Review of Cutaneous Blastomycosis Seen in Wisconsin.

INTRODUCTION: Blastomycosis is a fungal infection caused by Blastomyces dermatitidis that is hyperendemic in Wisconsin. It commonly presents as a pulmonary infection and frequently disseminates to the skin. Studies evaluating the presentation and diagnosis of blastomycosis with skin as a presenting sign have not been thoroughly evaluated, and understanding the most accurate way to diagnose this infection is important for earlier therapeutic intervention. METHODS: This is a retrospective chart review study of a single institution. Subjects were identified through a search of ICD-9 (International Classification of Diseases, Ninth Revision) and ICD-10 (International Classification of Diseases, Tenth Revision) codes for blastomycosis in the clinical record and pathology database. Patients were included if diagnosed with cutaneous blastomycosis infection or involvement of the skin from systemic infection from January 1, 2009, to June 1, 2021. RESULTS: Twenty patients with a diagnosis of cutaneous involvement of blastomycosis were identified; 65% (n = 13) were male. Median age of diagnosis was 55.5 years. Fifty-five percent of patients were White, 35% were Black or African American. In addition to residence in an endemic area, 50% (n = 10) had exposure risk factors. Fifty percent of patients (n = 10) initially presented with a skin concerns; 65% (n = 13) had extracutaneous involvement. Diagnosis was made by histopathology alone in 55% (n = 11), culture plus histopathology in 35% (n = 7), and culture alone in 5% (n = 1) of cases. CONCLUSIONS: Our study highlighted similarities to those previously performed. Half of the patients (n = 10) who had cutaneous involvement of blastomycosis did not demonstrate clinically significant pulmonary involvement. Histopathology and culture remain critical in diagnosing cutaneous blastomycosis.

Clinical Characteristics, Disease Course, and Outcomes of Patients With Acute Generalized Exanthematous Pustulosis in the US.

Importance: Acute generalized exanthematous pustulosis (AGEP) is a rare, severe cutaneous adverse reaction associated with systemic complications. Currently available data are largely limited to small retrospective case series. Objective: To describe the clinical characteristics, disease course, and outcomes of a heterogeneous group of patients with AGEP across the US. Design, Setting, and Participants: A retrospective review of a case series of patients was conducted from January 1, 2000, through July 31, 2020. All 340 included cases throughout 10 academic health systems in the US were scored retrospectively using the EuroSCAR scoring system, and patients with a score corresponding to probable or definite AGEP and aged 18 years or older were included. Main Outcomes and Measures: Patient demographic characteristics, clinical course, suspected causative agent, treatment, and short- and long-term outcomes. Results: Most of the 340 included patients were women (214 [62.9%]), White (206 [60.6%]), and non-Hispanic (239 [70.3%]); mean (SD) age was 57.8 (17.4) years. A total of 154 of 310 patients (49.7%) had a temperature greater than or equal to 38.0 °C that lasted for a median of 2 (IQR, 1-4) days. Of 309 patients, 263 (85.1%) developed absolute neutrophilia and 161 patients (52.1%) developed either absolute or relative eosinophilia. Suspected causes of AGEP were medications (291 [85.6%]), intravenous contrast agents (7 [2.1%]), infection (3 [0.9%]), or unknown (39 [11.5%]). In 151 cases in which a single medication was identified, 63 (41.7%) were ß-lactam antimicrobials, 51 (33.8%) were non-ß-lactam antimicrobials, 9 (6.0%) were anticonvulsants, and 5 (3.3%) were calcium channel blockers. The median time from medication initiation to AGEP start date was 3 (IQR, 1-9) days. Twenty-five of 298 patients (8.4%) had an acute elevation of aspartate aminotransferase and alanine aminotransferase levels, with a peak at 6 (IQR, 3-9) days. Twenty-five of 319 patients (7.8%) experienced acute kidney insufficiency, with the median time to peak creatinine level being 4 (IQR, 2-5) days after the AGEP start date. Treatments included topical corticosteroids (277 [81.5%], either alone or in combination), systemic corticosteroids (109 [32.1%]), cyclosporine (10 [2.9%]), or supportive care only (36 [10.6%]). All-cause mortality within 30 days was 3.5% (n = 12), none of which was suspected to be due to AGEP. Conclusions and Relevance: This retrospective case series evaluation of 340 patients, the largest known study cohort to date, suggests that AGEP onset is acute, is usually triggered by recent exposure to an antimicrobial, may be associated with liver or kidney complications in a minority of patients, and that discontinuation of the triggering treatment may lead to improvement or resolution.

Evaluation of a Case Series of Patients With Generalized Pustular Psoriasis in the United States.

IMPORTANCE: Generalized pustular psoriasis (GPP) is a chronic, orphan disease with limited epidemiological data. OBJECTIVE: To describe the clinical characteristics, treatments, longitudinal disease course, and disease-specific health care utilization among patients with GPP across the United States. DESIGN, SETTING, AND PARTICIPANTS: A retrospective longitudinal case series involving 95 adults who met the European Rare and Severe Psoriasis Expert Network consensus definition for GPP and were treated at 20 US academic dermatology practices between January 1, 2007, and December 31, 2018. MAIN OUTCOMES AND MEASURES: The primary outcome is to describe the patient characteristics, associated medical comorbidities, treatment patterns complications, and GPP-specific health care utilization. RESULTS: Sixty-seven of 95 patients (70.5%) were women (mean age, 50.3 years [SD, 16.1 years]). In the initial encounter, 35 patients (36.8%) were hospitalized and 64 (67.4%) were treated with systemic therapies. In total, more than 20 different systemic therapies were tried. During the follow-up period, 19 patients (35.8%) reported hospitalizations at a median rate of 0.5 hospitalizations per year (IQR, 0.4-1.6). Women had a decreased risk of an emergency department or hospital encounter (odds ratio, 0.19; 95% CI, 0.04-0.83). CONCLUSIONS AND RELEVANCE: Generalized pustular psoriasis is a rare, chronic disease without standard treatment and is associated with continued health care utilization over time.

Evaluation of a Case Series of Patients With Palmoplantar Pustulosis in the United States.

IMPORTANCE: Palmoplantar pustulosis (PPP) is a is a chronic, orphan disease with limited epidemiological data. OBJECTIVE: To describe the clinical characteristics, treatments, longitudinal disease course, and health care utilization in adults with PPP across the US. DESIGN, SETTING, AND PARTICIPANTS: This retrospective, longitudinal case series from 20 academic dermatology practices in the US included a consecutive sample of 197 adults who met the European Rare and Severe Psoriasis Expert Network consensus definition for PPP between January 1, 2007, and December 31, 2018. Data analysis was performed June 2020 to December 2020. MAIN OUTCOMES AND MEASURES: The primary outcome was to describe the patient characteristics, associated medical comorbidities, treatment patterns, complications, and PPP-specific health care utilization. RESULTS: Of 197 patients, 145 (73.6%) were female, and the mean (SD) age at presentation was 53.0 (12.6) years, with a mean (SD) follow-up time of 22.1 (28.0) months. On initial presentation, 95 (48.2%) patients reported skin pain, and 39 (19.8%) reported difficulty using hands and/or feet. Seventy patients (35.5%) were treated with systemic treatments, and use of more than 20 different systemic therapies was reported. In patients with at least 6 months of follow-up (n = 128), a median (IQR) of 3.7 (4-10) dermatology visits per year were reported; 24 (18.8%) patients had 5 or more visits during the study period. CONCLUSIONS AND RELEVANCE: In this case series, PPP was associated with persistent symptoms, continued health care utilization, and a lack of consensus regarding effective treatments, emphasizing the unmet medical need in this population. Additional research is necessary to understand treatment response in these patients.

Cutaneous Manifestations of Chronic Liver Disease.

Given the visibility of cutaneous findings, skin manifestations are often a presenting symptom of underlying systemic disease, including chronic liver disease. Many cutaneous signs and symptoms that correlate with chronic liver disease are common physical examination findings in patients with no history of liver disease. It is nonetheless important to be aware that these cutaneous findings may be an indication of underlying liver disease and often occur in the setting of such hepatic dysfunction. This article covers general cutaneous signs that may correlate with various liver diseases and describes specific cutaneous signs as they relate to more specific liver diseases.

Rapidly Enlarging Malignant Proliferating Trichilemmal Tumor in a Young Female

Malignant proliferating trichilemmal tumors are rare adnexal neoplasms that most commonly occur on the scalp in elderly women. These tumors are associated with recurrence and even nodal or distant metastatic spread. Here we describe a 38-year-old patient who presented with a scalp nodule that was diagnosed as a high-grade malignant proliferating trichilemmal tumor. J Drugs Dermatol. 2018;17(12):1325-1327.

"I am a Muslim and My Dad is an Alcoholic -- What Should I Do?": Internet-Based Advice for Muslims about Alcohol.

This article analyzes 113 fatwas (pieces of advice from Muslim scholars) in response to Internet user-contributed questions about correct behavior in situations involving alcohol. The fatwas are from IslamOnline.net, a popular Islamic Web site. Most of the questions on the English site are submitted by individuals living in non-Muslim countries, who are more likely to confront difficult situations relating to alcohol. In spite of the general condemnation of alcohol consumption in Islam, many individuals face ethical dilemmas and feel the need to request advice about proper behavior in situations involving alcohol, relating to the family, society, work, and bodily purity, as well as more abstract theological questions.