Penile Necrosis Associated with Local Intravenous Injection of Cocaine.

BACKGROUND Cocaine is a highly addictive drug and its use has increased in recent years. It is the second most popular illicit drug in the United States and is the second most trafficked illicit drug in the world. Intravenous (i.v.) drug use leads to severe injury to the veins, including erythema, thrombophlebitis, vasoconstriction, necrosis, development of venous ulceration, and vein occlusion. CASE REPORT A 35-year-old man presented to our Emergency Department with a 3-day history of excruciating and progressive penile and scrotal pain after having injected cocaine in the dorsal vein of the penis. A genital examination revealed ulcerations and swelling on the ventral proximal penis and scrotum junction, with foul-smelling serous discharge. There was no crepitus. He also had stellate purpura with necrosis of the dorsum of the penis and tender bilateral inguinal lymphadenopathy. Computed tomography of the pelvis, with contrast, showed subcutaneous edema of the penis with ulceration of the penile tip on the right. It also revealed left inguinal adenopathy. Vasculitis and concomitant sexually transmitted disease were ruled out as well as Fournier gangrene, and he was started on i.v. broad-spectrum antibiotics. The patient's clinical condition improved with antibiotics and local wound care. CONCLUSIONS Our case highlights the importance of taking a thorough history from i.v. drug users, as they are at risk of injecting drugs into unusual sites, such as the dorsal penile vein. It is important for the physician to counsel active i.v. drug users regarding possible complications of injecting drug into unusual sites.

New-onset vitiligo following mRNA-1273 (Moderna) COVID-19 vaccination.

The COVID-19 mRNA vaccines not only provide remarkable protection but also have been characterized by an overall safe and well-tolerated side effect profile. Herein, we discuss a rare but manageable cutaneous reaction to COVID vaccination in order to further characterize dermatologic reactions and stress the continued vaccination of eligible patients.

A Rare Case of DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms) Syndrome with Cholecystitis in a Patient on Levetiracetam.

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare idiosyncratic drug reaction with a mortality of up to 10%. As the name suggests, it is characterized by skin rash, eosinophilia, and systemic symptoms resulting from the involvement of visceral organs. We present a case of DRESS in a patient who was on both lamotrigine and levetiracetam, where levetiracetam turned out to be the inciting agent. The interesting features of the case include the onset of symptoms about 70 days after the initiation of levetiracetam, the lack of prominent eosinophilia and the involvement of the gall bladder, which was previously unknown with Levetiracetam. It also reinforces the importance of using the RegiSCAR score in the diagnosis of DRESS. The symptoms resolved over the next few months after drug withdrawal.

Dermatological conditions in international pediatric travelers: epidemiology, prevention and management.

With an increasing number of children traveling internationally, there has been growing interest in studying the burden of travel-associated illnesses in children. We reviewed recently published (2007-2012) studies on travel-associated illness in children, and extracted the reported spectrum of dermatological conditions in children. Dermatologic problems are among the leading health concerns affecting children during and after return from international travel. Most are mild and self-limited, but an extended spectrum of conditions has been reported from a large retrospective multicenter study. Children may be especially at risk for infections related to environmental exposures, arthropod-related problems, and animal bites. Of note are also tropical and cosmopolitan systemic infections with potential for transmission in the receiving communities. Implications for pre- and post-travel care of children are emphasized.

Differential diagnosis of round or discoid lesions.

Dermatologists are called on to diagnose a variety of skin conditions in diverse age groups. Dermatologic diagnosis, based on identification of a primary lesion, uses morphologic clues to categorize the pathologic process causing the eruption. In addition, distribution and grouping of lesions helps support a specific diagnosis. Dermatologists consciously or unconsciously use pattern recognition to arrive at their differential diagnosis based on clinical experience and their having previously viewed similarly appearing skin lesions in lectures, texts, and journals. Round and discoid patches and plaques are extremely common in the clinical practice of dermatology. This contribution reviews the dermatologic conditions that present as round or discoid lesions and presents an approach to diagnosis.

Hemophagocytic Lymphohistiocytosis in Association With Clostridium difficile Infection and Cutaneous T-Cell Lymphoma.

Hemophagocytic lymphohistiocytosis (HLH) or Macrophage Activation Syndrome (MAS) is a potentially life threatening disorder that presents with fever, suppressed blood cell counts, hepatosplenomegaly and multi-organ failure. HLH has been reported in association with genetic mutations, infections, autoimmune disorders, and various malignancies. However to the best of our knowledge, HLH in association with Clostridium difficile infection has never been reported. We present a case of HLH in a patient with Epstein-Barr virus (EBV) positive natural killer T (NKT) cell cutaneous lymphoma and active Clostridium difficile infection. A 35-year-old male with recently diagnosed EBV positive NKT cell lymphoma was admitted for Clostridium difficile associated diarrhea. During the course of hospitalization he gradually developed pancytopenia and multi-organ failure leading to death. Post-mortem examination confirmed the diagnosis of hemophagocytic lymphohistiocytosis.

Nutrition and water: drinking eight glasses of water a day ensures proper skin hydration-myth or reality?

How-to books, beauty journals, the Internet, and the media usually recommend drinking six to eight glasses of water each day for keeping the skin hydrated, helping it look healthier, and making it less prone to wrinkles. We have found no scientific proof for this recommendation; nor is there proof, we must admit, that drinking less water does absolutely no harm. The only certainty about this issue is that, at the end of the day, we still await scientific evidence to validate what we know instinctively to be true--namely, that it is all a myth.

Granular parakeratosis: response to calcipotriene and brief review of current therapeutic options.

A 34-year-old Hispanic woman presented with an 18-month history of an intermittent, asymptomatic eruption that began on her left axilla after using a depilatory cream containing corn starch and thioglycolate (Figure 1A). The eruption then spread to her right axilla and lower abdomen (Figure 1B). She reported worsening with deodorant use, but had been using the same deodorant for many years and had continued using it twice a day. Treatment with topical corticosteroids had not helped. The patient coincidentally had been started on isotretinoin 5 months previously for acne, but it had no effect on her axillary or abdominal lesions. Physical examination revealed multiple dark brown and black papules with a "stuck-on" appearance in both axillae and on the lower right abdomen. A biopsy of the left axilla revealed a thickened parakeratotic stratum corneum with retention of keratohyalin granules within the parakeratoric cells, which is considered diagnostic of granular parakeratosis (Figure 2). The patient was prescribed calcipotriene cream twice daily. After 2 weeks, she had complete resolution of the axillary lesions, but the abdominal lesions persisted. She has since had mild recurrences while using calcipotriene.

Atopic dermatitis: systemic immunosuppressive therapy.

Atopic dermatitis (AD) is a pruritic, relapsing skin disorder that negatively impacts the quality of life of those affected and that of their families. Treatment options for AD encompass a variety of emollients, topical corticosteroids, topical immunomodulators, phototherapy, and systemic agents. Such agents as systemic corticosteroids, cyclosporine, azathioprine, interferon-gamma, methotrexate, and mycophenolate mofetil have been shown to be efficacious in the treatment of moderate-to-severe AD but are not officially approved for this purpose. In this article, we review some of the data supporting efficacy of these medications and discuss some of the adverse events associated with their use.

Diagnostic dilemma: crusted scabies superimposed on psoriatic erythroderma in a patient with acquired immunodeficiency syndrome.

A 45-year-old man with AIDS presented with extensive erythema and scaling involving the face, trunk, and upper and lower extremities, and mild nail dystrophy. The patient had been diagnosed with psoriasis 2 years previously, and at the time of presentation was using emollients and topical corticosteroid creams with little improvement. He was receiving zidovudine, lamivudine, trimethoprim/sulfamethoxazole, acyclovir, rifabutin, and hydroxyzine. Pertinent laboratory data included CD4 lymphocytes (10 cells/mm(3)), viral load (32,000 copies per mL) white blood cell count (3.4 x 10(3)/microL), hemoglobin (13.5 g/dL), and platelets (204 x 10(3)/microL). Because of the extensive eruption and lack of response to topical agents, the patient was started on acitretin 25 mg daily. The patient had shown no signs of improvement 4 weeks later and was noted to have brownish gray crusted plaques involving the beard area, neck, upper part of the back, arms, trunk, genitals, and thighs in addition to his erythroderma (Figure 1 and Figure 2). Microscopic examination of scales from the upper part of the back revealed numerous scabies mites and eggs. He was then treated with lindane shampoo on the scalp and beard area and permethrin 5% cream to the body. The patient returned 2 weeks later with some improvement after thrice-weekly applications of this regimen; however, scrapings from the trunk once again revealed live scabies mites. Microscopic examination of scales that had fallen on the examination table revealed multiple mites and eggs. The patient was then given permethrin 5% cream, which he applied 3 times a week for 2 weeks, and 1 dose of oral ivermectin, 200 micro/kg. This resulted in a marked decrease in crusting and scaling. With resolution of the scabies lesions, the patient displayed marked erythema and scaling of the trunk and extremities consistent with generalized psoriasis (Figure 3). Treatment with acitretin resulted in gradual resolution of the erythroderma. A few months later, the patient presented with nodules on the upper part of the back, which on biopsy revealed a scabies mite (Figure 4).

Aggressive squamous cell carcinoma in Kindler syndrome.

A 57-year-old Hispanic man with a personal and family history of bullae and photosensitivity presented with a fungating, ulcerated squamous cell carcinoma on his left hand (Figure 1). Physical examination showed conjunctival injection, ectropion, symblepharon, urethral stricture, loss of teeth, short stature, and nail dystrophy. There was reticulated erythema, atrophy, hyperpigmentation and hypopigmentation, and telangiectasia of sun-exposed skin of the face, neck, and hands consistent with poikiloderma (Figure 2). In addition, there was foreshortening of the left thumb and sclerodermoid changes of his hands (Figure 3). Radiation therapy was applied to shrink the tumor before a local excision was performed. However, a local recurrence followed and axillary lymph nodes became clinically palpable, necessitating amputation and lymph node dissection. Extensive histologic evaluation of the specimen obtained following left arm amputation and lymph node dissection showed moderate-to-poorly differentiated deeply invasive squamous cell carcinoma. Two of 3 axillary lymph nodes were positive for metastatic carcinoma. A random biopsy of the trunk showed epidermal atrophy, telangiectasia, a perivascular lymphocytic infiltration, and pigment-laden macrophages consistent with poikiloderma. Electron microscopy illustrated extensive reduplication of the basement membrane, with loops, curls, and free extensions of the basal lamina in the superficial dermis; reduced numbers of hemidesmosomes and anchoring fibrils; and a basement membrane focally devoid of basal cells (Figure 4). On the basis of the clinical features and the characteristic basement zone changes, a diagnosis of Kindler syndrome was made.

Diltiazem induces severe photodistributed hyperpigmentation: case series, histoimmunopathology, management, and review of the literature.

BACKGROUND: Diltiazem hydrochloride is a commonly prescribed benzothiazepine calcium channel blocker for the treatment of cardiovascular disease. Recently, 8 cases of diltiazem-induced photodistributed hyperpigmentation occurring predominantly in elderly African American women were reported. Here, we report occurrence for the first time in a light-skinned African American woman and a Hispanic woman. We also report this finding in an African American man. Biopsy specimens of hyperpigmented areas were obtained for histopathologic evaluation and marker studies. Photospectrometry analysis for diltiazem was performed to analyze the photoabsorption properties of this drug. OBSERVATIONS: Routine laboratory examination results were normal in all patients. Serologic test results for antinuclear antibodies, including Sjögren antibodies anti-Ro (SS-A) and anti-La (SS-B), were negative. Histopathologic analysis of the skin biopsy specimens revealed a sparse lichenoid infiltrate, prominent pigmentary incontinence, and numerous melanophages in the dermis. There was no increase in dermal mucin suggestive of lupus. The mononuclear cells in the specimens were strongly positive for CD3, weakly positive for CD68, and either weakly positive or negative for CD79a. All specimens were negative for Alcian blue staining. Photospectrometry analysis of diltiazem showed an absorption range within the UV-B spectrum. CONCLUSIONS: Photospectrometry analysis revealed diltiazem could demonstrate a photosensitizing effect within the UV-B range. Discontinuation of therapy with diltiazem is the most effective modality in resolving hyperpigmentation. Avoidance of sun exposure and consistent use of sunscreens and sun-protective clothing are indicated for patients undergoing diltiazem therapy.

Smallpox: what the dermatologist should know.

Despite the eradication of naturally occurring smallpox in 1977, stores of the virus have been maintained in laboratories in the United States and Russia. It is feared that certain rogue states and terrorist organizations may have illicitly acquired the virus with the intent of unleashing it as an agent of bioterrorism. The United States and other nations have begun vaccinating individuals in the military and health care workers who might become exposed. Primary care providers and dermatologists will be called upon to evaluate potential index cases and vaccination reactions. In this report, the authors review the essential clinical aspects of smallpox and potential reactions to smallpox vaccination. Special attention is given to eczema vaccinatum, which can occur in vaccinees and their family contacts with active or quiescent atopic dermatitis or a personal history of eczema.

Frequency of culture-proven dermatophyte infection in patients with suspected tinea pedis.

BACKGROUND: This study examined the incidence of culture-proven tinea pedis in patients who presented with a foot rash clinically suspected to be tinea pedis. METHODS: Cultures were taken from 874 patients in 4 dermatology clinics across the country. The incidence of patients with positively cultured tinea pedis was compared with the total number of patients in the study. RESULTS: The surprisingly low percentage of patients correctly diagnosed with tinea pedis was determined to be 32%. The remaining 68% of patients either had a nonfungal foot dermatitis or tinea pedis with false-negative cultures. CONCLUSIONS: This study demonstrates the need for fungal cultures when patients present with scaling feet as well as the importance of a broad differential diagnosis to ensure timely and appropriate therapy.

Idiopathic splinter hemorrhages.

Splinter hemorrhages are non-blanchable usually distal reddish-brown linear hemorrhages beneath the nails. Among a variety of etiologic factors reported, trauma is the most common cause. A 26-year-old Hispanic female presented with asymptomatic, extensive fingernail hemorrhages of two months duration. There was no history of physical trauma to the nails. Treatment with a topical antifungal medication for one month produced no improvement. The past medical history was noncontributory. Extensive laboratory testing revealed no underlying systemic disease. Three months after the initial presentation, 6 of 10 fingernails showed signs of resolution without treatment. We conclude that idiopathic atraumatic subungual splinter hemorrhages can occur in healthy individuals. Spontaneous resolution occurred in our patient.