Adult Onset Orbital Xanthogranuloma, a Variant of Adult Orbital Xanthogranulomatous Disease: An Infrequent Entity.

Adult orbital xanthogranulomatous diseases (AOXGD) present clinically with symmetrical swellings around the eyes and are collectively considered within the broader group of non-Langerhans cell histiocytosis. A 45-year-old female presented with asymptomatic progressive, skin-colored, thick raised lesions around the eyes of 1 year duration. On dermatological examination, large indurated, lobulated, skin-colored thick plaques were seen bilaterally over infraorbital areas, along with a few hard, discrete nodules over the left infraorbital area. Histopathology showed pan-dermal infiltration with foamy histiocytes, non-lipidized histiocytes, a few multinucleate giant cells, lymphocytes, and a few plasma cells, with immunohistochemistry showing CD68 and S100 positivity. Laboratory and imaging studies did not show any abnormality. Based on the above findings and the absence of internal organ involvement, the patient was diagnosed with adult-onset orbital xanthogranuloma (AOX). The patient was treated with three monthly sessions of intralesional corticosteroid injections, along with methotrexate 12.5 mg per week for 8 weeks, resulting in a moderate reduction in the size of the plaques. The patient is under regular follow-up. The present case highlights the rare case of AOX and the importance of prompt recognition and evaluation in view of its potential hematological and systemic associations.

A Clinico-Mycological and Histopathological Study of Recurrent Dermatophytosis.

Background: A few recent studies have shown fungal elements within the hair follicle epithelium, which may act as a reservoir and responsible for recurrent dermatophytosis. Objectives: To assess the clinical patterns, mycological profile, and histopathology of recurrent dermatophytosis and to determine the prevalence of fungal hyphae in the hair follicle epithelium and other appendages. Materials and Methods: One hundred and fifty clinically diagnosed cases of recurrent dermatophytic infection were included. Skin samples were taken for direct microscopy, fungal culture, and histopathological analysis. Haematoxylin and eosin and special staining with periodic acid Schiff (PAS) and Gomori's methenamine silver (GMS) were performed to detect the fungal hyphae in the skin and hair follicle epithelium. Results: The most common clinical pattern observed was tinea corporis et cruris in 64 patients (42.66%). On direct microscopy and fungal culture, positive results were obtained in 116 cases (77.33%) and 78 (52%) cases, respectively. Presence of fungal hyphae in the stratum corneum, hair follicle, and acrosyringium was seen in 107 patients (71.33%), 47 patients (31.33%), and five patients (3.33%), respectively. Out of the 52 cases with hair follicle and eccrine gland involvement, history of fixed drug combinations (FDC) cream use was present in 42 cases (80.76%) and absent in ten cases (19.24%) (P = 0.000062). Limitations: Skin samples were taken only from a single skin lesion. Higher incidence of follicular invasion may have been detected if multiple biopsy samples were taken. Conclusion: Hair follicle/eccrine sweat gland involvement was observed in nearly one-third of the patients, which may act as a reservoir and may be responsible for recurrence and chronicity. Histopathology should be considered as an important adjuvant tool in recurrent dermatophytosis to establish the extent of the infection, which guides the further management.

A Clinico-mycological, Antifungal Drug Sensitivity and Therapeutic Study of Extensive Dermatophytosis in Coastal Andhra Pradesh.

Background: In India, an increased prevalence of chronic, recurrent, and recalcitrant dermatophytosis is being observed. The present study assesses the clinico-mycological profile, antifungal drug sensitivity and therapeutic efficacy of various systemic antifungal drug regimens, in extensive dermatophytosis patients of coastal Andhra Pradesh. Materials and Methods: One hundred and fifty clinically diagnosed cases of extensive dermatophytosis affecting more than one body region were enrolled. Skin samples were taken for direct microscopy and fungal culture. Antifungal drug sensitivity testing was done with broth microdilution test. Therapeutic efficacy of systemic antifungal drug regimens was determined by randomly dividing the patients into 5 groups of 30 each. Results: The most common clinical patterns observed were tinea corporis et cruris (62.7%) followed by extensive tinea corporis (11.3%). KOH and culture positivity were seen in 132 (88%) and 84 cases (56%) respectively. Trichophyton mentagrophytes was isolated in 78 cases (92.8%) followed by Microsporum gypseum in 6 patients (7.1%). The overall mean minimum inhibitory concentration values for itraconazole (0.04 µg/mL) were low when compared to griseofulvin (4.61 µg/mL) and terbinafine (6.9 µg/mL) (P < 0.05). Combination of itraconazole and griseofulvin achieved highest clinical and mycological cure rates (93.1%). Among patients receiving single drugs, itraconazole had higher cure rates (71.4%) compared to terbinafine (59.2%) and griseofulvin (53.8%) (P < 0.05). Conclusion: Trichophyton mentagrophytes has replaced Trichophyton rubrum as the predominant species causing dermatophytosis in Andhra Pradesh, presenting with a severe phenotype. Itraconazole was found to be the most effective drug both in vivo and in vitro. A combination of systemic drugs should be considered in cases of monotherapy failure and in recalcitrant dermatophytosis.

A Randomized Study to Evaluate the Efficacy Fractional CO2Laser, Microneedling and Platelet Rich Plasma in Post-Acne Scarring.

BACKGROUND: Acne scarring commonly seen in young adults causes marked psychological distress. Commonly used procedural treatments for post-acne scarring have limited efficacy. This prospective, randomized study was undertaken to evaluate the efficacy and adverse effects offractional CO2 laser, microneedling, and platelet-rich plasma (PRP) in post-acne scarring. MATERIALS AND METHODS: Sixty clinically diagnosed cases of post-acne scarring of both sexes were enrolled and divided into three groups of 20 patients each. The severity of scarring was graded as per the qualitative and quantitative grading system proposed by Goodman and Baron. Group A, B, and C patients were treated with fractional CO2 laser, microneedling, and PRP,respectively, at monthly intervals for foursessions. Improve men tin quantitative and qualitative grades of scars and adverse effects were noted at each session and 1 month after the final sitting. Statistical analysis was done using Student 't' test for quantitative values and Chi square test for qualitative values. RESULTS: At the end of foursessions, based on mean percentage of improvement in quantitative grade, the efficacy of fractional CO2 laser is significantly greater than that of PRP (P = 0.00), while CO2 laser and microneedling did not show significant difference (P = 0.106). Based on qualitative scores, fractional CO2 laser group showed statistically higher therapeutic efficacy compared to microneedling and PRP (P = 0.00).No significant adverse effects were encountered in any groups. CONCLUSION: Fractional CO2 laser resurfacing is more efficacious than microneedling and PRP. Unsatisfactory results were obtained with PRP as monotherapy in post-acne scarring.

Comorbidities in Lichen Planus: A Case-control Study in Indian Patients.

BACKGROUND: Many previous studies have observed an association of lichen planus (LP) with one or two comorbidities such as diabetes mellitus and thyroid dysfunction. This study was undertaken to determine the association of LP with common comorbidities including diabetes mellitus, dyslipidemia, metabolic syndrome, thyroid dysfunction, and hepatitis C virus (HCV) infection. MATERIALS AND METHODS: The study included 75 patients with clinical diagnosis of LP and 75 age- and sex-matched controls. After taking complete history, general examination and thorough dermatological examination were performed in all cases. Fasting serum samples were taken from all cases and controls and assayed for fasting plasma glucose, lipid profile, T3, T4, and thyroid-stimulating hormone levels, and anti-HCVantibodies. Metabolic syndrome was diagnosed according to 2005 revised National Cholesterol Education Programme's Adult Treatment Panel III. Two-sample Student's t-test was used for statistical analysis. RESULTS: Increased triglyceride levels were seen in 26 cases (34.67%) compared with 14 controls (14%), which was significant (P = 0.024). Statistically significant increased prevalence of increasedlow-density lipoprotein levels (P = 0.027), low high-density lipoprotein levels (P = 0.0189), and diabetes mellitus (P = 0.0217) was also observed in LP. Metabolic syndrome (P = 0.656) and hypothyroidism (P = 0.117) were not significantly associated with LP. Strong association was observed between oral LP and hypothyroidism. All patients screened for anti-HCV antibodies were found to be negative. CONCLUSION: There is a clear associationof LP with dyslipidemia and diabetes mellitus. Screening for dyslipidemia and diabetes mellitus in all patients of LP will help in early detection, initiation of treatment, and prevent long-term morbidity.

Pachyonychia congenita with late onset (PC tarda).

Pachyonychia congenita is a rare type of ectodermal dysplasia further classified into 4 types. Cutaneous manifestations seen in most of the cases of Pachyonychia congenita include palmoplantar keratoderma, follicular hyperkeratosis, wedge shaped nails, oral leukokeratosis and woolly hair. A 25-year-old male presented to us with thickened nails and scanty scalp hair. On examination, we noticed hyperkeratotic plaques over both the soles, palmoplantar hyperhidrosis and yellowish discoloration, wedging with subungual hyperkeratosis of all the nails. Follicular hyperkeratotic papules and steatocystoma multiplex were also observed over the scalp and face. The patient had history of natal teeth and on dental examination, lower central incisors were absent. All cutaneous changes in our case had manifested first in the 2(nd) decade except for natal teeth. All the above features suggested the diagnosis of pachyonychia congenita with late onset (PC tarda), which is an infrequently reported rare variant.

Increased prevalence of thyroid dysfunction and diabetes mellitus in Indian vitiligo patients: A case-control study.

BACKGROUND: Though it is well-known that vitiligo is associated with other autoimmune disorders, few Indian studies have focused on the relation between vitiligo, autoimmune thyroid dysfunction and diabetes mellitus. MATERIALS AND METHODS: This case-control study included 150 new cases of vitiligo and 100 age and sex-matched controls. A complete history and thorough dermatological examination was done. Serum samples from both patients and controls were collected and assayed for triiodothyronine, thyroxine, thyroid-stimulating hormone, anti-thyroid antibodies-anti-thyroid peroxidase and anti-thyroglobulin and fasting plasma glucose. RESULTS: Thyroid hormonal profile revealed autoimmune thyroid dysfunction manifesting as hypothyroidism in 30 (20%) vitiligo patients and two controls (2%). Diabetes mellitus was present in 24 (16%) vitiligo patients and five controls. Seven (4.7%) patients had both hypothyroidism and diabetes mellitus. CONCLUSION: There is a clear association between vitiligo, autoimmune hypothyroidism and diabetes mellitus. It would be very useful to screen for thyroid dysfunction and diabetes mellitus in all patients with vitiligo.

Mai infection simulating metastatic breast cancer.

We represent a case of an asymptomatic female who was found to have a mass in the right breast which confirmed an invasive ductal carcinoma by core biopsy. After 3 months of completion of chemo-radiotherapy, the patient remained totally asymptomatic. However, positron emission tomography scan showed four hypermetabolic lesions in the left lung thought to be consistent with metastatic disease. Standard uptake value ranged between 3.86 and 6; the results were consistent with metastatic breast cancer, so wedge resection was performed. Caseating granulomatous inflammation with necrosis was reported. Ultimately culture revealed Mycobacterium avium intracellulare infection. The lesions resolved completely after a course of antibiotics.

Constipation in Clostridium difficile infection.

A patient presented to our hospital with worsening shortness of breath, cough and respiratory distress that slowly worsened over 7-10 days. She had a viral-like illness with runny nose and cough for 1 week, which became productive of yellowish sputum. She was treated with antibiotic and steroid with clinical improvement. Her leucocyte count continued to increase despite discontinuation of both antibiotic and steroid. All culture results returned negative. She did not have any abdominal pain or diarrhoea. Her stool was positive for Clostridium difficile toxin assayed by PCR. A CT of abdomen showed distension of cecum and proximal colon. She was treated with intravenous metronidazole, oral and rectal vancomycin and intravenous immunoglobulin. She developed multi-organ failure and died.

Determination of oxidative stress in vitiligo by measuring superoxide dismutase and catalase levels in vitiliginous and non-vitiliginous skin.

BACKGROUND: Vitiligo is an acquired disorder characterized by circumscribed depigmented macules devoid of identifiable melanocytes. Complex genetic, immunological, neural and self destructive mechanisms interplay in its pathogenesis. According to autocytotoxic hypothesis, oxidative stress has been suggested to be the initial pathogenic event in melanocyte degeneration. AIMS: The aim of our investigation was to evaluate the role of oxidative stress by measuring levels of the antioxidant enzymes superoxide dismutase (SOD) and catalase (CAT) in lesional and normal skin of patients with vitiligo and in the skin of normal controls. METHODS: We determined the activity of SOD in lesional and non-lesional skin and CAT in lesional skin only of 25 vitiligo patients and 25 controls by using the spectrophotometric assay and Aebi's method, respectively. RESULTS: There was statistically significant increase in the levels of SOD in vitiliginous and non vitiliginous skin of patient group compared to the control group (P < 0.001). No significant difference was found between the levels of SOD in lesional skin and non-lesional skin of vitiligo patients. The levels of CAT in the skin of patients were found to be significantly lower than those of controls (P < 0.001). CONCLUSIONS: There is increased oxidative stress in vitiligo as is indicated by high levels of SOD and low levels of CAT in the skin of vitiligo patients.

Evaluation of narrow-band UVB phototherapy in 150 patients with vitiligo.

BACKGROUND: Very few studies have been performed to evaluate the efficacy and safety of narrow-band ultraviolet B (NBUVB) therapy in Indian patients with vitiligo and are of small sample size. AIMS: The purpose of this study is to know the efficacy and safety of NBUVB in 150 vitiligo patients of various age groups. METHODS: One hundred fifty patients (69 males, 81 females), aged 3-70 years, with vitiligo were treated twice weekly with NBUVB. The starting dose was 250 mJ/cm2 in adults and 150 mJ/cm2 in children, with 20% dose increments at each subsequent visit given for a maximum period of 1 year and were followed-up for 6 months for stability of repigmentation. Statistical methods were employed to establish the relation between the response and the number of exposures, duration of treatment, cumulative dose and the compliance. RESULTS: Analysis of our study showed that a majority of our cases, about 73, achieved 25-75% repigmentation, with an average of 51+/-19 exposures, 51 had <25% repigmentation, with an average of 19+/-11 exposures and 26 had >75% repigmentation, with an average of 74+/-24 exposures. Good response to therapy was directly associated with good compliance, more number of exposures and increasing cumulative dose, which was statistically significant (P<0.01). Adverse effects were minimal. Only three patients developed depigmentation of repigmented sites during follow-up. CONCLUSION: Our study proves that NBUVB therapy is an effective and safe tool in the management of vitiligo, with good stability of repigmentation and cosmetic appearance.

Herpes simplex virus 2 infection: a risk factor for HIV infection in heterosexuals.

BACKGROUND: Genital ulcerative disease is one of the risk factors for acquisition of HIV. As HSV-2 infection is currently the most common cause of genital ulcerative disease, it acts as a potential risk factor for HIV infection. The present study was undertaken to know the seroprevalence of antibodies to HSV-2 in HIV seropositive individuals and in the general population, and to ascertain if HSV-2 is a risk factor for developing HIV infection. METHODS: The study group included one hundred new HIV seropositive persons irrespective of active genital herpes or history of genital herpes. Fifty age- and sex- matched healthy volunteers were included as controls. In all patients and controls, diagnostic serology was done for HSV-2 using HSV-2-specific glycoprotein IgG2 by indirect immunoassay using the ELISA test. Statistical value 'P' was calculated using the Chi-squared test. RESULTS: Out of the 100 HIV seropositives, 66 were males and 34 were females with an age range of 20-54 years. In only 22 (19 males and 3 females) of these, positive history of genital herpes was obtained. In 49 out of the 100 HIV seropositives, IgG2 antibodies against HSV-2 were detected. In the control group, 11 out of 50 controls were seropositive for HSV-2 IgG2 antibody. There was a statistically significant association between HSV-2 and HIV seropositivity with 'P' value CONCLUSION: The high prevalence of HSV-2 seropositivity in the HIV-infected group (49%) as compared to normal controls (22%) was statistically significant. Prior HSV-2 infection could be an important risk factor for acquisition of HIV in our patients.

Forehead plaque: a cutaneous marker of CNS involvement in tuberous sclerosis.

BACKGROUND: Tuberous sclerosis complex (TSC) is a neurocutaneous genodermatosis characterized by hamartoma formation in multiple organs. There are no definite cutaneous markers suggestive of central nervous system (CNS) involvement in TSC. AIMS: To study association of forehead plaque seen in tuberous sclerosis patients and CNS involvement in TSC. METHODS: This is a retrospective study of 15 cases of tuberous sclerosis in varying age groups - from 1.5 to 50 years. All the cases were thoroughly evaluated with detailed history; clinical examination; and relevant investigations like X-rays of chest, skull, hands and feet; ultrasound abdomen and computed tomography of brain. RESULTS: Out of the 15 cases, CNS involvement was seen in 8 cases. Seizures were present in 8 cases (53.33%) and mental retardation was seen in 6 cases (40%). Computerized tomography of brain revealed subependymal nodules (SENs) in eight cases (53.33%). In addition to SENs, subependymal giant cell astrocytomas and cortical tubers were seen in 2 cases each. Out of these 8 cases having CNS involvement, in 7 cases forehead plaque was observed. In 1 case, no forehead plaque was observed (X 2 = 1.07, P < 0.05). CONCLUSION: This study shows that there is a statistically significant relationship between the presence of a forehead plaque and CNS involvement in TSC. Therefore, forehead plaque may be considered as a novel cutaneous marker to know the CNS involvement in TSC at an early stage.

Acute and sub-chronic functional neurotoxicity of methylphenidate on neural networks in vitro.

Methylphenidate (MPH) is the drug of choice in the treatment of attention deficit and hyperactivity disorders. Although a popular drug, concentration-dependent electrophysiological alteration or impairment (functional toxicity) and reversibility, have not been quantified. This study used spontaneously active neuronal networks growing on microelectrode arrays (MEA) to investigate functional neurotoxicity of MPH by assessing its acute and sub-chronic electrophysiologic effects on auditory cortex networks (ACN) and frontal cortex networks (FCN) at concentrations that reflect clinical doses and overdoses. Acute exposure to 1-300 microM MPH induced concentration-dependent inhibition of spontaneous activity with spike rate IC(50) values (concentration inducing 50% inhibition) of 112.9 +/- 18.6 and 108.0 +/- 18.9 microM for ACNs and FCNs respectively. Sub-chronic exposure to 1 mM MPH for 24 h blocked all activity followed by partial spontaneous recovery after 15 h. Tyrosine hydroxylase immunocytochemistry analysis indicated positive staining of neurons, confirming the presence of catecholaminergic neurons in cultured cortex networks.

Vitiligo: a part of a systemic autoimmune process.

BACKGROUND: Recent clinical and animal experimental studies postulate that the pathogenetic mechanisms of vitiligo could be of systemic origin as vitiligo is associated with ocular and auditory abnormalities as well as other autoimmune disorders.Hence, we studied genetic factors, systemic associations, ocular and auditory abnormalities of vitiligo. METHODS: The study group included 150 new cases of various types of vitiligo. One hundred age- and sex-matched nonvitiligo cases were included as controls in the study. A complete family history was taken for all patients. Examination was carried out taking note of the type of vitiligo and approximate percentage of body surface involved. All relevant laboratory investigations, a thorough audiological examination including pure tone audiometry and a complete ophthalmologic examination were carried out in all patients and controls. Statistical analysis was done using the Chi square test. RESULTS: Fifty-four vitiligo patients (36%) had a family history of vitiligo. Anemia was present in 30 (20%) vitiligo patients but only in five (5%) controls, a difference that was statistically significant (c2 = 15.8, P < 0.001). Diabetes mellitus was present in 24 (16%) vitiligo patients and only 2 (2%) of controls (Chi square, c2 = 12.4, P < 0.001). Hypothyroidism and alopecia areata were present in 18 (12%) and 11 (7.4%) vitiligo patients respectively and none of the controls. Hypoacusis was seen in 30 (20%) vitiligo patients and two (2%) controls (c2 = 8.19, P < 0.005). Twenty-four vitiligo patients (16%) and five controls (5%) had specific ocular abnormalities like uveitis, iris and retinal pigmentary abnormalities (c2 = 7.39, P < 0.001). CONCLUSION: This study demonstrates statistically significant clinical evidence confirming that vitiligo is a part of systemic autoimmune process.

An outbreak of cutaneous anthrax in a non-endemic district--Visakhapatnam in Andhra Pradesh.

BACKGROUND: Anthrax is a disease of herbivorous animals, and humans incidentally acquire the disease by handling infected dead animals and their products. Sporadic cases of human anthrax have been reported from Southern India. METHODS: Five tribal men presented with painless ulcers with vesiculation and edema of the surrounding skin on the extremities without any constitutional symptoms. There was a history of slaughtering and consumption of a dead goat ten days prior to the development of skin lesions. Clinically cutaneous anthrax was suspected and smears, swabs and punch biopsies were taken for culture and identification by polymerase chain reaction (PCR). All the cases were treated with intravenous followed by oral antibiotics. Appropriate health authorities were alerted and proper control measures were employed. RESULTS: Smears from the cutaneous lesions of all five patients were positive for Bacillus anthracis and this was confirmed by a positive culture and PCR of the smears in four of the five cases. All the cases responded to antibiotics. CONCLUSION: We report five cases of cutaneous anthrax in a non-endemic district, Visakhapatnam, Andhra Pradesh, for the first time.

The I' potential of the human auditory brainstem response to paired click stimuli.

When stimulated with an appropriate stimulus, the hair cells of the organ of Corti depolarize, causing the release of a neurotransmitter substance, which excites afferent VIIIth nerve dendrites. It is reasonable to hypothesize that excitatory postsynaptic potentials (EPSPs) generated by the dendrites of the auditory nerve in turn initiate a compound action potential (CAP). The EPSP is thought to be the generator potential for the CAP, and may be recorded in auditory brainstem responses (ABRs) as the I' potential. Determining the anatomical origin of I' may enhance the sensitivity of the ABR technique in hair cell/dendrite/auditory nerve evaluations. Whether I' is of sensory or of neural origin is equivocal, and therefore I' is not well understood. To investigate this dilemma, ABRs were recorded from human subjects using standard and paired-click stimuli, and using subtraction methods to generate a derived ABR. Two early peaks, designated as I degree and I', occurred before wave I in the derived ABR. It was hypothesized that peaks I degrees and I' represent the summating potential and the generator potential, generated by the cochlea and VIIIth nerve dendrites, respectively.