The use of dupilumab in patients with HIV.

BACKGROUND: The goal of this study was to complete the first Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) based systematic review of dupilumab use in patients living with human immunodeficiency virus (HIV). METHODS: A systematic literature review was performed using PubMed, Google Scholar, Ovid MEDLINE, and Science Direct databases as well as an internal review using University of Virginia's electronic medical record system. All reports of dupilumab use in patients with confirmed HIV were included. RESULTS: 14 published cases comprising 23 patients were identified and included in the review. Additionally, four unpublished cases from our own institution were included for a final cohort of 27 patients. A total of 25 patients (96%) were observed to have a clinical response, defined as improvement or complete resolution of their cutaneous or asthmatic symptoms. In 100% of patients, viral load improved or did not change, and in 80% of patients, CD4 counts remained stable. Side effects occurred in 48% of patients but were self-limited. DISCUSSION AND CONCLUSIONS: All reported cases indicate that dupilumab is safe in patients with HIV with stable CD4 counts and low viral loads. Most patients had significant improvement within 2 months of treatment with mild side effects.

Apple cider vinegar soaks do not alter the skin bacterial microbiome in atopic dermatitis.

INTRODUCTION: Atopic dermatitis is a common skin disease characterized by altered cutaneous immunity in which patients often exhibit lower skin microbiota diversity compared to healthy skin and are prone to colonization by Staphylococcus aureus. Apple cider vinegar has been shown to have antibacterial effects; however, its effects on the skin microbiome have not previously been well-described. OBJECTIVES: We aimed to examine the effects of topical dilute apple cider vinegar soaks on Staphylococcus aureus abundance, skin bacterial microbiome composition, and skin bacterial microbiome diversity in atopic dermatitis participants compared to healthy skin. METHODS: Eleven subjects with atopic dermatitis and 11 healthy controls were enrolled in this randomized, non-blinded, single-institution, split-arm pilot study. Subjects soaked one forearm in dilute apple cider vinegar (0.5% acetic acid) and the other forearm in tap water for 10 minutes daily. Skin bacteria samples were collected from subjects' volar forearms before and after 14 days of treatment. 16S sequencing was used to analyze Staphylococcus aureus abundance and skin bacterial microbiome composition, and alpha diversity of microbiota were determined using Shannon diversity index. RESULTS: There was no difference in skin bacterial microbiome in atopic dermatitis subjects after 2 weeks of daily water or apple cider vinegar treatments (p = 0.056 and p = 0.22, respectively), or in mean abundance of S. aureus on apple cider vinegar-treated forearms (p = 0.60). At 2 weeks, the skin bacterial microbiomes of healthy control subjects were not significantly different from the skin bacterial microbiome of atopic dermatitis subjects (p = 0.14, 0.21, 0.12, and 0.05). CONCLUSIONS: Our results suggest that daily soaks in 0.5% apple cider vinegar are not an effective method of altering the skin bacterial microbiome in atopic dermatitis. Further studies are needed to explore the effects of different concentrations of apple cider vinegar on skin microflora and disease severity. TRIAL NUMBER: UVA IRB-HSR #19906.

Case and review: Cutaneous involvement by chronic neutrophilic leukemia vs Sweet syndrome- A diagnostic dilemma.

Chronic neutrophilic leukemia (CNL) is a rare leukemia with approximately 150 total cases reported. Cutaneous neutrophilic infiltrates, including Sweet syndrome (SS) and leukemia cutis (LC), have been reported in six patients with CNL. In the setting of CNL, these two conditions are difficult to differentiate due to clinical and histopathological similarities, but it is important to do so because LC is associated with a worse prognosis. In general, SS is distinguished by its tenderness, fever, and improvement with steroids (vs chemotherapy for LC). Biopsy of LC reveals immature leukocytes, whereas SS shows almost exclusively mature leukocytes, but morphology alone may not be sufficient in some cases. Here, we report a case of a 72-year-old male with CNL and a cutaneous eruption with clinical and pathological features which made the distinction between the two diseases difficult.

Larval tick infestation causing an eruption of pruritic papules and pustules.

Ticks are well-documented human parasites and vectors of infectious disease. The larval ("seed") stage is 1 of 3 motile life stages, and larval ticks have been known to attack in droves, causing diffuse pruritic erythematous papules and pustules. In the absence of close examination, larval tick infestation can easily be missed in the wide differential for this clinical presentation. We present 2 cases of larval tick infestation occurring during the summer within the same month at a single institution. Our purpose is to encourage physicians to include larval tick infestation when generating a differential diagnosis for diffuse pruritic erythematous papules and pustules.

Apple cider vinegar soaks [0.5%] as a treatment for atopic dermatitis do not improve skin barrier integrity.

BACKGROUND/OBJECTIVES: Atopic dermatitis (AD) is a common chronic inflammatory skin condition associated with high transepidermal water loss, high skin pH, and Staphylococcus aureus skin colonization. The treatment of AD with bath additives remains highly debated. Recent evidence suggests that dilute apple cider vinegar (ACV) may improve skin barrier integrity in AD, but its safety and efficacy are not well studied. This pilot split-arm study analyzed the effect of dilute apple cider vinegar soaks on skin barrier integrity in patients with atopic dermatitis as measured by skin transepidermal water loss and skin pH. METHODS: A total of 22 subjects (11 AD and 11 healthy controls) were enrolled. Subjects soaked both of their forearms for 14 days, with one arm in dilute ACV (0.5% acetic acid) and the other in water 10 minutes daily. Transepidermal water loss and pH were measured pre- and post-treatment. RESULTS: In both groups, transepidermal water loss increased and pH decreased at 0 minutes post-ACV treatment, but these effects were not sustained at 60 minutes. In total, 72.7% (16/22) of subjects reported mild side effects from ACV with improvement after discontinuing the soaks. CONCLUSIONS: Dilute ACV soaks have no significant effect on skin barrier integrity but caused skin irritation in a majority of subjects. Study limitations include analysis of a single brand, dilution, and application of ACV. Future studies are needed to explore whether lower concentrations of ACV soaks or other applications such as a leave-on acidic ointment could improve skin barrier integrity in a safe, nonirritating way.

Necrobiosis lipoidica associated with sarcoidosis.

We report the case of a 40-year-old African-American female with biopsy-proven pulmonary sarcoidosis who developed atrophic plaques on her shins, trunk, and scalp that were clinically and histologically consistent with necrobiosis lipoidica (NL). The lesions appeared 3 years after her diagnosis of sarcoidosis, and progressed despite chronic prednisone. Sarcoidosis and NL are granulomatous skin disorders reported to coexist in the same patient only 10 times in the literature. Including the current case, patients have been exclusively females around middle age, and have greater tendencies to develop typical cutaneous sarcoidosis. The incidence of diabetes is rare in this group. Like typical NL, NL associated with sarcoidosis tends to ulcerate, and is difficult to treat. Interestingly, there are six similar cases reported in the literature of patients with sarcoidosis who developed lesions clinically and behaviorally consistent with NL, but received a final histological diagnosis of sarcoidosis. These cases share very similar demographics and clinical features with cases of true NL associated with sarcoidosis, and often have more ambiguous histology containing features of both cutaneous sarcoidosis and NL. Comparing the two sets of cases raises the possibility of a final common disease pathway shared by these two granulomatous skin disorders.

Epidemiologic and molecular characterization of an outbreak of Candida parapsilosis bloodstream infections in a community hospital.

Candida parapsilosis is an important cause of bloodstream infections in the health care setting. We investigated a large C. parapsilosis outbreak occurring in a community hospital and conducted a case-control study to determine the risk factors for infection. We identified 22 cases of bloodstream infection with C. parapsilosis: 15 confirmed and 7 possible. The factors associated with an increased risk of infection included hospitalization in the intensive care unit (adjusted odds ratio, 16.4; 95% confidence interval, 1.8 to 148.1) and receipt of total parenteral nutrition (adjusted odds ratio, 9.2; 95% confidence interval, 0.9 to 98.1). Samples for surveillance cultures were obtained from health care worker hands, central venous catheter insertion sites, and medical devices. Twenty-six percent of the health care workers surveyed demonstrated hand colonization with C. parapsilosis, and one hand isolate was highly related to all case-patient isolates by tests with the DNA probe Cp3-13. Outbreak strain isolates also demonstrated reduced susceptibilities to fluconazole and voriconazole. This largest known reported outbreak of C. parapsilosis bloodstream infections in adults resulted from an interplay of host, environment, and pathogen factors. Recommendations for control measures focused on improving hand hygiene compliance.