Amber Reck Atwater

Kikuchi's disease : Case report and systematic review of cutaneous and histopathologic presentations

Kikuchis disease, also known as histiocytic necrotizing lymphadenitis, is a systemic illness with classic clinical findings of cervical lymphadenopathy and fever. Diagnosis is confirmed by lymph node histology, which reveals paracortical foci of necrosis and a histiocytic infiltrate. Kikuchis disease has been associated with a number of infections, but no single source has been identified. Diverse, often nonspecific, cutaneous findings have been described in up to 40% of cases. Description of the histopathologic findings of skin lesions is limited to single case reports and one case series. We describe a 24-year-old woman with fevers, lymphadenopathy, hepatic and hematologic abnormalities, and a skin eruption involving the face, neck, trunk, and extremities with characteristic lymph node and cutaneous histopathologic findings. We completed a systematic review of the clinical presentations and histopathology of Kikuchis disease.

Patch Testing for Evaluation of Hypersensitivity to Implanted Metal Devices: A Perspective From the American Contact Dermatitis Society.

The American Contact Dermatitis Society recognizes the interest in the evaluation and management of metal hypersensitivity reactions. Given the paucity of robust evidence with which to guide our practices, we provide reasonable evidence and expert opinion–based guidelines for clinicians with regard to metal hypersensitivity reaction testing and patient management. Routine preoperative evaluation in individuals with no history of adverse cutaneous reactions to metals or history of previous implant-related adverse events is not necessary. Patients with a clear self-reported history of metal reactions should be evaluated by patch testing before device implant. Patch testing is only 1 element in the assessment of causation in those with postimplantation morbidity. Metal exposure from the implanted device can cause sensitization, but a positive metal test does not prove symptom causality. The decision to replace an implanted device must include an assessment of all clinical factors and a thorough risk-benefit analysis by the treating physician(s) and patient.

Stability of patch test allergens.

Patch testing is widely used in evaluating suspected contact dermatitis. One major component of a quality patch test result is a dependable, predictable allergen supply. The allergen needs to be present at a sufficient concentration to elicit a reaction in an allergic patient. To better understand the stability of patch-test allergens, we completed a systematic review of the literature. We found that there is variability in stability among patch-test allergens and that although a few have been shown to be stable, many degrade when in storage. In most cases, expiration dates should be honored. In addition, allergen panels should be prepared as close to the time of patch test application as is possible.

Leukocytoclastic Vasculitis as the Presenting Feature of Dermatitis Herpetiformis

BACKGROUND Dermatitis herpetiformis is an autoimmune disease typically characterized by pruritic vesicles located on the extensor surfaces. Classic disease consists of neutrophils in the dermal papillae. Additional histopathologic findings include fibrin deposition and edema within the dermal papillae. Subepidermal vesicles also may be present. Direct immunofluorescence demonstrates granular IgA in the dermal papillae. OBSERVATIONS A 58-year-old man with tender and pruritic erythematous macules and papules ranging from 2 to 6 mm in diameter had bilateral knee, elbow, forearm, scalp, and neck involvement. Petechiae also were present on the hands, thigh, knee, and ankle. A biopsy specimen initially demonstrated leukocytoclastic vasculitis. The results of workup for systemic vasculitis were negative. Subsequent biopsy specimens and direct immunofluorescence showed histologic evidence of dermatitis herpetiformis and leukocytoclastic vasculitis in the setting of an elevated serum IgA antitissue transglutaminase level. Marked improvement of the lesions was observed with a reduction of gluten in the patients diet. CONCLUSIONS Physicians should consider the possibility of dermatitis herpetiformis in patients with petechiae and leukocytoclastic vasculitis because leukocytoclastic vasculitis may be a prominent feature of dermatitis herpetiformis.

Gallate Contact Dermatitis: Product Update and Systematic Review

Allergic contact dermatitis related to cosmetic use can result from allergens not routinely evaluated by standard patch test protocols. Propyl, octyl, and dodecyl gallates are commonly used antioxidant preservatives with reports of associated allergic contact dermatitis in the literature. The objectAllergic contact dermatitis related to cosmetic use can result from allergens not routinely evaluated by standard patch test protocols. Propyl, octyl, and dodecyl gallates are commonly used antioxidant preservatives with reports of associated allergic contact dermatitis in the literature. The objectives of this review were to investigate the role of gallates in allergic contact dermatitis and to explore products containing these preservatives. A systematic review of the literature through April 2016 was performed to explore cases of reported gallate allergy. Food and cosmetic product databases were searched for products containing gallates. Seventy-four cases of gallate contact allergy have been reported. In addition, a variety of commercially available cosmetic products and foods contain gallate chemicals. Propyl gallate is the most commonly reported gallate contact allergen and often causes facial and/or hand dermatitis.

Developing Teaching Strategies in the EHR Era: A Survey of GME Experts

BACKGROUND There is limited information on the impact of widespread adoption of the electronic health record (EHR) on graduate medical education (GME). OBJECTIVE To identify areas of consensus by education experts, where the use of EHR impacts GME, with the goal of developing strategies and tools to enhance GME teaching and learning in the EHR environment. METHODS Information was solicited from experienced US physician educators who use EPIC EHR following 3 steps: 2 rounds of online surveys using the Delphi technique, followed by telephone interviews. The survey contained 3 stem questions and 52 items with Likert-scale responses. Consensus was defined by predetermined cutoffs. A second survey reassessed items for which consensus was not initially achieved. Common themes to improve GME in settings with an EHR were compiled from the telephone interviews. RESULTS The panel included 19 physicians in 15 states in Round 1, 12 in Round 2, and 10 for the interviews. Ten items were found important for teaching and learning: balancing focus on EHR documentation with patient engagement achieved 100% consensus. Other items achieving consensus included adequate learning time, balancing EHR data with verbal history and physical examination, communicating clinical thought processes, hands-on EHR practice, minimizing data repetition, and development of shortcuts and templates. Teaching strategies incorporating both online software and face-to-face solutions were identified during the interviews. CONCLUSIONS New strategies are needed for effective teaching and learning of residents and fellows, capitalizing on the potential of the EHR, while minimizing any unintended negative impact on medical education.

Contact Allergy to Hydroperoxides of Linalool and D-Limonene in a US Population

Background Linalool and D-limonene are common fragrance ingredients that readily oxidize on exposure to air. The resulting hydroperoxides of linalool and D-limonene have been shown to have high frequencies of positive patch test reactions in several European and international studies. Objective The aim of the study was to investigate the prevalence of contact allergy to the hydroperoxides of linalool and D-limonene in a US population. Methods In this retrospective study, 103 patients with suspected fragrance allergy were patch tested to linalool 10% petrolatum (pet), hydroperoxides of linalool 1% pet, D-limonene 10% pet, and/or the hydroperoxides of D-limonene 0.3% pet between July 9, 2014, and October 25, 2016. Conclusions In this study, the frequency of positive patch test reactions to the hydroperoxides of linalool is 20% (19/96), and the frequency of positive reactions to the hydroperoxides of D-limonene is 8% (7/90). These high frequencies suggest that patch testing to the hydroperoxides of linalool and limonene should be performed in all patients with suspected fragrance allergy.

Defining Gaps in Dermatitis Care

On March 1, 2017, the American Contact Dermatitis Society (ACDS) held an afternoon meeting in Orlando, Florida, “Defining Gaps in Dermatitis Care.” This included an Open Space session.This meeting, the day prior to the societys annual scientific session, was new and was publicized in ACDS news

Patch Testing Tools of the Trade: Use of Immunosuppressants and Antihistamines During Patch Testing

ABSTRACT Epicutaneous patch testing is the gold standard for obtaining a diagnosis of allergic contact dermatitis. Patients with allergic contact dermatitis who are undergoing patch testing may be taking or using topical, oral, or injectable immunosuppressant medications. Herein, we elucidate guidelines for the use of antihistamines and topical systemic immunosuppressants during the patch test process.

Pacemaker contact dermatitis: clinical and histopathologic description.

A 64-year-old man presented with several days of worsening erythema and pain over his pacemaker site. He denied fever, chills, or drainage from the site. His history was significant for a St. Jude dual-chamber pacemaker placed 7 years prior for vasovagal syncope and periprocedural bradycardia. In the following 6 years, there was intermittent discomfort at the site. Importantly, there had been new pruritus and pain over the site for 1 year and erythema for the last 6 months. There were no other implanted devices, and he had no history of reaction to metals. The differential diagnosis of dermatoses overlying pacemakers includes infection, irritant or allergic contact dermatitis, reticular telangiectatic erythema, and impending device extrusion. He received a 1 week course of oral cephalexin, despite negative blood cultures, normal temperature, and normal white blood cell count. His symptoms returned to his baseline for the last 6 months (pruritus, erythema, pain). Because of concern for device allergy, he was referred to our contact dermatitis clinic. Physical examination revealed erythema at the superior and inferior borders of the pacemaker (Fig. 1). Patch testing included the Duke 80 allergen series (modified American Contact Dermatitis Society), 42 metals, and 12 St. Jude pacemaker component allergens. There were positive reactions to the cured medical adhesive (silicone based adhesive) from the St. Jude allergen kit (Fig. 2) and gold sodium thiosulfate 2% petrolatum. The company confirmed that no gold was present in the device. All of the other allergens were negative. Laser lead extraction and pacemaker generator removal were completed. During the procedure, extensive inflammation, devitalized tissue, and purulent material were observed (Fig. 3). Biopsies were obtained from the area of erythema overlying the device and from the pocket. The dermis revealed a mild perivascular lymphocytic infiltrate, a few plasma cells, and scattered interstitial eosinophils (Fig. 4). The subcutaneous tissue revealed dense fibrous scar with hemosiderin deposition and perivascular lymphocytes and plasma cells. Culture from the pocket revealed 1 colony of coagulase negative Staphylococcus, and culture from the atrial lead tip was positive for coagulase-negative Staphylococcus. Multiple other cultures were negative. The positive cultures were Figure 1. Erythematous patches at the superior and inferior borders of the pacemaker.