Luminescence of favipiravir in skin appendages and sclera. A controlled study and literature review.

BACKGROUND/OBJECTIVES: Favipiravir is an antiviral agent, recently used for COVID-19 infections. Several reports associate favipiravir intake with Wood's lamp fluorescence of hair, nails, and sclera. The present study was designed to elucidate the positivity rates, and sites of favipiravir-related fluorescence and to unravel the site-specific changes in fluorescence positivity rates by a function of time past exposure. METHODS: The study population comprised 50 patients and 50 control individuals. All patients in the patient group had received a full dose of favipiravir for COVID-19 infection. Fifty volunteers served as the control group. Wood's lamp examination was performed in a completely darkened room, and the positivity rate, extent, pattern, and distribution of fluorescence were recorded. RESULTS: Wood's light revealed fluorescence of the fingernails, toenails, sclera, and hair in 35 (70%), 35 (70%), 22 (44%), and 8 (16%) patients, respectively. No control individual tested positive by Wood's lamp. Statistical analysis revealed significant differences between patient and control groups in terms of Wood's light luminescence in the fingernails (p = .000), toenails (p = .000), sclera (p = .000) and hair (p = .003). Although fingernail, toenail, and hair fluorescence positivity rates declined or ceased at or after 91 days of favipiravir exposure, ocular fluorescence positivity rates were prolonged up to 188 days. CONCLUSIONS: These findings confirm that favipiravir may produce fluorescence of nails, sclera, and hair, detectable by Wood's light starting from the initial month and peaking at second- and third months following exposure to the medication. Although nail and hair fluorescence tend to abate after 3 months, ocular fluorescence may persist even longer than 6 months after cessation of the medication.

Outcomes of high-risk breast lesions diagnosed using image-guided core needle biopsy: results from a multicenter retrospective study.

PURPOSE: The clinical management of high-risk lesions using image-guided biopsy is challenging. This study aimed to evaluate the rates at which such lesions were upgraded to malignancy and identify possible predictive factors for upgrading high-risk lesions. METHODS: This retrospective multicenter analysis included 1.343 patients diagnosed with high-risk lesions using an image-guided core needle or vacuum-assisted biopsy (VAB). Only patients managed using an excisional biopsy or with at least one year of documented radiological follow-up were included. For each, the Breast Imaging Reporting and Data System (BI-RADS) category, number of samples, needle thickness, and lesion size were correlated with malignancy upgrade rates in different histologic subtypes. Pearson's chi-squared test, the Fisher-Freeman-Halton test, and Fisher's exact test were used for the statistical analyses. RESULTS: The overall upgrade rate was 20.6%, with the highest rates in the subtypes of intraductal papilloma (IP) with atypia (44.7%; 55/123), followed by atypical ductal hyperplasia (ADH) (38.4%; 144/375), lobular neoplasia (LN) (12.7%; 7/55), papilloma without atypia (9.4%; 58/611), flat epithelial atypia (FEA) (8.7%; 10/114), and radial scars (RSs) (4.6%; 3/65). There was a significant relationship between the upgrade rate and BI-RADS category, number of samples, and lesion size Lesion size was the most predictive factor for an upgrade in all subtypes. CONCLUSION: ADH and atypical IP showed considerable upgrade rates to malignancy, requiring surgical excision. The LN, IP without atypia, pure FEA, and RS subtypes showed lower malignancy rates when the BI-RADS category was lower and in smaller lesions that had been adequately sampled using VAB. After being discussed in a multidisciplinary meeting, these cases could be managed with follow-up instead of excision.

Aquatic/aquagenic Dermatoses: The Thin Line Between Pool Palms and Aquagenic Syringeal Acrokeratoderma.

Pool palms and pool toes are friction or pressure-induced aquatic dermatoses resulting from extensive and repetitive rubbing of fingers, palms, soles, and toes against the rough anti-slippery surfaces or edges of pools. Aquagenic syringeal acrokeratoderma is a sporadic, episodic, and acquired disorder of palmar skin linked to water exposure. Herein we describe a case of aquatic/aquagenic dermatosis that presented clinical and diagnostic difficulties. Differentiating between pool palms and aquagenic syringeal acrokeratoderma is a challenge, and we believe that both disorders lie on a spectrum of watersport dermatoses.

Multiple Military Osteoma Cutis: Report of a Case and a Brief Review of the Literature.

A 39-year-old woman presented with a 4-year history of asymptomatic facial lesions that has progressively increased in number to become a cosmetic nuisance. These lesions have not responded to 6-months of topical 20% azelaic acid, 0.1% retinoic acid, and 20% vitamin C combination. She has had mild papulopustular acne. Her personal and family histories were unremarkable. On dermatologic examination, there were multiple flesh-colored to pigmented, firm ovoid to round papules, 2-5 mm in size, over the forehead and both cheeks (Figure 1). The dermatoscopic examination was nonspecific. Preliminary diagnoses were made of eccrine syringoma, steatocystoma multiplex, and papular elastorrhexis. A histopathologic examination from a punch biopsy displayed focal ossification within the dermis (Figure 2). Routine laboratory tests, including serum calcium, phosphorus, PTH, and vitamin D levels were within the normal ranges. A maxillofacial 3D CT scan, revealed multiple dermal and hypodermal ossifications, <3-5 mm in size-in the frontal, mandibular, and maxillary areas of the face (Figure 3). Scattered osteomas were also seen on the neck. A definitive diagnosis of multiple miliary osteoma cutis (MMOC) of the face and neck was firmly established based on clinical, histologic, and radiologic findings. Radiologically, the distribution and extent of the lesions were more pronounced than clinically anticipated. (SKINmed. 2022;20:469-471).

A Review on Cutaneous and Musculoskeletal Manifestations of CLOVES Syndrome.

CLOVES syndrome is a novel sporadic mosaic segmental overgrowth syndrome, currently categorized under the canopy of PROS (PIK3CA-related overgrowth spectrum) disorders. All PROS disorders harbor heterozygous postzygotic activating somatic mutations involving the PIK3CA gene. As an upstream regulator of the PI3K/AKT/mTOR signal transduction pathway, activating mutations of PIK3CA gene commence in uncontrolled growth of cutaneous, vascular (capillaries, veins, and lymphatics), adipose, neural, and musculoskeletal tissues. The excessive growth is segmental, patchy, asymmetric, and confined to body parts affected by the mutation. The term 'CLOVES' is an acronym denoting congenital lipomatous overgrowth, vascular malformations, epidermal nevi and spinal (scoliosis) and/ or skeletal anomalies. The syndrome is characterized by an admixture of overgrown tissues, derived mainly from mesoderm and neuroectoderm. Among PROS disorders, CLOVES syndrome represents the extreme end of the spectrum with massive affection of almost the entire body. The syndrome might judiciously be treated with medications hampering with the PI3K/AKT/mTOR signal transduction pathway. This article aims at reviewing the cutaneous and musculoskeletal manifestations of CLOVES syndrome, as the paradigm for PROS disorders. CLOVES syndrome and other PROS disorders are still misdiagnosed, underdiagnosed, underreported, and undertreated by the dermatology community.

Fluorescence in the Sclera, Nails, and Teeth Secondary to Favipiravir Use for COVID-19 Infections.

Favipiravir, an antiviral agent originally used for influenza infections, has become popular due to its beneficial signals in coronavirus disease. It is currently used in some countries within COVID-19 treatment protocols. This is an initial report of favipiravir-related fluorescence observed in three healthcare providers working in the same ward in our hospital. All three individuals had been diagnosed with COVID-19 two months earlier and were treated with favipiravir. None of the three individuals received hydroxychloroquine or tetracyclines. Wood's light examination led to an incidental discovery of favipiravir-induced fluorescence involving the sclera, nails, and teeth. In all patients, white linear, square, and band-like specks of fluorescence were noticed on the sclera of both eyes, some teeth, and the proximal part of all fingernails and toenails. Exposure of the eyes to the Wood's light was for a brief duration of 3 to 5 seconds during examination and photodocumentation. Favipiravir might cause bright white fluorescence of nails, sclera, and teeth, detectable by Wood's light even two months after its cessation.

Cystic renal diseases: role of ultrasound. Part II, genetic cystic renal diseases.

Kidney cysts are quite common in adults. Though small simple renal cysts in an adult over 30-40 years of age are not too unusual, however, if the same cysts are seen in a child, and especially if there are additional findings, then several diagnostic possibilities may come to mind. The role of ultrasound, together with the help of intravenous contrast agents and Doppler mode, are very critical in describing the morphologic features and follow-up of the complex or multiple and bilateral renal cysts. These sonographic signs are occasionally specific for diagnosis, but in many cases sonographic clues should be evaluated together with the other genetic and clinical data to reach diagnosis.The first part of this pictorial essay included the introduction into the subject and the classification of non-genetic cystic renal diseases. The key features for the non-genetic cystic renal diseases are illustrated. In the second part, eye-catching features of genetic cystic renal diseases are demonstrated.

The role of intraoperative ultrasonography in detection of hepatic vein variations in living donor liver transplantation.

BACKGROUND: With advances in surgical techniques and immunosuppression, liver transplantation has become the most effective treatment of acute and chronic liver failures. Evaluation of vascular anatomy and detection of hepatic vascular variations prior to surgery, especially transplantation surgery, can help reduce complications in both the donor and the recipient. Intraoperative ultrasonography (IOUS) is known to be beneficial during planning of the transplantation surgery, and can help direct the surgery itself. OBJECTIVES: To our knowledge, there are no existing studies that evaluate the number and diameter of segment 5 and 8 branches that need to be anastomosed with IOUS. PATIENTS AND METHODS: In this study, considering surgical anatomical evaluation as the gold standard, IOUS findings were compared to computed tomography angiography (CTA) findings. 40 patients were included in the study. RESULTS: The average diameters of segment 8 branches that were anastomosed and not anastomosed were significantly different when measured by IOUS (p = 0.016); however, no such statistically significant difference was found in measurements made with CTA (p = 0.89). CONCLUSION: CTA is superior to IOUS in detecting segment 5 and 8 veins draining into the middle hepatic vein. However, IOUS is more accurate in predicting which vessels are going to be anastomosed. For a complete and accurate assessment, both imaging modalities should be used to complement each other, and their respective advantages and disadvantages should be known.

The value of doppler ultrasound in predicting arterial injuries of the penetrating forearm trauma.

OBJECTIVE: The aim of this study was to determine the diagnostic value of Doppler ultrasound (DU) in predicting arterial injuries following the penetrating trauma of the forearm, by comparing preoperative diagnosis made by DU and that made by physical examination (PE) with the intraoperative diagnosis. METHODS: In this retrospective study, 48 patients (44 men, 3 women; mean age = 30 ± 12.5 years) who underwent surgical treatment due to a suspected arterial injury following a penetrating trauma in the forearm from 2016 to 2018 were included. The DU examination was frequently done before an orthopedic examination. In the orthopedic PE, the knowledge as to whether an arterial injury occurred or (if present) which artery was injured was noted. Preoperative diagnoses by PE and DU were first compared with each other, and then with the intraoperative diagnoses. The specificity, sensitivity, negative and positive predictive values were calculated. RESULTS: While the DU findings from 24 patients (50%) matched their intraoperative results, the result from the remaining 24 patients (50%) did not. Nine (18.75%) were considered false-positive and 15 (31.25%) were false-negative. Whereas the PE findings from 30 patients (62.5%) matched their intraoperative results, the remaining 18 patients (37.5%) did not. Six (12.5%) were considered false-positive and 12 (25%) were false- negative. No significant difference was found between the diagnoses of DU and PE, and there was good agreement between the DU and PE findings (P = 0,065, κ = 0,504). While the DU findings were significantly different from the intraoperative findings (P = 0.004), the PE findings were not significantly different from the intraoperative findings (P = 0.302). Sensitivities of DU and PE were both 75% for the diagnosis of radial artery injury as well as 63.3% and 70% for the ulnar artery injury, respectively. Specificities of DU and PE were 83.3% and 91.66% for the diagnosis of radial artery injury as well as 77.77% and 72.22% for the ulnar artery injury, respectively. CONCLUSION: The PE seems more sensitive and useful than the DU in predicting arterial injuries following the penetrating trauma of the forearm. LEVEL OF EVIDENCE: Level IV.

Primary Cutaneous Angiosarcoma of the Scalp with Cranial Invasion in a Patient with Metastatic Breast Cancer.

Idiopathic cutaneous angiosarcoma (CA) of the head and neck is a distinct subtype of angiosarcoma most commonly presenting as a single or multiple purple, bruise-like patches that arise de novo and enlarge over several months. In clinical practice, both misdiagnosis and delayed diagnosis are frequently encountered. Here, we present a case of idiopathic CA on the scalp with invasion to the cranium in a patient with breast cancer metastatic to the brain. The patient was initially misdiagnosed and mistreated with herpes zoster and breast cancer metastatic to the skin, which led to a delayed diagnosis by two months until dermatologic evaluation. The diagnosis was then firmly established as CA based on consistent clinical and histological features. Since the tumor was inoperable, radiotherapy and chemotherapy were been considered as the appropriate adjuvant modes of therapy. Despite an initial favorable response, the disease demonstrated a rapidly progressive course and the patient succumbed to the disease within six months. This report briefly reviews the clinical and histological portrait and management options for this aggressive tumor.

Demographic, clinical and dermoscopic features of melanocytic nevi on the scalp.

BACKGROUND: The scalp is a special anatomical area and dermoscopic findings of this region may significantly differ from other body parts. OBJECTIVE: To investigate and compare the clinical and dermoscopic patterns of scalp melanocytic nevi in patients ≤15 years of age and above, and to analyse their relevance to demographic features, atypical mole syndrome (AMS) and total body nevus count (TBNC). METHODS: In this retrospective cohort study, the clinical data and dermoscopic images of patients with scalp melanocytic nevi were retrieved, reviewed and analysed. Demographic, clinical and dermoscopic features were compared in patients ≤15 years of age and above. RESULTS: A total of 196 scalp melanocytic nevi in 126 patients (female/male:64/62; ≤15/>15 years of age: 49/77) with a median age of 18.5 years (range 0-72) were evaluated. Statistically, the globular pattern was significantly higher in all age groups, and the papillomatous pattern was significantly lower in patients ≤15 years of age (P = 0.008 and P = 0.005, respectively). The eclipse pattern was significantly higher, and the homogenous pattern was significantly lower in patients ≤15 years of age with AMS (P = 0.003 and P = 0.014, respectively). Finally, patients ≤15 years of age with 50 to 100 TBNC had a higher eclipse pattern than those with 0 to 25 TBNC. CONCLUSION: The findings of this retrospective study might implicate that children with eclipse pattern of scalp melanocytic nevi might be 'moley' in the future with an impending risk of AMS. This hypothesis requires confirmation in future prospective studies on a larger cohort of patients.

Livedoid cutaneous metastasis of signet-ring cell gastric carcinoma.

Cutaneous metastasis of gastric cancer is extremely rare. Nodular forms are more common and inflammatory forms are exceptionally encountered. Herein, we report a case of inflammatory cutaneous metastasis of signet-ring cell gastric cancer (poorly cohesive gastric carcinoma with signet-ring cell component) masquerading as livedo reticularis. To our knowledge, such a clinical presentation of cutaneous metastasis has not been reported for gastric cancer. It is imperative to preserve a high index of clinical suspicion for diagnosing cutaneous metastases. Our case highlights the importance of obtaining a skin biopsy in patients with a known history of internal malignancy. Bizarre, newly erupting, evolving, persistent, or treatment-refractory dermatologic lesions (such as nodules, ulcers, erythematous, reticular, or livedoid patches) might be clues for an underlying internal malignancy and require prompt histopathological sampling. Personal medical history, histopathological examination, and immunohistochemical profiling are equally important in distinguishing primary cutaneous carcinomas from secondary metastatic deposits. Early recognition of a cutaneous metastasis might enable appropriate staging and timely intervention, thereby prolonging survival.