Abhishek De

Chronic venous ulceration of leg associated with peripheral arterial disease: an underappreciated entity in developing country

Chronic venous ulcer can often be associated with asymptomatic peripheral arterial disease (PAD), which usually remains undiagnosed adding significantly to the morbidity of these patients. The Ankle‐Brachial Pressure Index (ABPI) is suggested for PAD evaluation. Many PAD studies were conducted in western countries, but there is a scarcity of data on the prevalence of PAD in clinical venous ulcer patient in developing countries. We conducted a study in a tertiary care hospital of eastern part of India to find out the prevalence of PAD in venous ulcer patients, and also to find the sensitivity of ABPI as a diagnostic tool in these patients. We evaluated clinically diagnosed patients with venous ulcer using ABPI and Colour Doppler study for the presence of PAD. Possible associations such as age, sex, body mass index (BMI), smoking, hypertension and atherosclerosis were studied. All results were analysed using the software Statistica version 6. PAD was present in 23 (27·71%) patients. Older age, longer duration, smoking, high BMI and hypertension were found to be significantly associated with PAD. A very strong level of agreement was found between venous Doppler and ABPI. Assessment for the presence of PAD is important in all clinically diagnosed venous ulcer patients. ABPI being a simple, non‐invasive outpatient department (OPD)‐based procedure, can be routinely used in cases of venous ulcer to find out the hidden cases of PAD even in developing countries.

A curious case of sweating blood

Hematohidrosis is a very rare condition in which an individual sweats blood. It may occur in an individual who is suffering from extreme levels of stress. Various causative factors have been suggested like component of systemic disease, vicarious menstruation, excessive exertion, psychogenic, and unknown causes. Fear and intense mental contemplation are the most frequent causes. It may also occur in bleeding disorders. We here report a case where bloody sweat was discharged from the forehead, face, and body episodically in a 12-year-old healthy girl with no bleeding disorder or any other underlying cause. All investigations done were within normal limits, except low intelligent quotient and loss of insight. The patient was given atropine sulphate transdermal patch with marked improvement in severity.

Idiopathic non-familial Acro-osteolysis: A rare case report

A 25-year-old woman patient presented with shortening of fingers with racket nails and numerous yellowish papules over the hands and forearms for 21 years. X-ray of the hands revealed destructive osteolytic changes in all the terminal phalanges. Skin biopsy from the yellowish papules showed epidermal proliferation, perivascular mononuclear infiltrate, thickening of dermal collagen, septal fibrosis and loss of adipocytes mimicking sclerodermatous changes in the dermis and hypodermis. The patient did not have any history of similar illness in the family or occupational exposure to vinyl chloride. After excluding all other possibilities of acral-osteolysis, we diagnosed the case as idiopathic non-familial variety of acro-osteolysis. This is a rare entity characterized by terminal resorption of fingers, sometimes associated with Raynauds phenomena and yellowish cutaneous papules.

Unique TTC repeat base pair loss mutation in cases of pure neural leprosy: A survival strategy of Mycobacterium leprae?

Background: Genomic reduction helps obligate intracellular microbes to survive difficult host niches. Adaptation of Mycobacterium leprae in cases of pure neural leprosy (PNL) in the intracellular niche of peripheral nerves can be associated with some gene loss. Recently, a stable but variable number of tandem repefzats (TTC) have been reported in strains of M. leprae. FolP and rpoB genes are the two common mutation sites which deal with the susceptibility of the bacteria to drugs. Aim: We attempted to find if genomic reduction of M. leprae in context of these TTC repeats or mutations in folP1 and rpoB can be the reason for the restriction of M. leprae in the nerves in PNL. Materials and Methods: DNA extracts taken from fine needle aspiration of affected nerves of 24 PNL cases were studied for tandem repeats with 21TTC primer in multiplex-PCR. Mutations were also studied by PCR Amplification of SRDR (Sulphone Resistance Determining Region) of the folP1 and multiple primer PCR amplification refractory mutation system (MARS) of the rpoB. Results: Of the 24 PNL, only 1 patient showed mutation in the rpoB gene and none in the folp1 gene. Studying the mutation in TTC region of the M. leprae gene we found that all the cases have a loss of a few bases in the sequence. Conclusion: We can conclude that there is consistent loss in the bases in the TTC region in all cases of pure neural Hansen and we postulate that it may be an adaptive response of the bacteria to survive host niche resulting in its restriction to peripheral nerves.

Does the Benefit of Salvage Amputation Always Outweigh Disability in Drug­ Failure Mycetoma?: A Tale of Two Cases

It is popularly believed that eumycetoma cases should be dealt with using surgical amputation for a better chance of cure especially when chemotherapy has failed. However, amputation leads to disability on one hand and on the other it may also fail to be curative. We present two cases with contrasting treatment options and outcome. In the eumycetoma case reported here, a 40-year-old male presented with right foot swelling for 16 years, from which Scedosporium apiospermum was isolated. He responded poorly to antifungal therapy and refused below-knee amputation 12 years ago. With counseling and wound care his condition improved, and Foot and Ankle Ability Measure (FAAM) score remained almost stable at 90% for 16 years, which is much better than the average functional outcome after amputation. Another 46-year-old female underwent below-knee amputation after receiving incomplete courses of antibiotics and antifungals for mycetoma of unknown etiology. She presented to us after recurrence of mycetoma on an amputated stump and was successfully treated by proper courses of antibiotics after detecting the causal agent, Actinomadura madurae. Her post-amputation disability and depression could have been avoided if the hasty decision of amputation had not been taken. In our opinion, living with drug-non-responsive mycetoma, supported by symptomatic management, may be a better option than amputation and its associated morbidities. So before taking the path of salvage amputation, we must consider many aspects, including patients livelihood, psychological aspects and chances of recurrence even after the procedure.

A case of ichthyosis hystrix: Unusual manifestation of this rare disease

Ichthyosis hystrix is a term used to describe an ichthyosiform dermatosis which is characterized by hyperkeratotic spiny scales mainly over extensor aspects of limbs with palmoplantar keratoderma and occasionally associated with deafness and neurological deficit. It is a rare autosomal dominant form of ichthyosis and very few cases are reported in literature. We are presenting a 46 years-old-male patient of ichthyosis hystrix with unusual presentation. He had lesions mainly over the face and scalp with palmoplantar keratoderma and significant nail changes.

In-depth molecular analysis of a small cohort of human and Aedes mosquito (adults and larvae) samples from Kolkata revealed absence of Zika but high prevalence of dengue virus

Purpose. Zika virus infections have recently been reported in many dengue‐endemic areas globally. Both dengue (DENV) and Zika (ZIKV) virus are transmitted by Aedes mosquitoes, raising the possibility of mixed infections in both vector and host. We evaluated DENV and ZIKV prevalence in human and vector samples in Kolkata, a DENV‐endemic city. Methodology. Blood samples were collected from 70 patients presenting dengue‐like fever symptoms at a hospital in Kolkata during 2015–16. Serum was obtained and tested for DENV infection by DENV NS1‐based ELISA. Adult (n=8) and larval stages (n=12) of Aedes were also collected. A RT‐PCR‐based screening of both viruses supplemented by amplicon sequencing was performed. Results. Of the 70 samples, 20 DENV NS1‐positive serum samples were used for detailed molecular study for DENV infection. Eighteen of these (90 %) were positive by hemi‐nested serotype‐specific RT‐PCR for DENV1/2/3, with four samples showing evidence of DENV2–3 or DENV1–3 mixed infection. None were ZIKV‐positive using NS5 or ENV‐based PCR, though weak amplification of a DENV1 NS5 sequence was detected in three serum samples indicating cross‐reactivity of the primers. All mosquito samples were ZIKV‐negative, whereas 5/8 (63 %) of adult mosquitoes and 11/12 (92 %) of larvae were DENV3‐positive. Conclusion. Both host and vector samples showed absence of ZIKV but high prevalence of DENV. The high rate of infection of larvae with DENV is suggestive of trans‐ovarial transmission that could contribute to the surge of human infections during each post‐monsoon season. It would be important to guard against false positives using the available Zika‐reporting primer sets.

“Turban PUVAsol:” A simple, novel, effective, and safe treatment option for advanced and refractory cases of alopecia areata

Background: Alopecia areata (AA) is an autoimmune characterized by nonscarring loss of scalp and/or body hairs. Topical PUVA has been reported to have good effect in AA. The modification of topical PUVA which we call, “Turban PUVA-sol,” is a method of localized immunotherapy using psoralen solution followed by sun exposure. Aims: We aim to study the therapeutic role and side effect profile of turban PUVA in the treatment of advanced and refractory AA. Methodology: Fifteen consecutive patients of alopecia subtotalis (at least 70% of scalp hair loss), totalis, and universalis, attending the dermatology outpatient department of a tertiary care hospital in eastern India were subjected to “Turban PUVA-sol” after duly signed consent. Alternate day therapy was given. Results: At the end of 10 months of study, 2 (13%) out of fifteen patients were lost to follow-up for some unknown reasons. The severity of alopecia tool scores showed a significant (P = 0.0002) decrease posttreatment. Correlation between the severity of alopecia and grade of improvement showed a rho value of −0.453. In the remaining thirteen patients, using physician global assessment (PGA), 4 (26%) showed good response, 4 (26%) showed moderate response, 3 showed mild (20%) response, and 2 patients (13%) showed negligible response. Three out of four patients who showed good improvement in PGA showed more than 80% of new hair growth. Side effects are minimal with some patients complaining of mild irritation and scaling. Conclusion: We found topical Turban PUVAsol to be a very cost-effective and safe treatment option for AA.

Occult hepatitis B virus infections (often with human herpesvirus 7 co-infection) detected in Pityriasis rosea patients: A pilot study

Background: The etiopathogenesis of Pityriasis rosea (PR), a papulo-squamous skin disease, remains elusive and hypothesized to be caused primarily by human herpesvirus (HHV) 6 or 7 or immune dysfunction. Aims: The recent increasing incidences of hepatitis B virus (HBV) infections, including asymptomatic occult HBV infections (OBIs), in a densely populated city in India, prompted us to investigate whether PR patients (from varied socioeconomic and immune status) harbor the underlying HBV infections. These cases were also investigated for HHV 6 and 7 infections. Materials and Methods: DNA from ethylenediaminetetraacetic acid blood samples from PR-diagnosed individuals (n = 13; mostly young adults) and healthy controls (n = 11) were subjected to virus gene-specific polymerase chain reactions (PCRs) for HBV and HHV 6 and 7. PCR products of expected length, when observed, were sequenced (bidirectional) using overlapping primers. Sequences were identified by NCBI BLAST and analyzed by multiple sequence alignment and phylogenetic studies. The blood samples were tested for HBsAg by EIA. Results: In 5/13 PR samples, only HBV DNA (4/5 being HBsAg negative) was detected, providing first-time evidence that PR may be manifested in asymptomatic HBV carriers. 6/13 cases were HHV 7 (not HHV 6) DNA positive, providing confirmatory molecular genetic evidence for the first time of PR association with HHV 7 from India. Surprisingly, 5/6 HHV 7-positive PR cases were also HBV positive. Overall, 10/13 PR samples showed evidence of HBV infection. 8/13 were OBI, harboring at least one OBI-signature S protein mutation. All healthy controls were HBsAg EIA and PCR negative. Conclusions: 77% of PR patients presented the evidence of underlying HBV infection (genotype D2), suggestive of horizontal HBV transmission. This warrants for mass HBV vaccination. PR patients should be tested for underlying virus infections for appropriate therapy and management.

Zinc-responsive acral hyperkeratotic dermatosis-A novel entity or a subset of some well-known dermatosis?

Background: We are reporting a series of interesting cases, which presented to us with psoriasiform lesions distributed over the acral regions of the body. The cases are unusual because they were resistant to conventional treatment modalities like topical corticosteroids, tacrolimus and oral methotrexate but showed significant improvement on oral zinc therapy. Materials and Methods: Ten patients with characteristic clinical features of distinctive hyperkeratotic plaque in the acral areas, who were resistant to treatment by different modalities including potent topical steroids and oral methotrexate, were included for detailed investigations. A proper history was taken and relevant laboratory investigations were done which included blood count, urine, liver function, renal function, hepatitis-C virus serology and serum zinc levels. Patients were followed up every 2 weeks. Histopathological examinations of the lesional tissue were done at baseline and after 6 weeks of therapy. Patients were given oral zinc daily and no other treatment during the 6 weeks course. Results: All our patients were non-reactive to hepatitis-C. Of the ten patients only one patient (10%) showed low titer of serum zinc, another (10%) showed higher zinc level, while the rest of the patients had normal zinc level. Five of our patients had chronic renal failure, one had Graves disease and the remaining had no associated systemic illness. Histopathology mostly showed hyperkeratosis, acanthosis, prominent granular layer, spongiosis and dermal infiltrate. After 6 weeks of follow up, all patients showed rapid and remarkable therapeutic response with zinc. Conclusions: We here report a series of patients, discernible because of their uniform clinical presentation of acral hypekeratotic plaques and in showing a noticeable response to zinc. Clinical, histopathological and laboratory investigations were done to rule out diseases of similar morphology including psoriasis, acral necrolytic erythema and lichen simplex chronicus. Authors understand that further studies with greater number cases and more detailed investigations are required to establish exact etio-pathogenesis and nomenclature of this distinct subset of patients.