Varied presentations of primary cutaneous lymphoma: A case series from a tertiary care center in South India.

BACKGROUND: Recent studies indicate an upsurge of primary cutaneous lymphoma (PCL) in the Indian population. Of late, we too have come across varied presentations of PCL in relatively younger individuals. Hence, we decided to study the clinical and immunohistological profile of patients with PCL in our department. METHODS: All cases diagnosed as PCL from October 2016 to October 2019 were included. Clinical details, complete blood count, peripheral smear, imaging, histopathology, and immunohistochemistry of skin specimens were analyzed. Lymph node biopsy and bone marrow studies were done in most cases. Human T lymphotropic virus-1 (HTLV1) serology was done in 10 cases. RESULTS: Of the 24 patients with PCL, 12 were below 50 years of age. Twenty-three patients (95.8%) had T-cell lymphoma and only one had B-cell PCL. Mycosis fungoides (MF) (n = 17; 71%) was the most common type of PCL. There were two (8.3%) cases each of adult T-cell lymphoma/leukemia (ATLL) and Sezary syndrome. MF had varied clinical morphology at presentation and variable clinical outcomes. Both cases of ATLL had features of immunosuppression in the form of infective dermatoses. CONCLUSION: We observed an increased proportion of T-cell type of PCL, with the age of onset being relatively early. HTLV-1 positivity was noted in three out of the 10 cases tested. More studies are needed to determine the factors responsible for the younger age of onset of PCL and the role of HTLV-1 infection in the development of PCL.

Syphilis in the era of re-emergence: A 6-year retrospective study from a tertiary care center in South India.

Background: During the last several years, we have observed a rise in the number of patients with syphilis in our center. Aims: To find out the trends in the presentation of syphilis to our clinic over a 6-year period and to analyze the clinicoepidemiological features of those patients. Settings and Design: A retrospective chart review. Subjects and Methods: We analyzed the case records of all cases of syphilis registered in our sexually transmitted infection (STI) clinic from October 1, 2012, to September 30, 2018. Syphilis was diagnosed based on clinical or serological evidence. We also evaluated these patients for any concomitant STI, including hepatitis B, hepatitis C, and HIV. Statistical Analysis Used: The data were analyzed using SPSS software (version 20). Chi-square test was done for comparing categorical data, and P < 0.05 was considered statistically significant. Results: During the study period, 215 patients with STI attended our clinic. Of these, 66 (31%) patients had acquired syphilis. Among them, 3 (4.5%) had primary syphilis, 23 (34.8%) had secondary syphilis, and 40 (60.6%) had latent syphilis. Fifteen (22.7%) patients had concomitant HIV infection. A statistically significant rise in the number of cases of syphilis compared with other STIs was noted in the latter half of the study period (P = 0.001). Among the 50 males with acquired syphilis, 29 (58%) were men having sex with men (MSM), including 19 bisexual persons. Among the five antenatal cases, two were detected very late in pregnancy. Conclusions: We observed a marked increase in the number of cases of syphilis during the latter half of the study period. Primary and secondary syphilis were more frequent among MSM, suggesting a need to strengthen targeted intervention programs among them. More rigorous antenatal screening is necessary to prevent congenital syphilis.

Bowenoid papulosis unveiling a rare cause of immunosuppression.

Bowenoid papulosis (BP) is a premalignant condition usually caused by oncogenic types of human papillomavirus (HPV) presenting clinically as warty genital papules. Adult T-cell leukaemia-lymphoma (ATLL) is a peripheral T-cell leukaemia-lymphoma caused by the retrovirus, human T-cell lymphotropic virus 1 (HTLV-1). We report a case of BP initially mistaken as genital warts; on detailed evaluation the patient had features of chronic immunosuppression. The presence of leukaemic cells in the peripheral blood, bone marrow and skin along with a positive HTLV-1 serology confirmed the diagnosis of ATLL.

Syphilis cornee mimicking lichen planus clinically and histologically.

Palmoplantar lesions of secondary syphilis are often termed "syphilis cornee." A 32-year-old male presented with itchy lichenoid papules on both soles and left palm associated with grayish white papules on the buccal mucosa and glans penis. Initial clinical diagnosis of palmoplantar lichen planus with mucosal involvement was supported by the histopathological finding of interface dermatitis. However, more detailed history, serological tests of syphilis, and review of histopathological findings led us to revise the diagnosis as syphilis cornee. This case highlights the uncommon presentation of syphilis cornee as pruritic palmoplantar lichenoid papules with histology showing interface dermatitis. A high index of clinical suspicion of secondary syphilis is needed as its manifestations are often deceptive.

Dermatitis Artefacta Presenting with Localized Alopecia of Right Eyebrow and Scalp.

Dermatitis artefacta (DA) and trichotemnomania are self-inflicted dermatoses often preceded by psychosocial stressful events. A 38-year-old female presented with sudden loss of hair in the right frontal area along with discoloration and edema of skin. On examination, there was complete loss of hair involving the right frontal area and the lateral half of right eyebrow with skin over that area appearing scalded, edematous, bruised, and discolored. After a detailed medical and psychological evaluation, a clinical diagnosis of DA with trichotemnomania was made. A tactful multidisciplinary approach is essential in managing such patients as outright referral to a psychiatrist could be counterproductive.

Disseminated cutaneous phaeohyphomycosis due to Cladophialophora bantiana.

Cladophialophora bantiana is a neurotropic dematiaceous fungus which only rarely affects the skin. We report a case of disseminated cutaneous phaeohyphomycosis caused by Cladophialophora bantiana in an immunocompromised female who presented with multiple pyogenic granuloma-like nodules, dermatophytosis-like plaque, and subcutaneous cysts on the upper and lower extremities without systemic involvement. Biopsy revealed black yeasts resembling sclerotic bodies and culture yielded irregular, velvety, grey colonies with black reverse. Excision of the nodules and treatment with oral itraconazole 100 mg twice daily resulted in complete clinical resolution within two months, following which itraconazole was administered for another 4 months.

Multifaceted adult T-cell leukemia/lymphoma in India: a case series.

BACKGROUND: Adult T-cell leukemia/lymphoma (ATL) is caused by human T-cell lymphotropic virus type-1 (HTLV-1). India is considered as a nonendemic region for HTLV-1. Recent upsurge of cases have been noted in southern parts of India. AIMS AND OBJECTIVES: The objective was to describe skin manifestations in various types of ATL. MATERIALS AND METHODS: Clinical examination, blood investigations, skin biopsies, lymph node biopsies, and immunohistochemistry were performed in five patients. Flow cytometry was performed in two cases. RESULTS: Serological testing was positive for HTLV-1 in all patients. All patients presented with skin lesions. Rare presentations of molluscum contagiosum like papules, purpuric macules and plaques, hypopigmented macules and verrucous papules were seen. Dermatophytic infections occurred in two patients. Mucosal lesion was seen in one patient. Histological features include dermal lymphoid infiltrate with or without epidermotropism. Presence of epidermotropism did not correlate with the severity of disease. All patients except one succumbed to illness within few months to 1 year period. CONCLUSIONS: ATL manifest in myriad presentations and skin lesions are often the earliest manifestation. Cutaneous manifestations of ATL vary from subtle hypopigmented macules to florid nodular lesions, and HTLV-1 screening need to be carried out in all doubtful cases.

Malignant pyoderma gangrenosum eroding the parotid gland successfully treated with dexamethasone pulse therapy.

BACKGROUND: Malignant pyoderma gangrenosum is a rare ulcerative variant of pyoderma gangrenosum (PG) involving the head and neck. Early intervention is crucial to prevent an aggressive outcome. OBJECTIVES: We report a patient with malignant PG eroding into the parotid gland treated with dexamethasone pulse therapy. METHODS: A 47-year-old man presented with necrotic ulcers, predominantly over the face and neck, of one month's duration. Findings of a thorough systemic evaluation were within normal limits. A Mantoux test and pathergy test were negative. Tissue specimens for acid-fast bacilli and fungal cultures were negative. A biopsy showed epidermal necrosis along with perivascular and periappendageal neutrophilic infiltrate without granuloma or vasculitis, consistent with PG. Over the next two weeks, the ulcers progressed in depth and width. The ulcer overlying the right parotid gland continuously discharged clear fluid. The invasive nature of the ulcers and histopathological findings confirmed the diagnosis of malignant PG. Dexamethasone pulse therapy was administered as 100 mg dexamethasone in 500 ml 5% dextrose infused over 3-4 hours on three consecutive days. RESULTS: This treatment resulted in complete healing of the ulcers within six weeks. The patient subsequently received nine similar pulses administered at 28-day intervals and has shown no evidence of relapse over the past year. CONCLUSIONS: In the present patient, parenteral antibiotics and daily steroids, colchicine, and oral minocycline had failed to halt the progression of ulcers. However, dexamethasone pulse therapy resulted in complete healing without sequelae and also proved cost-effective.

Childhood leprosy: a retrospective descriptive study from Government Medical College, Kozhikode, Kerala, India.

OBJECTIVE: To assess the profile and describe the clinical presentations and complications of childhood leprosy in a tertiary care hospital in North Kerala, South India during 2003-2012 and to analyse any change in the age-sex profile and the clinical pattern of leprosy in children below the age of 15 years over the 10-year study period. DESIGN: A retrospective descriptive study of children less than 15 years of age diagnosed with leprosy and registered for treatment in a tertiary care institution from 2003 to 2012. Demographic, clinical, investigative and treatment data were collected using a pre-set proforma. RESULTS: 138 (12.1%) of the total 1143 leprosy cases registered for treatment during the 10-year period were below 15 years of age. The 10-year study period witnessed a statistically insignificant decrease in the new childhood leprosy cases registered for treatment in our tertiary care institution. The majority of cases belonged to the 6-12 year age group (61.6%) with a male predominance. Borderline tuberculoid (BT) was the commonest clinical type (65.9%) followed by indeterminate leprosy (18.8%); 101 patients required paucibacillary (PB) and 37 needed multibacillary (MB) treatment. The number of patients requiring MB treatment showed a statistically significant increase and there was a significant decline in number of cases requiring PB treatment. During the entire study period no Type 2 lepra reaction was documented in patients below Hema 15 years and only two patients manifested Type 1 reaction. Ten (7.2%) out of the 138 patients were cases of relapse. There was a clear female predilection among relapse cases with the majority belonging to the adolescent age. CONCLUSIONS: Childhood leprosy still contributes to a significant proportion of the total case load denoting the continuing active horizontal transmission of leprosy. The rise in number of patients with more extensive disease in the background of declining disease prevalence is suggestive of the delay in diagnosis and treatment. A high relapse rate noted in the present study may be due to incorrect classification and treatment of MB as PB leprosy which in turn might have resulted in treatment failure due to inadequate treatment.

Kerion due to microsporum gypseum in a 1-month-old infant.

Microsporum gypseum is a rare cause of kerion in infancy. Light microscopy, fluorescent microscopy and fungal culture of the infected hair aids in early and correct diagnosis. Griseofulvin is the drug of choice for ectothrix fungi. We report a case of neonatal kerion caused by M. gypseum occurring at the age of 1 month, successfully treated with griseofulvin.