Management of snakebites by the staff of a rural clinic: the impact of providing free antivenom in a nurse-led clinic in Meserani, Tanzania.

In Tanzania, the impact, on clinical outcomes and treatment-seeking behaviour, of a rural, nurse-led clinic that provides free, antivenom-based treatment of snakebite envenomation was recently assessed. Data on all 85 patients who, between April 2007 and the end of 2009, received treatment for snakebite envenomation at the Snake Park clinic in Meserani, Tanzania, were collected prospectively. Although only four cases of snakebite envenomation were treated in the last 9 months of 2007, 34 such cases were treated in 2008 and 47 in 2009. The 85 snakebite cases had a mean age of 23 years and a male:female ratio of 1.4. Most of the bites occurred in the evening or at night and most also occurred during the rainy season. In some cases, the seeking of treatment from traditional healers delayed treatment at the clinic. After being bitten, the snakebite cases travelled a mean of 82 km (range=2-550 km) to reach the clinic. Thirty-two (37%) of the cases were each unable to identify the snake that had bit them. Of the bites in which the snake was identified, the puff adder (Bitis arietans) caused more (24) than any other snake. Forty-two of the snakebite cases received antivenom. Only one patient (1%), a 12-year-old girl, was believed to have died as the result of a snakebite but another six (7%) each required a skin graft or the amputation of a limb or digit. Establishment of the Snake Park clinic appears to have improved access to snakebite treatment, with cases of snakebite travelling long distances to reach the clinic (because of the lack of any other source of antivenom in Tanzania). Although the clinic is nurse-led, treatment outcomes among the snakebite victims who attend the clinic appear to be good.

Photodynamic therapy for superficial basal cell carcinoma and Bowen's disease.

Photodynamic therapy (PDT) is an effective treatment for superficial basal cell carcinoma (BCCs) and Bowen's disease. Several studies have reported complete response rates of 80-95% and an excellent cosmetic outcome. Bowen's disease and superficial basal cell carcinomas characteristically affect older patients who may also have associated difficulties with mobility. Using a portable PDT light source we were able to deliver PDT in a community setting with the aim of providing a more convenient service for patients. This randomised study confirmed that community delivered PDT is a viable treatment option and can be administered safely in the community by a trained dermatology nurse. The results from patient questionnaires suggest that community delivered PDT is more convenient to the patient, and also cost effective.

Tissue-engineered dermal skin grafting in the treatment of ulcerated necrobiosis lipoidica.

Necrobiosis lipoidica is a well recognized but comparatively rare cutaneous complication of diabetes mellitus. The aetiology is probably multifactorial with microangiopathy, immune complex formation, abnormal collagen synthesis and breakdown, and altered haemostasis all thought to play a part. Necrobiosis lipoidica often proves very resistant to treatment. We report a case of a 44-year-old woman with ulcerated necrobiosis lipoidica that healed following grafting with a tissue-engineered living dermal tissue.

Two cases of primary hyperparathyroidism associated with primary cutaneous lymphoma.

Primary hyperparathyroidism has been described previously in association with malignancy, but to our knowledge has not been reported in association with primary cutaneous lymphoma. We report two cases of parathyroid adenoma with primary cutaneous lymphoma, the first in a 42-year-old woman with CD30-negative cutaneous large cell lymphoma, and the second in a 67-year-old man with mycosis fungoides and CD30-positive anaplastic large cell lymphoma.

Unusual skin ulceration in an HIV-positive patient who had cutaneous syphilis and neurosyphilis.

We present a case of a patient coinfected with syphilis and the human immunodeficiency virus (HIV) who had unusual and severe cutaneous ulceration. The profound immune defects associated with HIV may lead to an altered clinical presentation and a more aggressive course in patients infected with Treponema pallidum. Despite non-confirmatory histological findings, we feel our patient's cutaneous ulcers probably represent superficial gummata, which have failed to resolve completely following currently accepted high-dose antisyphilis chemotherapy.

Cutaneous tuberculosis in Blackburn district (U.K.): a 15-year prospective series, 1981-95.

Data collected prospectively on all 1065 cases of tuberculosis occurring in the Blackburn district, U.K. (population 265,000), over a 15-year period have been analysed, and from these 47 cases of cutaneous tuberculosis have been identified. The most common form was scrofuloderma, skin involvement with adjacent structural disease, of which there were 26 cases (55.3%). There was no ethnic bias in this group. The eight white patients with scrofuloderma were of average age 66 years, and are thought to represent reactivation disease. Six patients (12.8%) had lupus vulgaris, four (8.5%) had metastatic tuberculosis and 10 (21.3%) were diagnosed as having one of the tuberculides, of which Bazin's disease (erythema induratum) was the most common. In addition, one patient (2.2%) had orificial tuberculosis. In contrast to scrofuloderma, all other forms of cutaneous tuberculosis occurred almost exclusively in patients from the Indian Subcontinent (ISC). The high incidence of tuberculosis in Blackburn is mainly linked to its significant proportion of residents of ISC ethnic origin. There were no cases of HIV infection coexisting with either cutaneous or other forms of tuberculosis. Recommendations for the treatment of cutaneous tuberculosis are made.

Factitious purpura.

Factitious purpura may present as a perplexing problem for the dermatologist and can mimic serious disease. This form of mechanical purpura, often caused by suction may be deliberately or unknowingly induced by the patient. Some cases may go unrecognized for a considerable length of time and undergo unnecessary investigation before the diagnosis is realized. Three cases of purpura are reported in which the causative agents were very different.

Harvest mites--a present from the Lake District.

A case of harvest-mite infestation acquired in the South Lakeland area is described in a 7-year-old boy and his immediate family. The characteristic papular urticarial lesions produced are extremely florid and may cause diagnostic problems when patients present in areas where the mite is uncommon. The life cycle of the harvest mite is discussed and recommendations for treatment given.

Lichen sclerosus et atrophicus following radiation therapy.

Several years after postmastectomy radiation therapy, lichen sclerosus et atrophicus (LSA) developed in two patients within the radiation fields. This sequence, to our knowledge, has not previously been described. The etiology of LSA is largely unknown, but trauma has been implicated as a provoking factor in some cases, and LSA might be an isomorphic response to the trauma of radiation therapy.

Multicentric pigmented Bowen's disease of the genitalia associated with carcinoma in situ of the cervix.

A case of multicentric pigmented Bowen's disease in a 45 year old woman with a previous history of carcinoma of the cervix is described. The two conditions may have a common pathogenesis, and a preceding viral infection with herpes simplex or human papillomavirus could be of aetiological relevance. Patients with multicentric pigmented Bowen's disease may be at risk of developing other tumours of the genital tract. Treatment with carbon dioxide laser proved effective.

Early diagnosis of infantile seborrhoeic dermatitis and atopic dermatitis--clinical features.

In a prospective study of thirty-seven infants presenting with dermatitis in infancy it was found that pruritus, a positive family history of atopy, and the age of onset of skin lesions were of little value in distinguishing atopic dermatitis from infantile seborrhoeic dermatitis. The most useful distinguishing features were the increased incidence of lesions on the forearms and shins in atopic dermatitis, and in the axillae in infantile seborrhoeic dermatitis. The onset of skin lesions solely in the napkin area favoured a diagnosis of infantile seborrhoeic dermatitis, but when more than one site was involved the distinction was less clear. Infantile seborrhoeic dermatitis carried a much better prognosis than atopic dermatitis. In thirty-six out of thirty-seven infants the definitive diagnosis could be made with confidence on clinical grounds by the age of I year, but was often difficult at first presentation in early infancy.