Aida Lugo-Somolinos

Nephrogenic Systemic Fibrosis: Change in Incidence Following a Switch in Gadolinium Agents and Adoption of a Gadolinium Policy—Report from Two U.S. Universities

PURPOSE To determine the incidence of nephrogenic systemic fibrosis (NSF) in tertiary care centers of two U.S. universities following the switch from the use of gadodiamide to gadobenate dimeglumine and gadopentetate dimeglumine, and the adoption of restrictive gadolinium-based contrast agent (GBCA) policies. MATERIALS AND METHODS Institutional review board approval with waiver of informed consent was obtained for this Health Insurance Portability and Accountability Act-compliant retrospective study. NSF patients were identified between January 2000 and December 2006 at center A and between October 2003 and February 2007 at center B (preadoption periods); and from June 2007 to June 2008 at both centers (postadoption period). The numbers of patients who underwent gadolinium-enhanced magnetic resonance at each center, patients at risk for NSF at center A, and dialysis patients at center B were identified in the pre- and postadoption periods. Gadodiamide was the only agent used in the preadoption period. Gadobenate dimeglumine and gadopentetate dimeglumine were the agents used in the postadoption period. A restrictive GBCA policy that limits the use and dose of GBCAs in patients with risk factors was adopted in the postadoption period. Follow-up lasted 9 months from July 2008 to March 2009. Corresponding incidences were determined and compared with the Fisher exact test. RESULTS Respective total benchmark incidence of NSF at both centers, at-risk incidence of NSF at center A, and dialysis incidence of NSF at center B were 37 of 65 240, 28 of 925, and nine of 312 in the preadoption period and zero of 25 167, zero of 147, and zero of 402 in the postadoption period. All three incidences demonstrated significant differences (P < .0001, .024, and .001, respectively) between the pre- and postadoption periods. CONCLUSION Following the switch from gadodiamide to gadobenate dimeglumine and gadopentetate dimeglumine, and the adoption of restrictive GBCA policies, no NSF cases were observed at either center.

Calcifying panniculitis associated with polycystic kidney disease and chronic renal failure

Tender erythematous nodules and plaques developed on the abdomen and legs of two women, 45 and 48 years of age, with hyperparathyroidism as a result of chronic renal failure caused by polycystic kidney disease. The histopathologic findings of these lesions were characterized by a calcifying panniculitis. Laboratory tests disclosed normal calcium levels and hyperphosphatemia with an elevated level of calcium phosphate product. Calciphylaxis appeared to be the mechanism of soft tissue calcification in these patients.

Quarter-Dose (0.025 mmol/kg) Gadobenate Dimeglumine for Abdominal MRI in Patients at Risk for Nephrogenic Systemic Fibrosis: Preliminary Observations

OBJECTIVE The purpose of this study is to evaluate the feasibility of 0.025 mmol/kg gadobenate dimeglumine, which is one quarter of the standard dose, for abdominal 3-T MRI studies in patients considered to be at risk for nephrogenic systemic fibrosis, using qualitative and quantitative measures and comparison with higher doses. MATERIALS AND METHODS The MRI database was retrospectively searched to select consecutive patients who underwent quarter-dose gadobenate dimeglumine-enhanced abdominal MRI at 3 T, between January 1, 2009, and January 15, 2010, and who underwent half-dose (0.05 mmol/kg) gadobenate dimeglumine-enhanced abdominal MRI at 3 T during one randomly chosen month. There were 25 patients in the final quarter-dose group (16 men and nine women; mean age, 57 years) and 44 patients in the half-dose group (21 men and 23 women; mean age, 58 years). The enhancement of abdominal organs and aorta was evaluated qualitatively and quantitatively on contrast-enhanced images. The overall quality of abdominal enhancement was also evaluated. RESULTS Reviewers rated the diagnostic enhancement of the evaluated organs in all phases of enhancement for both studied doses, but the half dose had significantly higher ratings than did the quarter dose in all comparisons (p, 0.034 to < 0.0001), except in the pancreas in the early hepatic venous phase (p = 0.095 for reviewer 1; p = 0.0611 for reviewer 2). The overall enhancement quality of the quarter dose was rated as good in all phases of enhancement, although it was significantly lower than that for the half dose (p ≤ 0.0001). The liver, pancreas, renal cortex, and aorta had 1.52-1.93-fold, 1.53-1.90-fold, 1.46-1.77-fold, and 1.58-1.84-fold, respectively, higher percentages of enhancement with the half dose than with the quarter dose (p, 0.0049 to < 0.0001). CONCLUSION A one-quarter dose of gadobenate dimeglumine at 3 T is a feasible alternative for abdominal MRI in patients at risk for nephrogenic systemic fibrosis. Our results might have important clinical implications, because greater safety may be conferred on patients with poor renal function with this low dose of contrast agent.

Pediatric Contact Dermatitis Registry Inaugural Case Data

BackgroundLittle is known about the epidemiology of allergic contact dermatitis (ACD) in US children. More widespread diagnostic confirmation through epicutaneous patch testing is needed. ObjectiveThe aim was to quantify patch test results from providers evaluating US children. MethodsThe study is a retrospective analysis of deidentified patch test results of children aged 18 years or younger, entered by participating providers in the Pediatric Contact Dermatitis Registry, during the first year of data collection (2015–2016). ResultsOne thousand one hundred forty-two cases from 34 US states, entered by 84 providers, were analyzed. Sixty-five percent of cases had one or more positive patch test (PPT), with 48% of cases having 1 or more relevant positive patch test (RPPT). The most common PPT allergens were nickel (22%), fragrance mix I (11%), cobalt (9.1%), balsam of Peru (8.4%), neomycin (7.2%), propylene glycol (6.8%), cocamidopropyl betaine (6.4%), bacitracin (6.2%), formaldehyde (5.7%), and gold (5.7%). ConclusionsThis US database provides multidisciplinary information on pediatric ACD, rates of PPT, and relevant RPPT reactions, validating the high rates of pediatric ACD previously reported in the literature. The registry database is the largest comprehensive collection of US-only pediatric patch test cases on which future research can be built. Continued collaboration between patients, health care providers, manufacturers, and policy makers is needed to decrease the most common allergens in pediatric consumer products.

A Pragmatic Approach to Patch Testing Atopic Dermatitis Patients: Clinical Recommendations Based on Expert Consensus Opinion

Allergic contact dermatitis (ACD) may complicate the clinical course of atopic dermatitis (AD), and patch testing remains the criterion standard for diagnosing ACD. To date, there have been no guidelines or consensus recommendations on when and how to patch test individuals with AD. Failure to patch test when appropriate may result in overlooking an important and potentially curable complicating comorbidity. In this article, we present consensus recommendations regarding when to perform patch testing in the AD patient, best practices, and common pitfalls. Patch testing should be considered in AD patients with dermatitis that fails to improve with topical therapy; with atypical/changing distribution of dermatitis, or pattern suggestive of ACD; with therapy-resistant hand eczema in the working population; with adult- or adolescent-onset AD; and/or before initiating systemic immunosuppressants for the treatment of dermatitis. A suggested patch testing algorithm for AD patients is provided.

Skin Cancer Knowledge and Skin Self-examinations in the Hispanic Population of North Carolina: The Patient's Perspective

T he incidence rates of melanoma in Hispanics are on the rise, and melanoma presents at a more advanced stage among Hispanics than other ethnic groups. Delay in diagnosis may be owing to a low index of suspicion for melanoma in Hispanics among both medical professionals and the Hispanic population. It has previously been shown that comprehensive skin selfexamination (SSE) may lead to earlier melanoma diagnosis. Despite this evidence, the percentage of patients in the Hispanic population performing SSE has been reported to be low, 15% compared with 32% in nonHispanic whites (NHWs). Several studies have reviewed skin cancer screening practices among Hispanics, but these studies have all been retrospective, and the conclusions are mainly speculative. Our objectives were to determine the percentage of Hispanics who undergo skin examination by a physician and perform regular SSE and to explore reasons why they might not. Additional focus was placed on participants older than 40 years because skin cancer screenings are recommended for patients in this age group owing to increased risk of melanoma with older age.

Mycobacterium immunogenum skin infections: two different presentations

Though the tuberculous variety of mycobacteria has developed greater notoriety with the general public, cases of infection with nontuberculous mycobacteria (NTM) have become a growing healthcare concern. Nosocomial outbreaks with NTM have occurred most often in association with plastic surgery procedures, abscesses at injection sites, and postoperative wound infections, particularly of the sternum. The source of the NTM can often be traced back to a hospital’s water supply, and efforts to eradicate the tenacious organism with chemicals and heat have proven difficult. Water in the natural environment has also been shown to harbor NTM and has been implicated in the pathogenesis of cutaneous infections occurring in both industrialized nations and tropical regions of the world. Although immunocompromised individuals are known to be more susceptible to NTM infections in general, a surprising number of cases in the literature describing cutaneous infection with NTM involve healthy patients with few co-morbidities. Perhaps the greatest challenge is the proper diagnosis of an NTM infection, as the clinical presentation can vary widely and a high index of suspicion must exist for a clinician to consider pursuing the culture of these fastidious organisms. We report two cases of a recently described species of NTM, Mycobacterium immunogenum, causing different skin presentations.

Patients' Perceptions of Physician Attire in Dermatology Clinics

C ompetence, trust, and approachability may be judged, at least initially, on a physician’s appearance as well as factors such as attire and verbal or nonverbal communication styles. While previously published studies have concluded that patients prefer “traditional” physician attire consisting of white coat and professional dress, other studies indicate that patients are equally satisfied with their physicians regardless of casual or business attire. Since these studies were conducted in different specialties, we thought it would be helpful to explore patients’ perceptions of physician attire in both adult and pediatric dermatology clinics.

Vitiligo-like primary melanoma.

Depigmented or hypopigmented macules and patches have been described in association to primary and metastatic melanoma. Primary melanoma presenting at the onset as a vitiliginous patch without histopathological evidence of regression seems to be a rare event. We report 2 patients with melanoma in situ that expressed clinically as vitiligo-like patches and review the possible immunologic mechanisms responsible for this unusual presentation.

Bruising and Hemorrhagic Vesicles on the Tongue.

Awoman inher 70swith recently diagnoseddiastolic heart failurewas admitted forworsening dyspnea. Her medical history was notable for hypertension and oral lichen planus. Over theprevious2 to3months, thepatient also reportedeasybruisingwithminor trauma and erosions on the lateral tongue. Findings fromphysical examination revealedperioral andperiorbital purpura, someof which she attributed to friction from her nasal cannula (Figure, A). Hemorrhagic vesicles and petechiaewere distributed over the lateral tongue (Figure, B) and buccalmucosa. Additional petechiaeandpurpurawerenotedonher lowerextremities, including inguinal fold, thigh, and crura. Laboratory values were notable for elevated serum troponin I levels of 0.144 ng/mL (to convert to micrograms per liter, multiply by 1), probrain natriuretic propeptide (BNP) levels of 14 000 pg/mL (to convert to nanograms per liter, multiply by 1), and proteinuria with hyaline casts. Biopsy specimens for histological analysis were obtained from the lower extremity petechia (Figure, C) and abdominal fat pad (Figure, D). Quiz at jamadermatology.com Photograph of hemorrhagic purpura A Photograph of hemorrhagic vesicles B