Secukinumab-associated localized granuloma annulare (SAGA): a case report and review of the literature.

Granuloma annulare (GA) is a benign, usually self-limited inflammatory skin dermatosis characterized clinically by pink-red to brown dermal papules or annular plaques. The main histologic feature is the presence of palisading or interstitial granulomas composed of necrobiotic collagen, elastic fibers, and mucin surrounded by a lymphohistiocytic infiltrate. Granuloma annulare is commonly associated with trauma, infections, diabetes mellitus, dyslipidemia, malignancy, thyroid disease, and a variety of medications. Two cases of GA have been reported in association with the use of secukinumab, a monoclonal antibody directed against interleukin 17A (IL17A), for the treatment of moderate-to-severe plaque psoriasis. We report the third case of secukinumab-associated GA in a 52-year-old woman with a history of diabetes mellitus type II, dyslipidemia, and non-alcoholic steatohepatitis. After four months of therapy with secukinumab, she presented with pink papules coalescing to plaques involving the antecubital fossae. Histology demonstrated a lymphohistiocytic palisading granuloma with central necrobiotic collagen and mucin, consistent with GA. Physicians should be aware of the possibility of GA developing in patients receiving secukinumab, especially in those with predisposing factors for GA. A better understanding of secukinumab-associated GA may lead to discoveries in GA pathogenesis and reveal broader immunomodulatory effects of secukinumab.

Managing diazepam abuse in an AIDS-related psychiatric clinic with a high percentage of substance abusers.

Controversy over using benzodiazepines in a human immunodeficiency virus (HIV)-positive population to relieve sleep and anxiety has not been addressed in the literature. Serious problems with diazepam abuse emerged in a psychiatric outpatient clinic for a predominately HIV-positive and illicit drug-using population, which led to a review of patient characteristics and prescribing policies and to a systematic problem-solving effort. The patients originally prescribed diazepam were significantly more likely to be on methadone and have histories of intravenous drug use compared with the patients not on benzodiazepines. Thus, the patients asking for diazepam are likely to have histories of substance abuse and have a high potential for abusing the medication. The authors found that diazepam can be discontinued without causing a significantly greater drop-out rate in that group.

Depression, HIV dementia, delirium, posttraumatic stress disorder (or all of the above)

A 29-year-old single Puerto Rican woman with AIDS was admitted to the Medical Service for pneumonia, seen by the Psychiatric Consultation Service, an eventually transferred to the Inpatient Psychiatric Unit with several possible psychiatric diagnoses including major depression, HIV dementia, delirium, and posttraumatic stress disorder. These possibly coexisting and interacting syndromes are discussed by three psychiatrists, one of whom is also a board-certified neurologist. This case illustrates the combined contribution of organic and psychological factor to complex behavioral disorders, which are increasingly common in HIV infection.