Skin changes in internal malignancy.

BACKGROUND: Internal malignancies are accompanied by various skin changes which may be specific infiltrates or non-specific changes. This study is aimed at determining the frequency of such changes in malignant disease treatment center attendees in India. METHODS: A study of 300 confirmed cases of internal malignancy at a malignant disease treatment center was undertaken to evaluate these skin changes. Specific infiltrates were confirmed by histopathology. Statistical methods were employed to calculate significance in non-specific lesions by comparing with 300 controls not suffering from internal malignancy. RESULTS: Skin changes were present in 82 (27.3%). Cutaneous metastases were found in 19 (6.3%); non-contiguous in 5 (1.6%); contiguous in 14 (4.3%). Non-specific skin lesions numbered 74 (11.6%) in 52 patients. Statistically significant non-specific skin changes were acquired ichthyosis, herpes zoster and generalized pruritus. CONCLUSION: Metastases usually occurred late in internal malignancy (17, 5.6%) except in a case each of histiocytic lymphoma and non-Hodgkin's lymphoma (2, 0.7%) where the lesions preceded malignancy by 3 months and 1 month respectively. Contiguous nodules were a marker of relapse after surgery in 3 (1%).

Serum Zinc Levels in Cutaneous Disorders.

Serum zinc levels were studied in 75 patients of different cutaneous disorders and 24 healthy controls. It was found to be significantly lower in acne vulgaris (71.5 ± 21.5µgm/100ml), leprosy(85.9 ± 26.9µgm/100ml) and psoriasis (93.3 ± 25.9µgm/100ml) as compared to healthy controls (105.3 ± 30.1µgm/100ml). No significant correlation was found in other cutaneous disorders studied i.e. vitiligo and aphthous ulcers where serum zinc levels were found to be 97.3 ± 26.6 µgm/100ml and 105.2 ± 23.5 µgm/100ml respectively.

DERMATOPHYTOSIS AND DERMATOMYCOSIS IN PUNE.

Dermatophytosis and dermatomycosis in patients reporting to Command Hospital (SC) were studied over a period of 3 years. A total of 126 cases were investigated. Commonest clinical diagnosis was tinea corporis (39.68%) followed by onychomycosis (20.63%). Some patients had infections of multiple sites. Direct examination under KOH and dimethyl sulfoxide (DMSO) revealed fungal elements in 43 (34.12%) cases. Fungi were isolated from 44 (34.92%) cases. Commonly isolated fungi were Candida albicans 11 (25%), Trichophyton spp 8 (18.18%), Microsporum audouinii 2(4.55%) and Epidermophyton floccosum 1(2.27%).

STUDIES ON HBsAG IN HIV SEROPOSITIVE CASES.

Two hundred and fifty five patients with human immunodeficiency virus (HIV) infection were screened for hepatitis B virus surface antigen (HBsAg) over a period of 3 years. These patients were followed up every 6 month. 10.2% of HIV seropositive cases revealed presence of HBsAg. It was also observed that almost half (47.6%) of these cases developed carrier state.

HIV IN TUBERCULOSIS.

This study was undertaken to evaluate clinical and laboratory parameters of 29 HIV-infected male patients with tuberculosis. Out of the 243 human immune deficiency virus (HIV) seropositive patients, 15 (6.2%) were diagnosed to be suffering from tuberculosis whereas out of 3502 cases of tuberculosis random HIV surveillance in 350 cases showed HIV infection in 14 (4%). Mantoux positivity at the time of diagnosis of tuberculosis was noted in 16 (55.1%) patients, and out of them 17.1% showed tuberculin conversion within 2 years of detection of HIV infection. Diagnosis of tuberculosis was based on demonstration of acid fast bacilli in sputum of 8 (27.6%), and in lymphnode aspirate in 4 (13.8%). Tubercular granuloma was demonstrated in 3 more patients, 2 in lymphnodes and one in liver parenchyma. In another 14 cases, there was classical clinical presentation and chest radiogram findings with excellent therapeutic response. Chest radiograms showed pulmonary infiltrate in 20, pleural effusion in 5, pleural thickening in 2, and intrathoracic adenopathy in 6 patients. Exclusive extrapulmonary tuberculosis was present in 4 patients.

A clinicopathological study of multidrug therapy in borderline tuberculoid leprosy.

A study was undertaken to evaluate the efficacy of multidrug therapy as per WHO recommendation in 50 fresh cases (46 males and 4 females) suffering from borderline tuberculoid leprosy. All were given multidrug therapy consisting of rifampicin 600 mg once a month and dapsone 100 mg daily for 6 months. At the end of 6 months all were evaluated clinically and histopathological examinations of the lesions were studied. The lesions were still active in 60% of patients clinically; 32% cases receiving multidrug therapy had shown marked improvement. Histologically lymphocytic infiltration in skin still persisted in all the slides examined and nerve infiltration was still present in 68% of cases at the end of 6 months after receiving multidrug therapy. The study shows that treatment with multidrug regimen for 6 months may not be sufficient to treat borderline tuberculoid leprosy cases.

A clinico-pathological study of macular lesions in leprosy.

One hundred twenty histologically confirmed cases of leprosy having macular lesions were evaluated clinically and histopathologically according to Ridley-Jopling classification. Of these 120 cases, the majority (91 or 75.8%) were young adults. The main clinical findings were: a single macule in 42 patients (35%), multiple macules 2-5 in numbers in 35 patients (29.1%), 6-10 macules in 17 patients (14.1%) and more than 10 macules in 26 patients (21.6%). Impairment of sensation over the macular lesions was present in 62 cases (51.6%), total loss of sensation was noticed in 31 patients (25.8%) and sensation was intact in 27 patients (22.5%). Acid-fast bacilli were detected in 11 cases (9.1%) by slit-skin smear examination. Clinical examination of the 120 cases revealed features of TT in 16 (13.3%), BT in 41 (34.1%), BB in 11 (9.1%), BL in 13 (10.8%), LL in 7 (5.8%) and indeterminate leprosy (IL) in 32 patients (26.6%). On the contrary, histologically there were 22 cases of TT (18.3%), 38 cases of BT (31.6%), 8 (6.5%) BB, 10 BL (8.3%), 7 LL (5.8%) and 35 cases of IL (29.1%). Histopathological features were consistent with the clinical picture in 84 patients (70%).

CHANGING TRENDS OF LEPROSY IN ARMED FORCES.

A total of 651 cases of leprosy were hospitalised from Jan 1987 to Dec 1992. Each patient underwent haemogram, total and differential white cell count, urinalysis, liver function tests, skin slit smear for AFB and skin biopsy. Nerve conduction studies, electomyographic studies and nerve/nerve sheath biopsies were undertaken as and when indicated. These patients were managed with multidrug therapy. Paucibacillary (PB) leprosy accounted for 476 (73.1%) cases which comprised of indeterminate leprosy 90 (13.8%), tuberculoid leprosy 14 (2.2%), borderline tuberculoid leprosy 310 (47.6%) and neuritic leprosy 62 (9.5%). The remaining 175 patients (26.9%) were multibacillary (MB) which included borderline leprosy 9 (1.4%), borderline lepromatous leprosy 129 (19.8%) and lepromatous leprosy 37 (5.7%) patients. There were total 153 patients in 1987. This number declined to 44 in 1992. PB declined from 113 in 1987 to 39 in 1992 and MB cases from 40 to 5.

PSYCHIATRIC EVALUATION OF HUMAN IMMUNODEFICIENCY VIRUS SEROPOSITIVES IN ARMED FORCES.

Fifty five Armed Forces personnel detected to be seropositives for human immunodeficiency virus were the subjects of the study. After baseline clinical evaluation, laboratory investigations and Centre for Disease Control classification, through a semistructured interview, their sexual orientation, behaviour and psychiatric morbidity were assessed. Sixtynine percent had another sexually transmitted disease as comorbidity. Heterosexual contact was responsible for the infection in 54 out of 55 subjects. Seven patients were freshly diagnosed to have psychiatric illness.

HIV infection and genital ulcer disease.

PIP: Between December 1990 and July 1991, 17 male HIV patients between the ages of 21 and 47 years in an Indian hospital were identified and information was obtained on their history, age, source of infection, hospitalization, places and sources of sexual contact, and extramarital sexual contacts. Each patient with a sexually transmitted disease (STD) underwent HIV testing too using ELISA whose results were subsequently confirmed by Western Blot. 15 of the 17 patients also had an associated genital ulcer disease (GUD), which was a significant relationship. 12 had asymptomatic generalized lymphadenopathy and 5 were afflicted with persistent generalized lymphadenopathy. Of the 17 patients, 9 had chancroid, 2 had an early phase of syphilis, 3 had lymphogranuloma venereum, 1 each had candidal balanitis, condylomata acuminata, and acute gonorrhea. Eight patients contracted the HIV infection in Bombay. 14 patients had contracted the disease from prostitutes. Homosexual contacts were denied by all. 13 patients admitted a single instance of extramarital sexual contact. In a study of 123 HIV seronegative prostitutes monitored regularly, HIV seroconversion was significantly associated with GUD. There is convincing evidence that GUD increases the risk of acquiring HIV infection because the breach of mucosal integrity of the genitalia provides a more efficient route for viral entry. Other risk factors documented for sexual transmission of HIV in addition to STDs are: lack of male circumcision, receptive anorectal sexual intercourse, lack of condom use, and advanced HIV-related immunosuppression in the index case. Since GUD predisposes to HIV infection, it is imperative to treat genital ulcer and to increase sex education regarding HIV.^ieng

A study on non-specific urethritis in males.

PIP: 31,042 cases of sexually transmitted disease (STD) were seen among male soldiers at the Command Hospital in Pune during the period 1980-89. All presented with the complaint of urethral discharge with or without dysuria. Among the 4823 cases of urethritis, 3881 men presented with gonorrhea and 942 with nonspecific urethritis. The incidence of nonspecific urethritis was therefore 3.03% of all STDs. 68% of the patients were aged 20-29 years and 72% were single. Urethral discharge was present at the first attendance in 96% of cases. The authors note that among the various types of STDs, the incidence of nonspecific urethritis has risen more rapidly than that of gonorrhea in the world and it is now recognized as the most common STD in Western countries.^ieng

Drug eruptions (a series of 148 cases).

A total number of 148 patients, comprising of 101 males and 47 females diagnosed as drug eruptions were reviewed. The youngest patient was eight and the oldest 73 years. The mean age was 34 years. 75(50.7%) patients were in the age group of 20 to 40 years. In 88(59.5%) pruritus was the chief associated symptom. 116(78.4%) developed eruptions within 2 weeks. 29(19.6%) had single site involvement, 92(62.2%) had lesions at more than one site and 25(16.9%) patients had generalised skin and mucous membrane involvement. The commonest skin reactions were fixed drug eruptions in 39(26.4%) cases. Almost all types of drug eruptions were observed. The eruptions were caused by 37 different drugs, the commonest being sulphonamides in 28(18.9%) cases. Systemic side effects were recorded in 13(8.8%) patients. 76(51.4%) were treated with topical medicaments. Out of the remaining, 33(22.3%) were managed by antihistamines and 26(17.6%) by steroids in addition to topical therapy. No treatment was required in 13(8.8%). 117(79.1%) were treated as out patients and 31(20.9%) were hospitalised. One (0.7%) patient died of toxic epidermal necrolysis due to penicillamine.

Analysis of dermatological referrals (a series of 662 cases from base and army hospital complex).

An analysis of 662 patients from non-dermatological wards and specialist out-patients referred for dermatological opinion is reported. There was a high proportion of referrals of 330 (49 8%) cases from internal medicine and allied specialties, followed by 150 (22.7%) from surgical disciplines, 65 (9.8%) by Paediatricians 30 (4.5%) by Otolaryngologists, 24 (3.6%) each by Ophthalmologists and specialists in Obstetrics and Gynaecology, 21 (3 2%) by dental surgeons and 18 (2.7%) from department of Psychiatry. The youngest patient was a new born and the oldest 87 years. 333 (50.3%) were in the age group of 21 to 40 years. 505 (76.3%) were males. Almost one fourth i.e. 152 (23%) presented with cutaneous manifestations of underlying diseases, another 82 (12.4%) were drug eruptions and other complications of treatment. The study emphasizes considerable interphase between cutaneous and systemic diseases and the need for close co-operation between dermatology and other specialist medical disciplines.

Paucibacillary leprosy: a comparative study of different schedules of multidrug therapy.

The study was undertaken to evaluate the efficacy of various multidrug regimens (MDT). Three groups of 10 cases each of Paucibacillary cases were given different schedule of multidrug therapy. First group (T-0) was administered modified WHO regimen consisting of Rifampicin 600 mg once a month, Clofazimine 100 mg alternate days and Dapsone 100 mg daily for 6 months. In second group (T-1) Rifampicin 600 mg was given daily for 6 weeks and in third group (T-2) Rifampicin 600 mg was given daily for 6 months. In both the latter groups Clofazimine 100 mg on alternate days and Dapsone 100 mg daily was also administered for 6 months. Objective clinical scoring was done at the time of admission, three months and six months after treatment in all three groups. The best results were obtained by T-2 followed by T-1; and least effective was T-0 regimen. Pinkish colour of urine and skin was observed in 26 cases and icthyosis in all the cases. All the patients remain under treatment. The work is in progress and subsequent results will be published later.