations to find an alternative cause.

LANGERHANS CELL HISTIOCYTOSIS IN A CHILD WITH MULTISYSTEMIC LESIONS ASSOCIATED WITH INFECTED POLIOMYELITIS AND SARS-COV-2, FEATURES OF DIAGNOSTICS. CLINICAL CASE.

Langerhans cell histiocytosis (LCH) is an abnormal clonal proliferation of Langerhans cells. The prognosis varies depending on the form of the disease and organ damage. Any organs and systems can be involved in the pathological process in various combinations. A poor response to standard therapy and an unfavorable prognosis are characteristic of patients with a multisystem form of LCH and involvement of organs at risk. Skin lesions are a classic sign of LCH. Purpose - to describe the complexity and duration of diagnosis of LCH with multisystem damage in a boy aged 2 years and 2 months, infected with poliomyelitis and coronavirus. Clinical case. The first clinical manifestations of LCH in the child debuted with an eczematous-seborrheic rash on the scalp with spread to the limbs and trunk. The child was treated for toxicoderma, hemorrhagic vasculitis at the place of residence for 6 months. The boy lost 1.5 kg of body weight in 1 month. At the time of hospitalization, seborrheic-eczematous rashes on the skin with a hemorrhagic component, trophic-inflammatory changes in the nails of the hands, signs of protein-energy deficiency, stomatitis, gingivitis, hepatosplenomegaly, polyserositis, diabetes insipidus, osteolytic foci of the frontal bones were found. Results of the tests: anemia, thrombocytopenia, hypoproteinemia and hypoalbuminemia, coagulation disorders. The patient had the onset of lower flaccid paraparesis, muscle hypotonia. The boy was diagnosed with a number of infectious complications, including poliomyelitis (a derivative of vaccine poliovirus type 2), COVID-19. The child received LCH-III cytostatic therapy with a positive effect. The research was carried out in accordance with the principles of the Helsinki Declaration. The informed consent of the patient was obtained for conducting the studies.Copyright © 2023 Institute of Physics of the Russian Academy of Sciences. All rights reserved.

PROGNOSTIC FACTORS AND EFFICACY OF DMARD USE IN GCA: RESULTS FROM THE PROSPECTIVE, LONGITUDINAL,MULTI-CENTRE HAS-GCA STUDY

BackgroundGCA is a critically ischemic large vessel vasculitis, varying in extent, severity and outcomes, hence requires disease stratification using clinical, laboratory and imaging parameters, for targeted management. Although DMARDs are used, the effectiveness in real life, such adjuvants remain un-elucidated. We performed a prospective, multi centre cohort study of new GCA stratified into remitting, relapsing, refractory, ischemic disease.ObjectivesWe assessed prognostic factors and compared critical outcomes such as remission with glucocorticoid (GC) monotherapy versus GC plus DMARDs in the first 12 months.MethodsHAS GCA study (1) recruited consecutive patients with new onset GCA from 7 centres (UK, Italy, Spain, Netherlands). diagnosis was confirmed used a modified GiACTA criteria at 6 months follow up. All underwent ultrasound (bilateral common, parietal, frontal temporal arteries, and axillary arteries) using accepted standard cut-off values [2]. GCA patients had US at baseline,1,3,6,12 months and halo count (HC) and Halo score (Temporal TAHS, axillary AAHS, total THS) assessed [3]. The primary outcome- remission at 12 months (absence of signs/symptoms, CRP<5 mg/dl, prednisolone < 5 mg daily). Results are reported as descriptive statistics.Results229 participants included in the study (GCA- 84 (36.68 %) (Figure 1). Study recruited during Covid pandemic,73 completed,11 lost to follow-up (died -7, withdrawn-4). The deceased/withdrawn patients (compared to completers) were older (80 v74 yrs, p=0.018), preponderantly male (73% v 36%, p=0.043) with visual symptoms (91% v 49%, p=0.010) partial/total sight loss (55% v 21%, p=0.024), lower CRP (21 v 68, p=0.061) and ESR (42 v 62, p= 0.317).Of 73 completers 36 required early DMARDs (<12 weeks) for refractory/relapsing/ischemic/GC related AEs. This group had more LV involvement (50% v 11%, p=0.0003), Remission attained at 12 months 32/36 (89%) in DMARD group was comparable to the remitting GC monotherapy group 33/37 (89%) with comparable cumulative GC doses (Figure 1, Table 1).At 12-months follow up, median TAHS, AAHS and THS reduced from 13 to 3, 12 to 9 and 21.5 to 12, respectively.ConclusionOur study suggests, elderly males with visual symptoms, sight loss, lower CRP are a high-risk group with increased mortality within GCA. Difficult to treat disease is seen in half of all patients especially with LV involvement. This group responds well to early DMARD use achieving remission comparable to the remitting group at 12 months. Current therapies fail to achieve remission in 9.5 % of cases. HS and HC show significant improvement mirroring clinical outcomes during first 12 months of therapy.References[1]Sebastian A et al. BMC Rheum. 2020[2]Schafer VS et al. Rheumatology 2017[3]van der Geest KSM et al. ARD 2020Table 1.comparison between the DMARD-used group and only GC group in all the GCA completed the 12 months follow upPatients' characteristicsGCA with completed follow-up (n=73)GCA treated with DMARD=36GCA not treated with DMARD=37Age, median (range) years73.5 (60-89)76 (60-89)Sex, Females, n (%)23 (64)24 (65)US halo score (HS)/IMT median (range)Temporal artery HS11 (0-23)13 (1-22)Axillary artery HS12 (0-21)12 (0-18)Axillary artery IMT (mm)0.77 (0.33-2.6)0.82 (0.39-1.21)Total HS22.5 (2-41)21 (5-40)Clinical features, n (%)Temporal headache25(69)30 (81)Scalp tenderness17 (47)19 (51)Jaw & Tongue claudication22 (61)24 (65)Polymyalgic symptoms21 (58)13 (35)Constitutional symptoms21 (58)18 (49)Any visual disturbance15 (42)21 (57)Partial or complete vision loss8 (22)7 (19)History of PMR6 (17)3 (8)Exam findings, n (%)Temporal artery abnormality24 (67)30 (81)AION/ CRAO8 (22)6 (16)Ocular nerve palsy1 (3)3 (8)Lab markers at baseline, median (range)CRP mg/dL,72.2 (6.4-292)59 (6-206)ESR mm/hr67 (9-130)57 (2-120)GC treatment, median (range)GC starting dose, (baseline)45 (0-60)50 (0-60)GC dose at 12m,5 (0-25)2.5 (0-10)Cumulative GC dose at 12m4627.5 (2600-10260.5)4622.5 (944-10737.5)Remission with prednisolone dose ≤5 mg at 12m, n (%)32 (89)33 (89)Acknowledgements:NIL.Disclosure of InterestsBhaskar Dasgupta Consultant of: Roche, Chugai, Sanofi, Grant/research support from: Roche, Sanofi, AbbVie, and GlaxoSmithKline, Kornelis van der Geest Speakers bureau: Roche, Grant/research support from: AbbVie, Alessandro Tomelleri: None declared, Pierluigi Macchioni: None declared, Giulia Klinowski: None declared, Carlo Salvarani: None declared, Abdul Kayani: None declared, Mohammad Tariq: None declared, Diana Prieto-Peña: None declared, Edoardo Conticini: None declared, Muhammad Khurshid: None declared, Sue Inness: None declared, Jo Jackson: None declared, Alwin Sebastian: None declared.

VCA waiting list and transplant trends in the US

Introduction: VCA transplantation is progressing despite challenges including the COVID-19 pandemic. Method(s): The OPTN cohort includes 108 VCA candidates listed and 66 recipients transplanted between 7/3/2014 - 4/30/2022. Result(s): Seven VCA candidates were listed in 2021: 3 abdominal wall (AW) and 4 uterus. One AW and 2 uterus candidates were listed in the first 4 months of 2022. AW registrations became the predominant registration type on the VCA waiting list in 2022, surpassing uterus registrations. As of 4/30/2022, the waiting list included 17 candidates: 6 AW, 5 uterus, 4 upper limb (UL;1 bilateral, 3 unilateral), 1 face, and 1 face/scalp. Since 7/3/2014, 66 recipients received 67 VCA transplants, including 14 UL (9 bilateral, 5 unilateral), 9 face, 1 bilateral UL and face, 1 scalp, 1 trachea, 2 AW, 36 uterus (14 deceased donor, 22 living donor), and 2 penis recipients. In 2021, 1 bilateral UL, 1 trachea, and 2 living donor uterus transplants were performed. In the first 4 months of 2022, 3 uterus transplants (2 deceased donor, 1 living donor) were performed. Discussion and Conclusion(s): The composition of the VCA waiting list is changing. VCA transplantation continues to advance despite the COVID-19 pandemic.

Scalp, Oral, and Nail Pemphigus Vulgaris: Clinical Characteristics and a Review of the Literature.

Pemphigus vulgaris (PV) is a rare disease that affects the skin and mucous membranes, causing blistering and erosions. Identifying and effectively managing atypical presentations of pemphigus vulgaris can be challenging due to its rarity. We describe a 32-year-old male patient with a medical history including prediabetes, moderate asthma, hyperlipidemia, coccidioidomycosis, and respiratory infections. He was evaluated via telehealth in the allergy and immunology clinic for uncontrolled asthma. Initially, he complained of a whitish film in the mouth while on treatment with fluticasone and salmeterol. He also noted new vesicular lesions on his scalp and body. When evaluated later in the clinic, he was found to have oral and periungual erosions as well as paronychia. After promptly referring to dermatology, histopathological examination and direct immunofluorescence testing were performed on the patient's lesions, revealing changes consistent with PV. Treatment with prednisone and rituximab resulted in the complete resolution of the patient's bullae and nail deformities over several months. This case highlights the importance of a thorough evaluation of complex medical histories and diagnostic testing in managing asthma and allergy symptoms. It also emphasizes the need for a multidisciplinary approach involving specialists such as immunologists, dermatologists, and infectious disease experts in the diagnosis and management of complex cases.

Navigating Giant Cell Arteritis (Gca) Service during and Post Covid-19 Pandemic: An Audit of Gca Care at North Bristol Nhs Trust against the Bsr Quality Standards

Background/Aims GCA is a systemic vasculitis predominantly affecting the large vessels that requires prompt diagnosis and management. This clinical audit aims to study the impacts of COVID-19 pandemic on our GCA service and to identify areas for improvement to ensure good and safe practice amid healthcare crisis. Methods We audited referrals for suspected GCA from February 2021 until September 2022 and measured our patient care against the BSR quality standards. We performed retrospective data collection from digital care record systems and analysed our data using the IBM SPSS Statistics version 29. Results 106 patients with suspected GCA were included, 73% were female and the mean age was 70 years. 75% of the referrals were from primary care. Main presenting symptoms were headaches (95.7%), scalp tenderness (69.6%), tongue/jaw claudication (52.2%), visual symptoms (47.8%), constitutional symptoms (43.5%) and polymyalgic symptoms (21.7%). 33% of patients were diagnosed and treated as GCA. Mean CRP was 23.9mg/L and mean plasma viscosity was 1.89mPA. The mean referral-to-specialist review time has reduced to 1.6 days, compared with 2.7 days pre-pandemic. All patients had vascular ultrasound but only 7.5% had a temporal artery biopsy (TAB), compared with 41% pre-pandemic. Table 1 compares expected and achieved BSR quality standards. Conclusion Changes in work pattern during the pandemic meant that the time from referral to specialist review was significantly reduced, by implementing twice weekly registrar-led 'Hot' clinics and reserving ad hoc slot(s) in on-call consultant's clinics for GCA referrals. We have ramped up our vascular imaging capacity for vascular ultrasound during the pandemic in response to reduced surgical operating capacity for TAB. Strategies to address areas for improvement identified in this audit include: (1) clear and timely communication with referrer about steroid initiation and dosage, at the time of referral;(2) improving communication with primary care, emphasising need for urgent Ophthalmology input in patients with suspected GCA-related visual symptoms, through updating our regional GCA guideline for primary care;(3) standardising and implementing a GCA review proforma or checklist in our department to ensure that the BSR GCA care bundle is being implemented and addressed at the earliest opportunity. (Table Presented).

An Experience of Scalp Island Flap Based on the Posterior Branch of the Superficial Temporal Artery for Patients with Mucormycosis and Cancer.

To find out the utility of the scalp flap based on the posterior branch of the superficial temporal artery in patients with head and neck mucormycosis and malignancy. This was a multi-institutional observational study conducted at a tertiary cancer centre in North East India and a super-speciality hospital in Maharashtra from January 2021 to June 2021. Patients with malignancy and mucormycosis were only considered. In our study, we have seven patients (n = 7), two of them had mucormycosis and 5 had squamous cell carcinoma of the head and neck region. Out of the 5 cases of the head and neck malignancy, two cases were recurrent ones, another two cases where primary flap failed and in the last case, the patient was unfit for free tissue transfer due to cardiac issues. The mean age in the series was 50.42 years and the average duration of raising the flap was 22.86 min. Average hospital stays for head and neck cancer patients are 4.6 days and for mucormycosis patients, it is 22.5 days. No flap related complications were noted during the series. Scalp flap based on the posterior branch of the superficial temporal artery is a useful option in recurrent malignancy cases, in primary cases as a salvage option and in patients where long duration surgery is not possible due to poor general condition like in critical mucormycosis. Post-operative hair growth at the flap site and alopecia at the donor scalp are concerns and therefore, careful patient selection is a must.

Central cicatricial centrifugal alopecia or something else?

A 58-year-old African woman was referred for the management of scalp alopecia that had started in her thirties over the vertex of her scalp and had progressively involved > 90% of her scalp over the years. She was diagnosed with central centrifugal cicatricial alopecia of many years' duration and was being managed with annual wigs. On further questioning in the clinic, her chief complaint was a painful area over the vertex of the scalp, which had been affecting her sleep for years. She admitted to having used hair treatments in the past, after her hair loss had started. Clinical examination revealed a soft, tender, boggy swelling at the site of pain;however, the rest of her scalp felt like palpating cotton wool. Trichoscopic examination showed no remnant follicular openings, and histology showed end-stage alopecia. Her body mass index (BMI) was noted to be > 45 and there was an associated ichthyosiform rash on her shins bilaterally. Magnetic resonance imaging of her brain was requested for suspected lipoedematous scalp alopecia. Radiological findings led to a diagnosis by demonstrating 24-mm-thick subcutaneous adipose tissue - the highest recorded for this condition. Normal scalp thickness is suggested to be 6 mm. The patient declined a trial of intralesional steroids and topical Dermovate was unsuccessful. Lipoedematous scalp is a rare disease marked by a soft thickening of the scalp, first recorded in 1935 (Cornbleet T. Cutis verticis gyrata? Lipoma? Arch Dermatol Syphilol 1935;32: 688). A similar clinicopathological entity associated with nonscarring but permanent acquired alopecia was described in 1961 (Coskey RJ, Fosnaugh RP, Fine G. Lipedematous alopecia. Arch Dermatol 1961;84: 619-22) and termed lipoedematous alopecia. Our case was associated with a raised BMI and also with an ichthyosiform rash on her shins, which started when she was in her teens and needs further evaluation after the COVID-19 pandemic. It was also associated with scarring alopecia rather than nonscarring alopecia, as seen in other cases. We wonder if there is a genetic cause as the disease predominantly occurs in African patients. Also, lipoedematous alopecia may be associated with nonscarring alopecia, as well as scarring alopecia, as seen in our case.

Aplasia cutis congenita in dizygotic twin infants

Aplasia cutis congenita (ACC) is often sporadic, but familial cases have been reported. We report a case of a dichorionic diamniotic twin pregnancy in which both the male and female twins had matching areas of aplasia cutis on their scalps. An Irish couple sought fertility treatment using a donor egg and paternal sperm. Successful in vitro fertilization (IVF) and the transfer of two embryos resulted in a diamniotic dichorionic twin pregnancy. Two fetal poles were noted at the 12-week ultrasound (US) scans. The mother suffered from a minor urinary tract infection during the first trimester but had no other history of infection, including herpes simplex virus or COVID- 19. She was known to be varicella immune prior to pregnancy. The twins were born by elective caesarean section owing to breech presentation. Twin one was female and twin two was male. Both infants were born with scarring on the crown of their head, which was consistent with ACC. Cranial US showed no underlying bony abnormality. The rest of the cutaneous examination was normal and there were no other congenital anomalies. ACC is a rare, heterogeneous group of disorders characterized by the congenital absence of skin, which can be focal or widespread. It is thought to affect 1-3 per 10 000 live births. The exact cause of ACC is unclear. Various hypotheses have been suggested, including defective closure of the neural tube or embryonic fusion lines, intrauterine trauma, placental insufficiency, fetus papyraceus, amniotic membrane adhesions, intrauterine infections, teratogens and genetic mutations. The classification of ACC is based on the area affected, type of skin irregularity, associated congenital defects and mode of inheritance. Scalp ACC without multiple anomalies (category 1) is generally associated with an autosomal dominant or sporadic pattern of inheritance. These twins may have an autosomal dominant mutation that led to this phenotype. ACC can also be associated with fetus papyraceus or placental infarct. This is less likely in this case as only two embryos were transferred, and the pregnancy was dichorionic. Most cases of ACC associated with fetus papyraceus occur in monozygotic pregnancies. ACC lesions often heal spontaneously by re-epithelialization resulting in a hairless superficial scar. Twin one had a slightly smaller area affected by ACC and overlying eschar resolved several weeks after birth. Twin two has had no hair growth in the area. This case highlights the difficulties in ascertaining the aetiology of this rare condition in twin pregnancies.

A bleeding tumor on the scalp

A 83-year-old man presented with a large tumour on his head. He had been postponing his visit due to COVID. Physical examination revealed an ulcerating, bleeding tumour of 5.5x5x3 cm. Histologic analyses showed a poorly differentiated squamous cell carcinoma. Additional imaging displayed damage of the tabula externa without pathological lymph nodes.

Systemic lupus erythematosus cutaneous flare following COVID-19 vaccination: A case report

Objective: To present a case of a SLE cutaneous flare following COVID-19 vaccination in a patient with low disease activity Background: Disease flare in a patient with underlying autoimmune rheumatic disease (AIRD) after vaccination had already been experienced with other vaccines, such as influenza, hepatitis B, and HPV vaccines. Given the relatively unknown safety profile of the COVID-19 vaccine among patients with AIRD, the probability of a disease flare is not a remote possibility. Several case reports available had already reported few cases of AIRD disease flare following vaccination, some of which requiring escalation of the treatment regimen. Molecular mimicry, as had been described with other vaccines, is still implicated as the possible explanation for such a phenomenon. Case: A 57 year old female with systemic lupus erythematosus with nephritis since 1994 with low disease activity, maintained on hydroxychloroquine and low dose methylprednisolone daily who developed multiple well-defined elevated erythematous and pruritic plaques on both thighs, spreading to the face, scalp, trunk, and extremities 3 weeks after receiving her first dose of viral vector vaccine. Work-ups included eosinophilia on CBC, elevated ESR, anti-dsDNA, ferritin, and LDH, with low C3, with proteinuria and hematuria on urinalysis. She was admitted and her glucocorticoid was increased and tapered accordingly. Skin punch biopsy with alcian blue staining was also done which revealed interface dermatitis consistent with lupus erythematosus. Few days after increasing her glucocorticoid, cutaneous lesions gradually resolved and she was discharged improved. She received her second dose of vaccine 2 months after her first dose with no reported incidents of adverse events. Conclusion(s): This is one of the few cases of a reported SLE flare confirmed by disease activity index and biopsy-confirmed skin rashes. The development of such an adverse reaction to a vaccine may be relatively low but still possible due to intricate interaction of the immune system and vaccine.

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.

VCA Waiting List and Transplant Trends and Challenges in the US

Purpose: VCA transplantation has grown and changed, encountering challenges such as scarce funding sources and the COVID-19 pandemic. Method(s): The OPTN cohort includes 105 candidates listed and 62 recipients transplanted 7/4/14-10/31/21. Result(s): VCA candidates included 47 uterus, 26 upper limb (UL, 14 bilateral, 12 unilateral), 1 UL/face, 12 face, 1 scalp, 2 face/scalp, 1 trachea, 12 abdominal wall (AW), and 3 penis candidates. Waiting list additions increased in 2016 after uterus transplants began in the US. Head and neck and UL additions held relatively steady through 2019. The COVID-19 pandemic caused a decrease in VCA waiting list additions in 2020 - 1 AW, 1 uterus, and two UL candidates. In the first 10 months of 2021, 5 VCA candidates were added - 2 AW and 3 uterus candidates. In April 2020, 11 of 23 VCA candidates were inactive;on 10/31/2021, 8 of 21 were inactive. 62 candidates received 64 transplants (including 1 uterus re-transplant and 1 face/ UL transplant). Others refused transplant (n=7), became ineligible (n=4), could not be contacted (n=2), condition improved (n=1), were too sick (n=2), died (n=3), or were removed for other reasons (n=2). Median time on the waiting list for recipients was 217 days (IQR: 76.0-404.25 days). VCA transplants in the U.S. 7/3/14-10/31/21 include 14 UL (9 bilateral;5 unilateral), 9 face, 1 UL/face, 1 scalp, 1 trachea, 2 AW, 2 penis, and 33 uterus (12 deceased donor;21 living donor). In 2016, VCA shifted from mostly UL and face to a larger proportion of uterus transplants. UL and face transplants decreased in 2017, then increased and held steady through 2019. VCA transplants decreased in 2020 with the COVID-19 crisis and included 2 uterus transplants, the first U.S. face re-transplant, and the first successful UL/face transplant in the U.S. In the first 10 months of 2021, 2 living donor uterus, 1 bilateral UL, and the first trachea transplant in the US occurred. Out of 62 recipients, 21 were funded by the hospital, 15 by donations, 7 by Medicare/ Medicaid, 1 by Dept of Veterans Affairs, 3 by private insurance, and 2 by recipient. Conclusion(s): VCA transplantation continues to faces challenges such as the COVID-19 pandemic and chronic issues such as funding sources, but has shown signs of resilience in 2021. (Figure Presented).

Transcutaneous Electrical Cranial-Auricular Stimulation (Tecas) for Treatment of Insomnia Disorder with Comorbid Major Depressive Disorder: A Case Series: E-Poster Viewing

Introduction: Insomnia disorder (ID) and major depressive disorder (MDD) are highly comorbid, above 80% of MDD patients have insomnia disorder. Acupuncture as a major complementary and alternative medicine (CAM) therapy, is utilized extensively in Asia to treat mental health disorders.Transcutaneous electrical cranial-auricular stimulation (TECAS) is a potential new type of acupuncture treatment for MDD and ID which combines the scalp points and auricular points most commonly used by acupuncturists. It has the advantages of portability, quantifiable stimulation parameters and comfort, especially for home treatment under the normal situation of COVID-19, which can avoid the risk of infection due to frequent hospital trips. Materials / Methods: 10 ID-MDD patients were treated by TECAS which was administered at the bilateral auricular acupoints, Bai Hui (GV-20) and Yin Tang (GV-29) (waveform:4/20 Hz, wave width: 0.2ms+/-30%) for twice a day last 8 weeks. Pittsburgh Sleep Quality Index (PSQI) and Hamilton Depression Rating Scale(HAMD) of ID-MDD patients were evaluated before and after treatment. Result(s): HAMD-17 scores of 10 patients were lower at 4 and 8 weeks than before TECAS treatment, and the reduction was greater at 4 weeks than at 8 weeks. PSQI scores of 8 patients decreased at 4 and 8 weeks compared with before treatment, and the decrease was greater in the fourth week than in the 8th week. Insomnia of 2 patients improved at 4 weeks of treatment, but became worse in the 8th week as before treatment.7 out of 10 patients showed full insomnia response (50% reduction in PSQI) and 8 patients showed full depression response (50% reduction in HAMD-17 scores). Discussion(s): We suggest TECAS is a good therapeutic strategy to modulate the vagus nerve and trigeminal nerve propagate through electrical stimulation projected by neurons from peripheral sites to the central nervous system. Furthermore, we speculate that TECAS can make the trigeminal nerve afferent fibers and vagus nerve auricular branch carry messages from head facial stimulation to NTS, locus coeruleus, raphe nucleus, medullary reticular activating system and structure of the thalamus, and then to feel, edge, cortical and subcortical structures, so the electrical stimulation subcortical can cause direct regulation, namely the change of cortical excitability. Conclusion(s): These preliminary results in this group of CID-MDD patients are encouraging and need to be replicated in prospective sham-controlled studies with larger sample sizes. In addition, for patients with insomnia and depression, it is important to consider combining TECAS with psychotherapy to avoid the interference of acute negative emergency events. Acknowledgements: The support of National Key R&D Program of China (No.2018YFC1705800) and Key Laboratory of Acupuncture and Chronobiology of Sichuan Province(No.2021004) for this project is gratefully acknowledged. Learning Objectives: 1. To provide a new non-drug method for acupuncture treatment of insomnia and depression;2. Provide preliminary experimental results for the large-sample experimental design of TECAS for the treatment of insomnia and depression;3. Compared with previous studies on insomnia and depression, the regularity and characteristics of TECAS in treating insomnia and depression were found. Keywords: Transcutaneous Electrical Cranial-Auricular Stimulation (TECAS), insomnia disorder, a case series, acupuncture, Major Depressive Disorder Copyright © 2022

White piedra: An uncommon cause of pseudonits in Northeast Mexico

Introduction: White piedra is a rare superficial mycosis caused by the genus Trichosporon. Its prevalence is higher among tropical climates and predominantly affects children and women. Less than 17 cases have been described in Mexico, none of them in the Northeast region. We present the first case reported in this zone. Case presentation: A 27-year-old otherwise healthy woman presented to our clinic with a 1-month history of asymptomatic pseudonits on her scalp hair. Physical evaluation revealed numerous small white concretions over the majority of the hair shafts. At trichoscopic inspection, multiple white-yellowish ovoid nodules were observed. Direct microscopic examination with 20% potassium hydroxide (KOH) and blue cotton showed nodules composed of arthroconidia and hyphae over the hair shaft. Additionally, fungal culture was positive for Trichosporon inkin, confirming the diagnosis of white piedra. Treatment was initiated with ketoconazole shampoo and systemic itraconazole with favorable response. Discussion(s): Since the first case description by Beigel in Germany, most white piedra cases have been reported in tropical and humid climates. This mycosis typically affects females and subjects under 15 years of age. Some risk factors include poor hygiene, excess humidity, diabetes, and long, curly hair. In our case, the patient had curly hair and she constantly tied her hair up wet as she worked as a full-time nurse in a COVID-19 reference center. In our country, 50% of previous reported cases are from nontropical regions. Although infrequent in cosmopolitan areas in Northeast Mexico, white piedra should be considered in the differential diagnosis of pseudonits. Copyright © 2022

SEVERE ALLERGIC ERYTHEMATOUS REACTION POSTMESSENGER RNA-BASED COVID-19 VACCINE

SESSION TITLE: Issues After COVID-19 Vaccination Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Covid 19 pandemic has infected 125 million people so far (1). The development of safe and effective vaccines is crucial to lessen the impact of SARS-COV 2 on global health. Some adverse events of the covid 19 vaccination have been reported including few dermatological reactions. We report a case of severe allergic erythematous drug reaction that occurred 3 days after the second dose of messenger RNA (mRNA) Pfizer vaccine. CASE PRESENTATION: A 42 year old female with past medical history of Grover's disease and Multiple Sclerosis presented to the Emergency department from the nursing home with complaints of erythematous, scaly, painful rash that occurred 3 days after the second dose of mRNA covid 19 vaccine. Patient states she had a generalized rash after the first dose of vaccine but it resolved spontaneously and did not require treatment. This time the rash started on the scalp and gradually progressed to the rest of the body. It was associated with severe itching, burning and serosanguinous discharge. Patient did not report any change in medication, use of new detergent or contact with an offending agent. The patient denied fever, chills, nausea, vomiting, diarrhea, constipation, abdominal pain, chest pain or palpitations. She had no history of similar complaints in the past. On physical examination, she was afebrile and hemodynamically stable but in severe distress due to pain. The rash covered 95% of the body surface area and was more severe around the mouth, in the axilla, neck and the inframammary area. Erosions could be seen in the skin folds with serosanguinous discharge. The laboratory results were positive for eosinophilia with absolute eosinophil count of 0.7. Remaining laboratory results were within normal limits. The pathology report for the erythematous rash was consistent with drug reaction. A slight vacuolar degeneration along the dermal epidermal junction with few apoptotic keratinocytes were noted. A compact horn and band-like lymphoid infiltrate were also noted. The patient was started on high dose steroids, analgesics and antihistamines. Petroleum gel impregnated gauze was used for dressing. She was placed in the intensive care unit for careful monitoring. Her rash resolved gradually and her symptoms improved. DISCUSSION: mRNA vaccines are associated with type 1 interferon responses that result in inflammation and autoimmune conditions. This could explain the skin manifestations associated with these vaccines. Allergenic components in the vaccines could also be a possible cause of these reactions. A patch test can be performed to prevent these reactions in susceptible individuals. CONCLUSIONS: This report highlights the need for vigilance to detect severe allergic reactions after covid 19 vaccination to improve the safety of the vaccine. Reference #1: WHO coronavirus (COVID-19) dashboard. [ Jul;2021 ];https://covid19.who.int/ 2021 DISCLOSURES: No relevant relationships by Ruhma Ali No relevant relationships by Sneha Bijoy No relevant relationships by Chrystina Kiwan no disclosure on file for Richard Miller;No relevant relationships by Aditya Patel No relevant relationships by jihad slim, value=Honoraria Removed 03/25/2022 by jihad slim No relevant relationships by jihad slim, value=Honoraria Removed 03/25/2022 by jihad slim No relevant relationships by jihad slim, value=Honoraria Removed 03/25/2022 by jihad slim No relevant relationships by jihad slim, value=Honoraria Removed 03/25/2022 by jihad slim No relevant relationships by jihad slim, value=Honoraria Removed 03/25/2022 by jihad slim

Psoriasis Induced by COVID 19 Vaccine: An International Journal of Medical Toxicology and Drug Experience

Introduction: Psoriasis is a chronic, immunologically mediated, inflammatory skin condition. It is characterized by well-defined, erythematous, indurated scaly plaques, with predilection of extensor surfaces, the scalp and the nails. It may be caused by drug, infection, stress, physical trauma, and vaccination. COVID 19 vaccines have recently been linked to worsening of pre-existing psoriasis. Objective: We report an exceptional case of new onset of psoriasis following COVID-19 vaccine. Methods: This case was reported in February 2022 to The National Centre of Pharmacovigilance and evaluated according to the updated French method of causality assessment. Results: A 58-year-old female patient with a past medical history of hypothyroidism treated by sodiclevothyroxin received on 07 August 2021 her first dose of VAXZEVERIA COVID-19vaccine. On 17 August 2021, she presented to the emergency department because of anerythematous and febrile eruption on her limbs. Dermatological examination, revealed, erythematous skin with yellow crusts on the limbs and desquamation over the upper and lower limbs. No mucosal membrane or palmo-plantar involvement was noted. The bacterial skin swab was negative. Histological findings confirmed the Psoriasis. Based on the history and clinical findings, she was diagnosed with psoriasis onset with the vaccine. The patient was started on betametasone an calcipotriol resulting in a significant resolution of the skin eruption one month later. Conclusion: In this case, the responsibility of the COVID-19 vaccine in inducing Psoriasis was evaluated as I4 (C2S2) according to the updated French method of imputation in front of: a suggestive delay (10 days after starting the treatment), mainly the favorable outcome after the vaccination and the finding of skin biopsy. The responsibility of sodic levothyroxin was non retained because of the favorable outcome despite his pursuit. Psoriasis associated with COVID-19 vaccine is a rare condition.

Case report: Hair care routine to treat the telogen effluvium associated with post–COVID-19 infection

Introduction: Telogen effluvium (TE) is characterized by diffuse hair shedding 2-3 months after a stressor, and factors such as hypoxia, inflammation (interleukin 6), medications and need for mechanical ventilation may play a role in the development and severity of TE caused by COVID-19. Aims: Evaluate the benefit of the hair care routine using products containing active ingredients to reduce the microinflammation of the scalp and increase the resistance of the hair strand to treat subjects with TE caused by COVID-19. Case presentation: After 60 days of the hospitalization due to COVID-19 infection, a 58-year-old woman showed a typical diagnostic of TE associated to post–COVID-19 infection, presenting positive results to traction test, trichoscopy, and trichogram. During 30 days, she used: 1) Product A: shampoo containing Aminexil, niacinamide, pyridoxine and panthenol;2) Product B: conditionate containing SP94 (glucose + linoleic acid);and 3) Product C: treatment ampoules containing creatine, panthenol, and ceramide R. The products A plus B were used once time for daily and the product C was used 3 times a week. Results: After the treatment, the subject presented an improvement of 100% of the hair loss, with negative results to traction test, trichoscopy, and trichogram analysis. The subject reported a high satisfaction with the treatment (ratio 10/10). Discussion: The hair care routine using the products A, B, and C could improve the TE caused by COVID-19, maybe by reduction inflammatory process in the scalp. Clinical studies in the high scale must be conducted to proof this hypothesis.

Audit of child protection medicals and investigation in children age 0–2 years for the period January – December 2020: a reflection of the Covid-19 pandemic and current literature?

988 Table 1ConclusionThere were less medicals carried out in 2020, likely a reflection of the reduction in face to face contact with health professionals. The pandemic heightened risk factors for abuse which our data appear to reflect. 26% of infants with concerns for NAI following JPFME had head injuries on imaging and 20% had occult fractures on skeletal survey. This is higher than the average yield expected for this age group described in the literature. These audit findings at a local level, support findings published by a large centre for Paediatric abusive head trauma in the UK in 2020.This audit further provides evidence to consider the risk of occult injuries and support the existence of policies and protocols with a low threshold for information sharing and investigation. This also highlights the importance of training those working with families with young babies to support parents with keeping their babies safe and reducing the risk of non-accidental head injuries in the form of standardised training packages for example.

Prompt Diagnosis and Intervention of Oxalate Nephropathy to Salvage Kidney Function

Hyperoxaluria can be primary due to defective glyoxylate metabolism leading to hepatic oxalate overproduction or secondary due to increased intestinal oxalate absorption. Oxalate nephropathy is the deposition of calcium oxalate crystals leading to tubular injury, interstitial fibrosis, and AKI or CKD. This describes three cases of renal oxalosis. First is a 60 year old male with stroke, hypertension, diabetes who presented with AKI of 4.5 mg/dL from 1.6 that rose to 11 mg/dL. Serologies for glomerulonephritis and paraproteinemia were negative. Biopsy showed tubular oxalate crystal deposition with tubular injury and interstitial nephritis. His renal failure required dialysis. Second is a 58 year old female with gastric bypass surgery who presented for edema and AKI from 1.3 to 3.6 mg/dL. Serologies were also negative. Biopsy showed interstitial nephritis with tubular calcium oxalate deposition. She was started on prednisone 60 mg. Creatinine stabilized to 2.2 mg/dL, not requiring dialysis. Third is a 82 year old male with obesity and sarcoma of the scalp treated with pembrolizumab who presented with dyspnea, edema and an AKI from 1 to 8.6 mg/dL. Urine sediment was bland with negative serologies. Differential included AIN due to pembrolizumab. Patient was started on high dose prednisone and biopsy showed interstitial nephritis and calcium oxalate crystal deposition. Patient endorsed taking frequent vitamin C as prophylaxis for Covid. Creatinine stabilized to 2.9 mg/dL not on dialysis. Classic etiologies of hyperoxaluria include dietary oxalate from ascorbic acid and fat malabsorption from gastric bypass surgery. Treatment includes increased fluid intake, oral calcium supplements and low oxalate diet. Oxalate nephropathy remains an under recognized cause of kidney failure, as such, early biopsy and intervention are necessary. (Figure Presented)