Challenges in culture-negative cases of Madurella mycetomatis: A case report re-accentuating PCR as an essential diagnostic tool.

Identification of dematiaceous fungi responsible for black-grain mycetoma has remained cumbersome and time consuming for years leading to delayed diagnosis and thereby increased agony to patients. Moreover, difficult morphology of some of these fungi demanding enough expertise for species identification in addition to culture-negativity has often led to misdiagnosis and hence inapt treatment to the patients. We report the identification of Madurella mycetomatis from culture-negative black granules discharged from foot nodular lesions of a 27 years old male using PCR followed by sequencing of the internal transcribed spacer region. The patient's lesions were successfully treated using a combination of itraconazole (200mg) and terbinafine (250mg), confirming our diagnosis. Our case study proves the clinical value of PCR as the best, rapid and accurate diagnostic method for the identification of Madurella mycetomatis and related fungi, particularly in culture-negative cases.

Dermatitis artefacta manifesting as genital scars: a result of an unusual behaviour pattern.

A 25-year-old man, diagnosed previously with borderline personality disorder, presented with curvilinear genital scars. A meticulous history and examination led to a diagnosis of dermatitis artefacta with an atypical behaviour pattern.

Lichen planus of the external urinary meatus masquerading sexually transmitted disease.

Lichen planus is a chronic inflammatory mucocutaneous disorder of the skin including the scalp, the nails, and the oral and genital mucosae. Ocular, oesophageal, bladder, nasal, laryngeal, otic, gastric, and anal involvement has been documented. In this report, we describe a unique case of orogenital lichen planus affecting the external urinary meatus, masquerading as sexually transmitted urethritis and erosive genital disease.

Contact depigmentation induced by propyl gallate.

We report a 41-year-old woman who developed contact depigmentation at several body sites after using lipstick, liquid kumkum (a colouring usually made from turmeric or saffron used for social/religious markings), and plastic or rubber slippers (flip-flops). Propyl gallate, a common ingredient to all and a previously undocumented depigmenting agent, was incriminated on patch testing with the Indian standard series.

Myiasis arising in condylomata acuminata: an unusual presentation.

Myiasis is infestation of skin, mucosa, orifices or natural cavities of humans or animals by larvae of flying dipterous insects that, at least for a certain period of their life cycle, feed from live or necrotic tissue of the host. The distribution is worldwide with more cases being reported from tropical, subtropical and warm temperate areas. This report describes a rare case of perianal condylomata acuminata complicated with myiasis due to Chrysomya bezziana, seen in the presence of poor hygiene in a tropical country with a high fly population.

Adult onset, hypopigmented solitary mastocytoma: report of two cases.

Solitary mastocytoma is known to occur predominantly in children below 2 years of age and onset in adulthood is rare. Lesions are hyperpigmented in the majority of cases owing to the stimulation of melanin synthesis by mast cell growth factor. We hereby report two patients with adult onset solitary mastocytoma presenting as hypopigmented plaque. The first case was a 24-year-old man who presented with a plaque on the back of the neck of 5 years duration. The second case was a 30-year-old man who had a well-defined solitary, oval 3 x 2.5 cm plaque on the nape of the neck. Stroking of lesion resulted in a wheal with flare (Darier's sign) in both cases. Systemic examination was within normal limits in both cases. Histopathology revealed a dense toluidine blue-positive infiltrate of mast cells in the upper dermis in both cases.

Lepromatous leprosy with bilateral facial nerve palsy and hyperthyroidism.

Bilateral lagophthalmos secondary to facial nerve is extremely uncommon. Further, the aetiology in most of these cases is of central origin unlike the peripheral involvement in leprosy. A patient of lepromatous leprosy (LL) may be euthyroid or hypothyroid on account of leprous involvement of the thyroid gland. A case of LL with bilateral lagophthalmos and hyperthyroidism is reported.

Eyelid involvement in disseminated chronic cutaneous lupus erythematosus.

Eye involvement in chronic cutaneous lupus erythematosus (CCLE) has been reported infrequently. We describe two cases of disseminated CCLE, a 50-year-old woman and a 45-year-old man, with eyelid involvement and disease duration of 4 and 20 years respectively. The first patient showed an excellent response to chloroquine while there was lack of response in the second patient.

Involvement of genitofemoral nerve with genital lesions in lepromatous leprosy.

The case of a male patient diagnosed to have lepromatous leprosy with type 2 reaction on multibacillary multidrug therapy, with unusual, widespread involvement of genitalia in the form of plaque and nodules of leprosy over scrotum and perimeatal region of glans, necrotic lesions of erythema nodosum leprosum over scrotum, neuritis of genital branch of genitofemoral nerve bilaterally, and azoospermia, is reported.

Cutaneous tuberculosis in Indian children: the importance of screening for involvement of internal organs.

AIMS AND OBJECTIVES: Resurgence of skin tuberculosis especially with drug-resistant strains has been well documented in recent years, but this problem has not received much attention in the paediatric age group. Hence, we carried out the present study to analyse the clinical and therapeutic aspects of cutaneous tuberculosis in children. MATERIALS AND METHODS: A detailed clinical examination, investigations, such as haemogram, serology for HIV, Mantoux test, chest X-ray, cytology, culture and histopathology were carried out in all children. They were treated with antitubercular therapy (WHO regimen), and the clinical response was followed up. RESULTS: Of 142 patients with cutaneous tuberculosis, 68 were children (40 females, 28 males). These children were aged from 9 months to 14 years. The duration of the disease varied from 1 month to 6 years. Family history of tuberculosis was present in 28 (41.2%) of the patients. Scrofuloderma was the most common presentation encountered in 30 (44.1%) patients with preferential involvement of the cervical (56.2%) and inguinal (20%) regions. Fifteen (22.1%) patients had lupus vulgaris, of which the keratotic type was the most common (46.7%), 16 had lichen scrofulosorum, three had tuberculosis verrucosa cutis, and four had more than one type of tuberculosis. Involvement of the lung in 14 (20.6%), bone in seven (10.2%), and both in four (5.9%) was found. Histopathology corroborated the clinical diagnosis in 54 (80.6%), culture was positive in six (8.8%). Fifty (73.5%) patients completed the treatment with an excellent response, no multidrug resistant cases were seen. CONCLUSIONS: Cutaneous tuberculosis in children continues to be an important cause of morbidity, there is a high likelihood of internal involvement, especially in patients with scrofuloderma. A search is required for more sensitive, economic diagnostic tools. Response to treatment at 4 weeks often helps in substantiating the diagnosis of tuberculosis in doubtful cases.

Rowell's syndrome and associated antiphospholipid syndrome.

We report a 27-year-old primigravida with systemic lupus erythematosus, erythema multiforme-like lesions and a peculiar immunological pattern consisting of antinuclear antibody (speckled pattern) and rheumatoid factor, an association known as Rowell's syndrome. She also had a probable antiphospholipid syndrome as evidenced by the presence of a prolonged activated partial thromboplastin time, kaolin clotting time and thrombocytopenia.

Parakeratosis pustulosa--a distinct but less familiar disease.

Parakeratosis pustulosa (PP) is a distinct but less commonly known skin disease, which is frequently seen, in young girls. We describe the clinical and histological features of PP in a 7 month old female baby. Further, it is stressed that unless carefully looked for, this entity may be easily misdiagnosed as chronic paronychia, acrodermatitis of Hallopeau, pustular psoriasis, atopic dermatitis, tinea pedis or dry fissured eczematoid dermatitis and mistreated subsequently.

Watering can perineum--a forgotten complication of gonorrhoea.

In the modern era of broad spectrum antibiotics, urethral fistulae (watering can perineum) is one of the forgotten sequelae of chronic gonococcal infection. We report a 20-year-old unmarried male with gonococcal urethritis and two sinuses in the scrotum (watering can perineum). The micturating and retrograde urethrogram revealed mucosal irregularity and extravasation of contrast medium at the junction of bulbous and membranous urethra. Recent worldwide emergence of multidrug resistant strains of gonococci give rise to alarm. In the present scenario of HIV pandemic, ineffective treatment of patient or partner with gonorrhoea may result in development of these complications.

High incidence of treatment failure of Neisseria gonorrhoeae isolates to ciprofloxacin in male gonococcal urethritis in Delhi.

Several treatment failures and widespread antimicrobial resistance to ciprofloxacin have been documented, subsequent to its initial recommendation in 1989 as a single dose alternative therapy for gonorrhoea. Still, it continues to be part of various treatment schedules in National STD control guidelines including India. This prompted us to study the current status of this drug in the treatment of gonorrhoea. Thirty-five male patients with gonococcal urethritis were included in the study. The susceptibility to penicillin, tetracycline, ciprofloxacin and ceftriaxone was determined by Kirby-Bauer disc diffusion method and minimum inhibitory concentration (MIC) of ciprofloxacin by agar plate dilution method. The clinical and bacteriological response was assessed on day 5 after treatment with single dose ciprofloxacin, 500 mg. The sensitivity pattern of Neisseria gonorrhoeae was observed to be: ceftriaxone 100%, azithromycin 100%, tetracycline 65.7%, penicillin 40% and ciprofloxacin 5.7% by disc diffusion method. The MIC for ciprofloxacin was below 0.06 microg/mL (sensitive) in one (2.5%) isolate only. On the fifth day a large number of treatment failures (88.5%) were seen with ciprofloxacin while none was noted one week after re-treatment with ceftriaxone. The location of endemic quinolone-resistant N. gonorrhoeae (QRNG) in New Delhi has increased alarmingly, resulting in an extremely high proportion of therapeutic failures, and thus requiring appropriate alterations in the presently recommended treatment regimens.

Lupus vulgaris mimicking lichen simplex chronicus.

Cutaneous tuberculosis is not an uncommon entity but it often remains undiagnosed and is inappropriately treated due to its varied presentation. We present a 42-year-old male with lupus vulgaris in the perianal area, who was treated as lichen simplex chronicus with steroids for two years. With four drug antitubercular treatment, the patient had a dramatic response. The case is being reported because in this HIV era with the resurgence of tuberculosis, not only will there be an increase in incidence but also more involvement of atypical sites.