C. Ajith

Genital elephantiasis and sexually transmitted infections – revisited

Genital elephantiasis is an important medical problem in the tropics. It usually affects young and productive age group, and is associated with physical disability and extreme mental anguish. The majority of cases are due to filariasis; however, a small but significant proportion of patients develop genital elephantiasis due to bacterial sexually transmitted infections (STIs), mainly lymphogranuloma venereum (LGV) and donovanosis. STI-related genital elephantiasis should be differentiated from elephantiasis due to other causes, including filariasis, tuberculosis, haematological malignancies, iatrogenic, or dermatological diseases. Laboratory investigations like microscopy of tissue smear and nucleic acid amplification test for donovanosis, and serology and polymerase chain reaction for LGV may help in the diagnosis, but in endemic areas, in the absence of laboratory facilities, diagnosis largely depends on clinical characteristics. The causative agent of LGV, Chlamydia trachomatis serovar L1–L3, is a lymphotropic organism which leads to the development of thrombolymphangitis and perilymphangitis, and lymphadenitis. Long-standing oedema, fibrosis and lymphogranulomatous infiltration result in the final picture of elephantiasis. Elephantiasis in donovanosis is mainly due to constriction of the lymphatics which are trapped in the chronic granulomatous inflammatory response generated by the causative agent, Calymmatobacterium (Klebsiella) granulomatis. The LGV-associated genital elephantiasis should be treated with a prolonged course of doxycycline given orally, while donovanosis should be treated with azithromycin or trimethoprim-sulphamethoxazole combination given for a minimum of three weeks. Genital elephantiasis is not completely reversible with medical therapy alone and often needs to be reduced surgically.

Lichen sclerosus: Role of occlusion of the genital skin in the pathogenesis

Lichen sclerosus (LS) is a chronic inflammatory skin disease, which most commonly involves the anogenital region. The etiology of LS is obscure, but genetic susceptibility, autoimmune mechanisms, infective agents like human papillomavirus and spirochaetes, and Koebner phenomenon has been postulated as causative factors. We report our observation in 6 patients (3 males and 3 females) with histologically proven lichen sclerosus that showed relative sparing of the uncovered areas of the genitals, thereby suggesting that the occlusion of the genital skin may be playing a greater role in the causation of LS than is currently thought, in both sexes.

Laugier-hunziker pigmentation

Laugier-Hunziker pigmentation (LHP) is an acquired disorder of hypermelanosis characterized by mucocutaneous hyperpigmentation. LHP may resemble various disorders characterized by mucocutaneous pigmentation. A 58-year-old lady presented with progressively increasing number of variable sized, hyperpigmented macules over the lips, fingers, toes and nails. There was no family history of similar illness. Systemic examination and all relevant investigations were within normal limits. Histopathology of a skin lesion had features consistent with LHP. The diagnosis of LHP must be made only after relevant investigations to rule out any associated systemic involvement. This case further highlights that LHP is not restricted to European countries.

Saxophone penis revisited

Saxophone deformity of the penis is commonly secondary to diseases causing chronic lymphatic obstruction. Lymphogranuloma venereum (LGV) is an important cause for this deformity. A case of LGV in genito-anorectal syndrome with a saxophone penis is reported along with the contrast-enhanced computed tomography (CECT) findings of anorectal involvement, and a probable hypothesis for this typical appearance of the penis.

Kaposi's varicelliform eruption in a patient with phenytoin‐induced drug rash

References 1 Seggev JS, Lagstein Z. Photosensitivity skin reactions to calcium channel blockers. J Allergy Clin Immunol 1996; 97: 852–855. 2 Stern R, Khalsa JH. Cutaneous adverse reactions associated with calcium channel blockers. Arch Intern Med 1989; 149: 829–832. 3 Scherschun L, Lee MW, Lim HW. Diltiazem-associated photodistributed hyperpigmentation. Arch Dermatol 2001; 137: 179–182. 4 Knowles S, Gupta AK, Shear NH. The spectrum of cutaneous reactions associated with diltiazem: three cases and a review of the literature. J Am Acad Dermatol 1998; 38: 201–206.

Granulomatous rosacea mimicking eyelid dermatitis.

366 medications was made. Patch testing with the Indian standard series and his topical medications as antigens was negative. He was prescribed topical fluticasone dipropionate cream and was advised to avoid the ocular medications he was using. At follow-up after 2 weeks, the response was not satisfactory. Hence, a biopsy was done from the skin lesions. A H and E stained histopathological section showed a normal epidermis and dense collections of predominantly lymphocytic infiltrates surrounding the dilated blood vessels and hair follicles; features consistent with granulomatous rosacea [Figure 2]. A final diagnosis of granulomatous rosacea was made. Topical fluticasone dipropionate was Granulomatous rosacea mimicking eyelid dermatitis

Vaginal discharge due to primary varicella

Cervicitis is an important cause of abnormal vaginal discharge. We describe a case of vaginal discharge due to cervicitis caused by primary varicella zoster infection in a patient with chronic immunosuppression. Though a few reports of genital infection due to chicken pox are available, to the best of our knowledge, there are no reports of abnormal vaginal discharge due to cervicitis caused by chicken pox.