Govind Srivastava

An appraisal of epidemiologic, clinical, bacteriologic, histopathologic, and immunologic parameters in cutaneous tuberculosis.

ABSTRACT: Cutaneous tuberculosis incidence was recorded as 0.15%. Of the 42 patients, 23 had scrofuloderma, 17 lupus vulgaris, and 2 tuberculosis verrucosa cutis. Both men and women were affected by the disease in the second and third decades. Its duration was variable. An affirmative family history was elicited in five scrofuloderma patients. The clinical expression largely conformed to the ritual text. Variation in Mantoux test positivity was unremarkable. The disparity in the demostration of bacilli in the smear and tissue sections was. however, quite apparent in scrofuloderma. The correlation of different parameters indicates a continuous spectrum, formed at one end by lupus vulgaris, and at another by scrofuloderma. A moderate to strongly positive Mantoux text, enormous lymphocytes in the granuloma, absence of tubercle bacilli, negative culture, and an apparently normal immunoprofile were features of lupus vulgaris; whereas scrofuloderma had a moderately positive Mantoux test, lesser number of lymphocytes in the granuloma, large number of bacilli in tissue smear and/or tissue section, raised levels of immunoglobulins, and a grossly lowered C3 levels. The other variants probably occupy a position in between.

Paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome.

Paraneoplastic pemphigus is the term used for an exclusive subset of pemphigus. The clinical lesions may resemble pemphigus, pemphigoid, erythema multiforme, graft‐vs.‐host disease, or lichen planus. A common denominator in all patients is the concomitant occurrence of either occult or confirmed systemic neoplasm. It is imperative to confirm the diagnosis through microscopy, where intraepidermal suprabasal cleavage, epidermal acantholysis, dyskeratotic keratinocytes and vacuolar changes in the basal epidermis, interfacial dermatitis, and epidermal exocytosis can be seen. Furthermore, the deposition of immunoglobulin G (IgG) and complement in the epidermal intercellular spaces, detected by direct and/or indirect immunofluorescence, is equally crucial for confirming the diagnosis.

Fixed drug eruption (FDE): changing scenario of incriminating drugs

The various side-effects of drugs have been recorded since time immemorial. They may be trivial or may cause considerable morbidity or mortality. The skin is the largest organ of the body and displays various facets of drug eruption; fixed drug eruption (FDE) is one of them. It is a fascinating adverse drug effect. Ever since the entity was first described by Bourns 1 in 1889, it has attracted attention. 2–6 Brocq 3 is credited with assigning the name. Several studies on FDE are on record that have aimed to unfold its possible pathophysiology. 7–11 The advent and use of new drug(s) in the therapy of the disease has brought into focus new drugs and new chemical agents that cause FDE, 12–14 and the many unusual presentations of the entity. 15–17 The purpose of this article is to review the available information regarding FDE.

Changing pattern of cutaneous tuberculosis: a prospective study

ABSTRACT: During the past 3 years, we have seen a changing pattern of cutaneous tuberculosis, in which its incidence was recorded to show an upward trend affecting predominantly the adult men. The latter was true in reinfection‐lupus vulgaris and tuberculosis verrucosa cutis, whereas a substantial number of children were victims of reactivation‐scrofuloderma. The duration of the disease was usually short in reactivation tuberculosis. Its clinical expression, however, conformed largely to the ritual text except that apple‐jelly nodules were infrequently demonstrated. Similarly, the morbidity was low. The affliction of the extremities in lupus vulgaris, in particular, was a contrasting feature. The histopathology invariably either confirmed or supplemented the clinical impression. The ultimate confirmation of cutaneous tuberculosis was done only by the demonstration of Mycobacterium tuberculosis in smears, or its recovery in vitro. In view of the limitations of the preceding parameters, the diagnosis may reasonably be made based on the history and evolution of the disease, cardinal morphologic features of reinfection and reactivation tuberculosis, and histopathologic characteristics. A response to antitubercular drugs may be of assistance.

Darier's (Darier-White) disease/keratosis follicularis

Darier’s (Darier–White) disease/keratosis follicularis was initially reported in the year 1889 by Darier and White independently. Darier’s disease has since (for over a century) fascinated research workers. 1–12 Almost all cases of the disease are attributed to mutations in the sarcoplasmic endoreticulum Ca 2+ -ATPase isoform-2 (SERCA-2). 13–24 The original suggestion that dyskeratotic cells represented an organism was dispelled long ago. 25 The genetic nature of the disease was initially suggested for the first time by White, when he reported the simultaneous affliction of a mother and her child. 25 The discovery that the disease is due to specific mutations has provided an excellent opportunity to study its genetic epidemiology. 22–24 The present update is an attempt to comprehensively review the developments in the field to date, and to correlate the various facets of the entity.

Status of histoid leprosy--a clinical, bacteriological, histopathological and immunological appraisal.

The study of different aspects, namely clinical, bacteriological, histopathological and immunological, of 23 cases of histoid leprosy were quite revealing. The salient features included the occurrence of histoid lesions in a proportion of untreated leprosy patients in addition to those on dapsone treatment for a variable periods of time, a high bacteriological index in spite of infrequent formation of globi, high morphological indices and the immunological status of these patients. Cell‐mediated immunity, which was deficient in relation to healthy controls, appeared to be augmented when compared with active lepromatous (LL) patients. A few contributory factors to the development of such a situation are discussed.

Angiokeratoma circumscriptum: a case report and review of the literature.

The term “angiokeratoma” is applied to several distinct conditions with vascular skin lesions, the histology of which shows superficial vascular ectasia and overlying hyperkeratosis. 1 The angiokeratomas should be regarded as capillary vascular malformation rather than hemangiomas. 1 Apart from angiokeratoma corporis diffusum (Fabry), which is a disorder of phospholipid metabolism, at least four types of purely cutaneous angiokeratoma are known: the Mibelli type, the Fordyce type, angiokeratoma circumscriptum and “solitary and multiple angiokeratoma” (Imperial and Helwig). We present here a case of angiokeratoma circumscriptum and a brief review of the literature.

Histoid Leprosy: A Prospective Diagnostic Study in 38 Patients

Histoid leprosy is a fascinating expression of multibacillary leprosy, the incidence of which was 3.6%. It was seen predominantly in males of the younger age group, who were on inadequate and irregular dosage of diaminodiphenyl sulfone. Papules, cutaneous and/or subcutaneous nodules and plaques appearing over apparently normal skin were its exquisite prospective clinical features. It was invariably supported by enormous, uniformly solid staining discrete bacilli from the lesions, in contrast to their virtual absence from the surrounding normal-appearing skin. Encapsulated tumorous mass, formed primarily by spindle-shaped histocytes, displayed either in intertwining, criss-cross or whorled fashion in haematoxylin-eosin-stained sections, were supplementary. The morphology of acid-fast bacilli was, however, similar to skin-slit smears.

Melasma: Treatment strategy

Abstract Melasma, a hypermelanosis of the face, is a common skin problem of middle-aged women of all racial groups, especially with dark complexion. Its precise etio-pathogenesis is evasive, genetic influences, exposure to sunlight, pregnancy, oral contraceptives, estrogen-progesterone therapies, thyroid dysfunction, cosmetics, and drugs have been proposed. Centro-facial, malar, and mandibular are well-recognized. Epidermal pigmentation appears brown/black, while dermal is blue in color, and can be distinguished by Woods lamp illumination. The difference may be inapparent with mixed type of melasma in skin types V and VI. An increase in melanin in epidermis: basal and suprabasal layers and/or dermis is the prime defect. There is an increased expression of tyrosinase related protein-1 involved in eumelanin synthesis. The use of broad-spectrum sunscreen is important, lightening agents like retinoic acid (tretinoin), azelaic acid, and combination therapies containing hydroquinone, tretinoin, and corticosteroids, have been used in the treatment of melasma, and are thought to have increased efficacy as compared with monotherapy. Quasi-drugs, placental extracts, ellagic acid, chamomilla extract, butylresorcinol, tranexamic acid, methoxy potassium salicylate, adenosine monophosphate disodium salt, dipropyl-biphenyl-2,2′-diol, (4-hydroxyphenyl)-2-butanol, and tranexamic acid cetyl ester hydrochloride, in addition to kojic and ascorbic acid have been used. Chemical peeling is a good adjunct. Laser treatment is worthwhile.

Juvenile) Pityriasis rubra pilaris

Pityriasis rubra pilaris (PRP) comprises a group of chronic disorders displaying circumscribed follicular keratosis with palmoplantar keratoderma. 1,2 Both familial and acquired forms have been recognized. The former is infrequent and usually occurs in childhood. The bior trimodal distribution with regard to age usually involves a peak case incidence in the first and second decades. 3–5 Despite a significant peak in young children, there is a paucity of reports in this age group. 6,7