Ercan Karabacak

Are port-wine stain and pneumosinus dilatans associated? A controlled study

The first case demonstrating the association of a port wine stain with pneumosinus dilatans was reported in 2003 by Dogan B et al. The current study is an extension of that case report, attempting to demonstrate that the association of pneumosinus dilatans and port wine stain is clinically significant and warrants clinical evaluation in patients with port wine stains. We aimed to evaluate the patients with or without facial port wine stains if they had pneumosinus dilatans. Twenty-three patients with port-wine stains, and 20 controls without port wine stains were compared. Facial CT scan were performed on each of the 43 subjects and analysed for radiological evidence of pneumosinus dilatans. A grading system was used to assess the extent of sinus enlargement noted on CT. Statistical analysis was also done. Ten out of 20 controls had minimal enlargement, 22 out of 23 patients with a port-wine stain had minimal to marked enlargement. The differences of having pneumosinus dilatans or not and the severity of enlargement between controls and patients were statistically significant (p=0.001; p=0.00001 respectively) This study showed that the association of port wine stain and pneumosinus dilatans was not a coincidence and the diminished density of peristructural nerves might be the common cause of these two pathological conditions, especially when they are together.

Ultrasound imaging for the follow-up of patients with leprosy: a pictorial essay.

DEAR EDITOR, Leprosy is a chronic, granulomatous, destructive disease caused by Mycobacterium leprae. The disease affects primarily the peripheral nerves, skin, eyes and nose. The musculoskeletal system, testis and other systems may also be involved. Several modalities, for example X-ray, computed tomography, magnetic resonance imaging and ultrasound (US), can be used for either diagnosis or monitoring of relevant complications of the disease. In this paper, we will focus mainly on US imaging, which has recently gained attention in the realm of dermatology. It has several important advantages, in that it is convenient, patient/physician friendly, cost-effective and repeatable, does not involve radiation, and provides dynamic imaging and real-time guidance for possible interventions. Neural involvement is one of the diagnostic criteria of leprosy and has a chronic course. Furthermore, it is noteworthy that this condition can be reversible with early adequate treatment, otherwise it may cause skin ulcers, osteomyelitis or neuro-osteoarthropathy (Charcot foot or tarsal disintegration), which may even necessitate amputation of the affected limb. Therefore, prompt imaging is a prerequisite. With its higher resolution and the aforementioned advantages, US seems to be an important imaging tool particularly in patients with widespread involvement of the peripheral nerves. The US probe can readily be used to ‘sono-auscultate’ the peripheral nerves or check for ‘sono-Tinel’. In this way, US also serves as a definite complementary tool for electrophysiological assessments. During US imaging, acute or subacute neuritis – seen in type 1 or type 2 reactions of leprosy – is observed in different forms of nerve enlargement (Fig. 1a,b), such as changes in size, echotexture or vascularity. Additionally, thickening of the epineurium can be observed. Involvement of the skin, nail and soft tissues may present complications in patients with leprosy. Sensory nerve impairment may result in secondary skin changes such as skin ulcers, which in turn can predispose to secondary infections resulting in cellulitis, abscess formation and articular/bony involvement. US might again serve as a handy imaging tool for the clinician. The only exception would be intraosseous pathologies, as the sound waves do not penetrate inside the bones and thus do not provide information about such lesions. Common nail changes in leprosy include subungual hyperkeratosis, pterygium unguis, pitting, longitudinal ridging and

Topical Ozone and Chronic Wounds: Improper Use of Therapeutic Tools May Delay Wound Healing

Dear Editor, We present a patient with multiple non-healing lower extremity ulcers, and further discuss the inappropriate use of topical ozone therapy and the need for a comprehensive approach to wound management. A 40-year-old male patient, with diabetes mellitus and coronary artery disease of two years’ duration, applied to our hyperbaric and wound care center for multiple non-healing necrotic ulcers over his legs [Figure 1]. Ulcers occurred around his ankles three months ago and spread proximally thereafter, despite topical antibiotic therapy and gauze dressings delivered at a local hospital. Sunk into despair, he was attracted from flyers advertising ozone therapy for chronic wounds. Thus, during the following four weeks, he received several topical ozone therapy sessions, which yielded no further significant signs of improvement. Eventually, he was suggested bilateral lower extremity amputation by a surgeon. On physical examination, he had multiple, necrotic, and infected deep ulcers in variable sizes reaching tendons in some areas [Figure 1]. The ulcers had sharp edges and erythema around. He had significant bilateral edema on his lower extremities due to heart failure. He showed high levels of inflammatory markers [WBC: 22.400/ μl, C-reactive protein (CRP): 49 mg/L, erythrocyte sedimentation rate (ESR): 92 mm/h] and wound culture grew Escherichia coli. Pathology of the lesions revealed leukocytoclastic vasculitis. We hospitalized the patient and undertook a holistic approach comprising aggressive anti-edema treatment, culture-driven intravenous antibiotic regimen, and comprehensive daily wound care, including debridement of necrotic tissues and management of exudates. The multidisciplinary approach resolved his lesions rapidly, and the wound size and depth showed significant reduction. We discharged the patient after one-month care and continued follow-up as an outpatient for an additional four weeks. All ulcers of both legs almost totally epithelized in 8 weeks [Figure 2]. The patient was lost to follow-up after this time. Figure 1 He had multiple, necrotic, and infected deep ulcers on both legs Figure 2 Almost all ulcers of both legs epithelized in 8 weeks Ozone therapy is administered for a wide spectrum of disorders ranging from diabetes to rheumatoid arthritis and from Alzheimers disease to HIV. Although recent studies highlight the mechanism of action of ozone, improper use and toxicity of ozone therapy is still a concern. Ozone is a reactive gas and may be toxic if not used in therapeutic doses. Medical ozone therapy uses a gas mixture of ozone and oxygen, which never contains less than 95% oxygen.[1] There are several routes of ozone application. These include autohemotherapy, intramuscular, intra-articular, and paravertebral injections, rectal or vaginal insufflations, and topical ozone application. A number of studies suggest that ozone therapy may have a role in the treatment of chronic wounds. Martinez-Sanchez et al. used three different routes of ozone application concurrently in diabetic patients with chronic wounds and compared the results with matched controls.[2] Patients in the ozone therapy group were treated by rectal ozone insufflations, topical ozone, and wound dressings with ozonized sunflower oil. Although the number of patients with complete healing was similar in both groups, ozone therapy increased the healing rate of wounds and reduced the hospitalization time.[2] Wainstein et al. used topical ozone therapy in addition to standard therapy in diabetic wounds.[3] Although the intention-to-treat analysis failed to show any benefit, the per-protocol analysis revealed that topical ozone therapy might confer clinical benefit when added to conventional treatment in diabetic wounds smaller than 5 cm2.[3] Yet, the treatment of problem wounds accompanying multiple comorbidities, such as the one described here, presents a considerable therapeutic challenge and requires a multidisciplinary approach. The standard of care for treating chronic ulcers has been well established, and early and appropriate treatment is the cornerstone of treatment because even superficial wounds may, in time, progress to the subcutaneous tissues, muscles, tendons, or bones. Focusing on the so-called “advanced wound healing modalities” may sometimes result in an unintentional neglect of principles of wound care, and hence may lead to incurable wounds, which may ultimately require foot amputation. Our case is a representative of improper wound management and improper implementation of ozone therapy, which although caused no direct harm to the patient, failed to heal the wounds. Once comprehensive wound care management policies targeting underlying factors were applied in our department, all ulcers responded well and showed a significant step towards healing. This case report highlights two major issues. First, the role of ozone therapy is still poorly defined in the management of foot ulcers and should be used with caution. Randomized controlled studies are necessary to validate its beneficial effects (if any) and to define those patients who can be expected to derive the maximum benefit from ozone therapy. Second, adjunctive therapies should only be applied when conventional treatments fail to heal the wound.

Ultrasound imaging for neurofibromatosis: from the dermatologist's perspective.

Recently, musculoskeletal ultrasound (US) has received increased attention in the field of dermatology [1]. While ultrasound can be used to image the skin (epidermis, dermis, subcutaneous fat), nail and the nearby soft tissues/joints [2, 3], it can be particularly useful in patients with leprosy and neurofibromatosis (NF) to demonstrate the extent of peripheral nervous system involvement [4, 5]. We have previously shown the role of ultrasound in the diagnosis and follow-up of several complications in leprosy (submitted data); and similarly in this short report describing two military, we underscore the convenient role of ultrasound for imaging the peripheral nerves in NF. Neurofibromatosis, described by Friedrich Daniel von Recklinghausen in 1882, is a neuroectodermal abnormality Clinical letter comprised of a set of clinical symptoms that compromise the skin, nervous system, bones, eyes and other sites [6]. It is believed that at least one million individuals worldwide are living with neurofibromatosis [7]. It is inherited in an autosomal-dominant pattern and considered one of the most common disorders in humans inherited in this manner [6, 7]. Neurofibromas are the hallmark tumors of NF and predominantly involve the peripheral nerves [8]. They can be of different types such as localized (90 %), diffuse and plexiform [9]. The localized form presents as an ovoid or a fusiform mass through which the nerve trunk passes. The diffuse form grows in an infiltrative pattern and entraps adjacent normal structures. The plexiform neurofibroma has a serpentine-like appearance and characteristically involves a long segment of the nerve with its branches. This form is pathognomonic for NF type 1 and can potentially be malignant [4, 5]. For peripheral nerve problems, a thorough physical examination combined with nerve conduction studies usually suffices for the diagnosis. However, imaging may be needed to identify the underlying cause of nerve dysfunction or to assess the extent for more widespread disease. Ultrasound using a linear array high frequency probe, 7–12 MHz offers numerous advantages (patient and physician friendly, costeffective, no ionizing radiation, dynamic imaging) has become the method of choice for peripheral nerve imaging – not only for diagnosis but also for guiding possible surgery or

An unusual garlic burn occurring on an unexpected area

A 24-year-old otherwise healthy woman presented with an itchy, burning, erythematous lesion located over her neck. She had applied crushed raw garlic over her neck for about 5 h following a sore throat. On dermatological examination an erythematous demarcated area with eruption, patchy squamous and vesicular lesions were present over the submandibular region (figure 1). On the basis of history …

Arterial Stiffness Without Other Inflammatory Markers May Not Accurately Provide Information to Clinicians About the Severity of Psoriasis

We read the article ‘‘Aortic Arterial Stiffness is a Moderate Predictor of Cardiovascular Disease in Patient with Psoriasis Vulgaris’’ by Balta et al with interest. This well-presented study investigated the relationship between arterial stiffness and high-sensitivity CRP (hsCRP) in patients with psoriasis. The authors concluded that arterial stiffness correlated positively with age, sex, body mass index, diastolic blood pressure, and hsCRP level. These findings provide further evidence of a link between premature atherosclerosis and psoriasis. Arterial stiffness represents vascular damage and is a measure of the degree of atherosclerosis. Arterial stiffness has received increased attention because of its role as an independent predictor of cardiovascular disease and relationship to the metabolic syndrome. Increased arterial stiffness is a common indicator of atherosclerotic involvement of the vascular structure, indicating cardiovascular diseases, stroke and renal diseases, as well as total mortality. It can also be affected by atherosclerotic risk factors such as smoking, alcohol consumption, hypercholesterolemia, hypothyroidism, plasma homocysteine, and serum gamma-glutamyltransferase (GGT). Furthermore, in recent studies, plasma homocysteine concentrations were found to be significantly higher in patients with psoriasis. In this point of view, in the present study, the authors did not mention about some of the factors affecting arterial stiffness, including alcohol consumption, hypothyroidism, plasma homocysteine, and serum GGT levels. If the authors had described these factors, they would have obtained different results. More severe psoriasis was significantly associated with higher prevalence of concomitant disease, greater involvement (nails, scalp, palm soles), and poorer quality of life. Severe psoriasis is also associated with increased risk of cardiovascular mortality and morbidity due, in part, to shared immune–inflammatory mechanisms. In our opinion, it would have been better if the authors of the present study had included information about disease severity (mild, moderate, or severe), mean Psoriasis Area and Severity Index, and presence of psoriatic arthritis. In conclusion, arterial stiffness was shown as a noninvasive method to assess endothelial dysfunction in clinical practice, which is affected by many factors. Arterial stiffness itself without other inflammatory markers may not provide information to the clinicians about the endothelial inflammation on psoriasis. So we believe that it should be evaluated together with other serum biochemical markers.

Unexpected wound occurring following negative pressure wound therapy

Dear Editors, A 67-year-old man with type 2 diabetes mellitus of 2 years duration was presented 4 weeks after amputation of a gangrenous and infected toe, with a large non-healing wound at the surgical site (Figure 1). Pedal pulses were non-palpable and he had severe loss of foot sensation. The patient had a poor diabetes control with a haemoglobin A1c level of 8·4% (normal 3·3–6·4%). Apart from hypertension, he did not have any other known comorbidities. Infection markers at admission were as follows: white blood count = 13500 (mm3/L), erythrocyte sedimentation rate = 105 mm/hour, C-reactive protein = 57 mg/l. The patient received comprehensive wound management including daily wound care, culture-driven antimicrobial treatment, hyperbaric oxygen therapy and negative pressure wound therapy (NPWT). The NPWT system, which has been shown to promote wound healing, consists of a vacuum pump and a canister connected to each other and to the wound site with several tubes. The system drains excess fluid from the wound base and thereby sustains an optimum moist milieu, helps control bacterial burden and restores microcirculation by decreasing interstitial pressure. In the current case, we had fixed the drainage tube, one of the pieces of the NPWT system, over the dorsal aspect of the patient’s foot. On opening the dressing 3 days after its application, to our great surprise we

Efficacy of Omalizumab in a Patient with Angioedema Clinically Resembling a Hereditary Angioedema.

Dear Editor: A 20-year-old man was referred to our allergy and immunology department with complaints of recurring angioedema attacks, lasting 48~96 h, on his lips, eyes, and face, as well as swelling of the extremities and testicles during the last 1 year. Regular use of antihistamine and steroid drugs was generally ineffective against the frequency and severity of the angioedema attacks. He experienced recurrent abdominal pain attacks during the evaluation period. He was hospitalized in another center with a prediagnosis of familial Mediterranean fever; however, that diagnosis was excluded later. Urticarial lesions were not observed during the angioedema attacks. He did not have a history of drug or food allergy, and no specific family history for angioedema was reported. A detailed evaluation for arthritis and rheumatologic disorder was done but no specific findings were found. Furthermore, rheumatologic markers were negative (IRB No. 1491-21-16/1539). Routine laboratory tests for the management of chronic urticaria-angioedema and for anti-nuclear antibody, rheumatoid factor, anti-cyclic citrullinated peptide antibodies, C3, and C4 were within the reference limits. The total immunoglobulin E (IgE) value was 213 IU/ml, and the C4 levels during the attacks were normal. However, C1 esterase inhibitor was measured to be 28.3 mg/dl (reference, 32~39 mg/dl), and hereditary angioedema (HAE) was clinically considered. Danazol treatment up to 400~600 mg/day was started; however, no significant benefit was observed. As the 1,000 U C1 esterase inhibitor administered during the attacks (Cetor, 500 U; Sanquin, Amsterdam, The Netherlands) was ineffective, the diagnosis of HAE was excluded. Because the urticarial complaints started in addition to the angioedema complaints, our patient received 300 mg omalizumab (Xolair 150 mg; Novartis Pharmaceuticals, Basel, Switzerland) subcutaneously every 4 weeks according to conventional asthma treatment protocols. He was treated with omalizumab for 6 months. His angioedema attacks ceased completely within 2 weeks after the start of this treatment. Except for the very short period for the formal procedures required for the procurement of the drug, he had no other complaints during the 6 months follow-up. In randomized, placebo-controlled trials, omalizumab was shown to have excellent efficacy in chronic spontaneous urticaria1. A growing number of case reports and series suggest that anti-IgE treatment may also be beneficial for patients with physical urticarias and chronic angioedema. Recently, omalizumab treatment for inducing and maintaining long-term remission in patients with severe chronic urticaria has been demonstrated2. Unfortunately, for such disorders with complex and unclear etiology, no randomized placebo-controlled trial has been performed yet3. The mechanism of omalizumab activity in angioedema is currently not well defined. However, several mechanism may be considered. Even if the pathogenesis of angioedema in the present case may not be directly mediated by IgE, omalizumab may be effective through an unidentified and indirect anti-inflammatory manner. Sayama et al.4 reported that the stimulation of high-affinity IgE receptor (FceRI) in human umbilical cord mast cells causes substantial change in the expression of many genes, including Interleukin-11 (IL-11), and at least 30 other cytokines and chemokines and several adhesion molecules involved in potential interactions with T cells, B cells, or dendritic cells. Another work, in which the anti-inflammatory activity of omalizumab was mediated, has provided evidence showing the efficacy of this drug in idiopathic angioedema through eosinophil apoptosis induction and downregulation of the inflammatory cytokines IL-2 and IL-135. In conclusion, it seems that therapeutic efficacy spectrum of anti-IgE treatment comprises many allergic disorders with unknown etiology, including angioedema.

Pitfalls of Intralesional Ozone Injection in Diabetic Foot Ulcers: A Case Study

Although the history of ozone therapy dates back to the 19th century, its use has shown a rapid growth of interest in recent decades. Intralesional ozone injection is seldom performed and its safety has not yet been reliably assessed for the treatment of diabetic foot wounds. Herein, we describe a diabetic patient who developed severe foot necrosis and infection after receiving intralesional ozone injections for a non-healing wound.

Resistance status of antibiotics in Gram-positive bacteria isolated from acne lesions in İstanbul

Address for Correspondence/Yazışma Adresi: Bilal Doğan MD, University of Health Sciences, Sultan Abdülhamid Han SAUM, Departments of Dermatology, İstanbul, Turkey Phone.: +90 532 567 72 40 E-mail: gatadermdogan@yahoo.com Received/Geliş Tarihi: 28.10.2015 Accepted/Kabul Tarihi: 16.06.2016 University of Health Sciences, Sultan Abdülhamid Han SAUM, Departments of Dermatology and *Medical Microbiology, İstanbul, Turkey Bilal Doğan, Bayhan Bektöre*, Ercan Karabacak, Mustafa Özyurt*