Anupam Varshney

Incidence of various clinico-morphological variants of cutaneous tuberculosis and HIV concurrence: a study from the Indian subcontinent.

Background and Objectives: There are few reports of cutaneous tuberculosis with immunosuppressed states such as HIV, use of immunosuppressants or malignancy. Diagnosis is thus difficult and despite scientific advances such as polymerase chain reaction, it is frequently missed. Although rare, given its worldwide prevalence and the rising incidence of HIV, it is important for clinicians to recognize the variants and promptly treat the patient. Design and Setting: Retrospective study of all cases of cutaneous tuberculosis diagnosed from October 2007 to November 2009 at an outpatient clinic of a tertiary-care hospital in northern India. Methods: We collected information on the clinical form of disease, histopathology and HIV concurrence rates and looked for differences in presentation between mmunocompetent and immunocompromised states. We also looked for differences and HIV concurrence between immunocompetent and immunocomprised patients. Diagnosis was based on clinical, histopathological and microbiological tests for tuberculosis and a test for HIV. Results: The overall incidence of cutaneous tuberculosis was 0.7% (131 of 18720 outpatients). HIV concurrence was 9.1% (12 cases) of all cutaneous tuberculosis cases. Most common variants seen were scrofuloderma (36.5%), lupus vulgaris (31%), tuberculosis verruca cutis (12.9%), lichen scrofulosorum (11.4%), papulonecrotic tuberculids (3.8%), erythema nodosum (2.2%) and erythema induratum of Bazin (1.5%). Conclusions: Cutaneous tuberculosis rates were slightly higher in our study than in other studies from India. HIV co-infection rates were similar to those in other studies. Many atypical morphological forms and presentations were observed in HIV co-infected patients. Due to the varied clinical presentations, physician awareness and a high index of suspicion are necessary to diagnose cutaneous forms of tuberculosis.

Buffalo pox outbreak with atypical features: a word of caution and need for early intervention!

Despite repeated outbreaks of poxvirus infections unique to the Indian subcontinent region and veterinary research work in this field, much less diagnostic awareness with resultant treatment protocols have been formulated in the human medical field.

Phacomatosis cesioflammea: first case report from India.

Phacomatosis cesioflammea is a rare condition defined by the simultaneous presence of both vascular and pigmentary nevus in the same patient. We report a case of a 4-year-old Indian female child who presented with diffuse dermal melanosis on the upper shoulders, upper anterior chest and lower back and extending to involve both sides of the arms and forearms, generalized port-wine stain on the back, shoulders and both upper limbs with sparing of the right palm. At places, the two types of lesions were superimposed on each other and were also present discretely on the back, but in close proximity to each other. There was the presence of melanosis bulbi on the right side of the eye. She was otherwise normal. She was clinically diagnosed as a case of phacomatosis pigmentovascularis cesioflammea. The nonallelic twin spotting phenomenon has been proposed in the pathogenesis of this disorder.

A rare case of facial annular bullous erythema nodosum leprosum reaction in a young boy.

ear epidermolytic ichthyosis have little been investigated. The subtle specific histopathologic features of this case were presence of focal parakeratosis in accordance with granular degeneration. We performed electron microscopy to explore the pathogenesis. The ultrastructural study identified the common features of epidermolytic ichthyosis, including abnormal keratin tonofilament aggregates, wreath-like distribution around the nuclei, discrete peripheral filament aggregates, and vacuolated changes with lack of normal filaments. These were consistent with features of typical epidermolytic ichthyosis. The ultrastructural study further detected the shrinking nuclei showing focal parakeratosis. These were unusual, indicating the subtle, specific histopathologic features. In conclusion, we report a case of linear epidermolytic ichthyosis with shrinking nuclei in an ultrastructural study. This study illustrated not only the common features in epidermolytic ichthyosis but also the subtle, specific histopathologic features of the shrinking nuclei. Further accumulation of subtle diverse characteristics in linear epidermolytic ichthyosis would be needed to elucidate further variable pathogeneses.

Disseminated anetoderma in a patient with nodal Epstein–Barr virus-associated classical Hodgkin lymphoma: Anetodermic form of a concurrent discordant cutaneous marginal zone lymphoma

Patients with a lymphoma have an increased risk of developing a second lymphoproliferative disorder. The association of nodal Hodgkin lymphoma and primary cutaneous marginal zone lymphoma (MALT type) is exceptional, and only very few cases have been documented. Anetoderma represents a circumscribed loss or rarefication of elastic fibers. Different underlying processes may result in anetoderma, including cutaneous marginal zone lymphoma. We report a 50‐year‐old male patient with Epstein–Barr virus (EBV)‐associated nodal Hodgkin lymphoma who presented with disseminated anetodermic skin lesions. Biopsies of the skin lesions revealed a B‐cell infiltrate containing monoclonal plasma cells but without detection of EBV. The skin lesions represent an anetodermic form of primary cutaneous marginal zone lymphoma. It is the first case report of an association of anetodermic cutaneous marginal zone lymphoma and a synchronous EBV‐associated nodal Hodgkin lymphoma.

The study of clinical outcome of systemic methotrexate uses in moderate to severe childhood psoriasis

Background: Currently, very few studies exist regarding the use of systemic methotrexate (MTX) in childhood psoriasis. Aim: The aim is to study the effect of systemic MTX with respect to overall efficacy and safety in varied spectrum of severe childhood psoriasis patients and to assess the degree of improvement objectively by measuring psoriasis area severity index (PASI) at each visit. Materials and Methods: All patients <18 years of age having PASI >10, not responding to topical therapy and without having any contraindication to systemic MTX use were included in the study done during a period of two years. MTX was prescribed orally at a dose of 0.2–0.4 mg/kg/week and folic acid on daily basis except on the day of MTX to all the patients. Both clinical and laboratory follow-ups were done weekly for the first 2 weeks and then at 15 days interval for 1 month and monthly after that for measuring PASI and to rule out any side effects of MTX. After 75% improvement in PASI score the dose was decreased at rate of 2.5 mg/week and stopped after complete resolution of the lesions. Results: Out of nine cases (M/F - 6/3), quickest response to MTX was seen in pustular psoriasis (4.5 weeks) and one case of plaque psoriasis (5 weeks) and slowest response was seen in rupoid variant (13 weeks). Mean duration to achieve 50% and 75% improvement in PASI overall were 4.6 ± 2.46 weeks and 7.6 ± 3.36 weeks, respectively. The mean cumulative dose of MTX in all cases was 231.1 ± 176.1 mg without any major side effects. Conclusion: MTX is a safe therapeutic option in severe refractory cases of childhood psoriasis if used with proper monitoring and follow-up.

Primary cutaneous plasmacytosis: Masquerading as hidradenitis suppurativa

Isolated cutaneous plasmacytosis (CP) is a rare entity with few cases reported in world literature. CP masquerading as hidradenitis suppurativa like presentation is a unique case with some features differentiating it clinically from it which were further confirmed by histopathology and immunostaining. Our case showed hyperplasia of mature plasma cells and polyclonal hypergammaglobulinemia, immunostaining for CD138 positivity and kappa: lambda ratio more than 3:1. Extensive clinical and laboratory investigations failed to reveal any underlying pathology, presence of any underlying disease accompanying the hypergammaglobulinemia and/or plasma cell proliferation.

Ectopia cilia with pedigree analysis: Second case report in the world

We present a case of ectopia cilia in a 28-year-old male patient. Ectopia cilia was were seen in the outer third of left upper eyelid. The patients maternal grandfather also had ectopia cilia of the left upper eyelid as reported by the patients mother. Ectopia cilia is a rare condition seen in humans. Only 12 cases of ectopic cilia in humans have been reported so far in the world. The present case of ectopia cilia is the second case report in the world with pedigree analysis.

Co-existence of extramammary Paget's disease and Bowen's disease of vulva.

Extramammary Pagets disease and Bowens disease are histologically similar and immunohistochemistry is often required to make the diagnosis. We present a case of vulval Pagets disease with Bowens disease in an elderly female. Strong positivity for cytokeratin 7, anti CAM 5.2, carcinoembryonic antigen (CEA) and periodic acid-Schiff (PAS) stain in clitoral, left labial and interface regions of the vulvectomy specimen confirmed the diagnosis of Pagets disease (PD) while positive staining for p63 in the right labial and interface regions helped in establishing the diagnosis of concurrent Bowens disease (BD).

Malignant mediterranean spotted fever in the setting of diabetes mellitus: An uncommon cutaneous entity

In this era of immune suppression and potential biological warfare, we need to be aware of cutaneous manifestations of relatively uncommon bacterium, their atypical variants, and the early treatment protocols. We present atypical presentation of Indian possible tick typhus diagnosed clinically and confirmed both by biopsy of the lesion and serological tests.