Julian Trevino

Retinoids for Chemoprophylaxis of Nonmelanoma Skin Cancer

The authors have indicated no significant interest with commercial supporters.

Acute generalized exanthematous pustulosis induced by clopidogrel.

Acute generalized exanthematous pustulosis (AGEP) is an acute febrile eruption of uniform, sterile, non-follicular pustules that is drug-induced in 90% of cases. Antibiotics are the main cause and represent the underlying trigger in 80% of cases. The eruption may occur within one week of the initial drug administration. A shorter interval, sometimes of <24 hours, between drug administration and onset of AGEP occurs in patients with previous exposure to the drug responsible for the reaction. Laboratory studies often reveal neutrophilic leukocytosis, elevated aminotransferases, and a mild reduction in creatinine clearance. Rising awareness has resulted in the increasing recognition of additional medications as triggers for AGEP. Instances of AGEP induced by clopidogrel have been reported only twice in the literature. We report a 54-year-old woman with recent myocardial infarction and hospitalization for urgent cardiac catheterization, who was started on clopidogrel after the placement of a drug-eluting stent. Five days later, widespread edematous erythematous papules and small pustules appeared on the intertriginous and flexural regions of her body (Fig. 1). This eruption was associated with low-grade fever and neutrophilia. Liver and renal function studies were normal. Punch biopsy performed on the right buttock revealed a subcorneal pustule, interface vacuolopathy, and superficial perivascular lymphocytic infiltrate with few eosinophils and neutrophils (Fig. 2). The findings of direct immunofluorescence and tissue culture with Gram staining were unremarkable. The clinical and histopathologic findings established a diagnosis of AGEP. Clopidogrel was discontinued, and a new anti-platelet agent, ticagrelor, was initiated. The majority of the lesions were successfully treated with triamcinolone acetonide 0.1% ointment administered twice per day. Four weeks later, the patient developed large areas of desquamation with complete resolution of her symptoms. The patient is subject to close follow-up and has demonstrated no recurrence of the lesions. This case further supports the inclusion of clopidogrel in the list of drugs that trigger AGEP. Additionally, both previously reported cases of AGEP induced by clopidogrel occurred in women started on anticoagulant therapy after stent placement. These case reports should alert dermatopathologists and dermatologists to this Figure 1 Diffuse scarlatiniform erythema and non-follicular pustules in a 54-year-old woman with recent myocardial infarction and urgent cardiac catheterization, who was started on clopidogrel

Common Child and Adolescent Cutaneous Infestations and Fungal Infections

Cutaneous infections and infestations are common among children and adolescents. Ectoparasitic infestations affect individuals across the globe. Head lice, body lice, scabies, and infestations with bed bugs are seen in individuals who reside in both resource poor areas and in developed countries. Superficial cutaneous and mucosal candida infections occur throughout the life cycle. Dermatophyte infections of keratin-containing skin and skin structures result in tinea capitis (scalp), tinea corporis (body), tinea pedis (foot), and tinea unguium (nails). Less frequent endemic fungal infections such as blastomycosis, coccidiodomycosis, and histoplasmosis may present with skin findings. This article will describe the epidemiology and transmission of these conditions as well as their clinical manifestations. The approach to diagnosis will be addressed as well as primary prevention and current therapies.

Dermatitis Herpetiformis: Rare Cutaneous Manifestation of Colon Adenocarcinoma

A previously healthy mildly obese 72-year-old Caucasian male with well-controlled type II diabetes presented with a 2-month history of a pruritic papulovesicular rash on the extensor surface of the forearms. Skin punch biopsy showed subepidermal multilocular bullous lesions with edema and neutrophils (Fig. 1). Direct immunofluorescence showed dense granular deposits of IgA in the basement membrane and at the tips of dermal papillae, consistent with the diagnosis of dermatitis herpetiformis (DH) (Fig. 2). The patient did not have any gastrointestinal symptoms, and celiac disease serology including anti-endomysial antibodies and anti-tissue transglutaminase IgA and IgG were negative. The patient did not have any significant improvement in skin lesions on dapsone and gluten-free diet. Six months later, the patient presented with acute onset of right-sided abdominal pain, generalized weakness, anorexia, 25-lb weight loss, and several episodes of melena with iron deficiency anemia. A CT scan of the abdomen showed focal colonic wall thickening and a 5.5-cm hepatic flexure pericolonic fluid collection containing air, which was suggestive of focal perforation with a pericolonic abscess. Multiple enhancing liver lesions were noted which were suspicious for metastatic disease. Lymphadenopathy was noted in the right upper abdomen, involving the portacaval, periportal, and celiac axis regions. The largest lymph node, located in the portacaval region, measured up to 3.2 cm. Colonoscopy 3 years prior was normal. Carcinoembryonic antigen level was elevated at 414. Due to risk of perforation, colonoscopy was delayed pending image-guided biopsy. Biopsy of the liver lesions revealed poorly differentiated adenocarcinoma. Subsequent colonoscopy showed a 9-cm friable, ulcerated, partially obstructing mass extending from the hepatic flexure to the proximal transverse colon (Fig. 3). Endoscopic mucosal biopsies were consistent with poorly differentiated adenocarcinoma. Immunohistochemistry was positive for CK7, mucin, and CK20 and negative for CDX2, TTF-1, chromogranin, synaptophysin, PSA, and PAP. The patients clinical condition deteriorated rapidly, and he passed away 1 month following the diagnosis of metastatic colon cancer.

Subcorneal pustular dermatosis and episcleritis associated with poorly controlled ulcerative colitis.

A man aged 56 years with a history of ulcerative colitis (UC) status postsubtotal colectomy was hospitalised with fevers, dry cough, eye redness and a new bloody, mucoid rectal discharge. 2 months prior to admission, the dermatologist had started him on dapsone for subcorneal pustular dermatosis but did not recognise that he had recently self-discontinued mesalamine enemas, inducing a flare of his UC. After a thorough inpatient evaluation, including flexible sigmoidoscopy, active UC involving the rectal stump was determined to be driving his dermatological and ophthalmological findings. By reinstituting mesalamine enemas, control of his UC was achieved and the extraintestinal manifestations of his inflammatory bowel disease (IBD) resolved. This case illustrates the importance of careful history taking and of early recognition of extraintestinal manifestations of IBD in order to appropriately target treatment and prevent unnecessary morbidity.

Chronic Cutaneous Blastomycosis

A 71 year-old male veterinarian developed swelling and an erythematous eruption on his right 4th finger two weeks after receiving a puncture wound from the claw of a cat. The patient denied pain, pruritus, or ulceration, and review of systems was negative. Four weeks later, the patient developed tender right epicondylar lymphadenopathy. His primary care physician treated him empirically with multiple antibiotics including amoxicillin/clavulanic acid, doxycycline, and rifampin. His lymphadenopathy resolved; however, the rash persisted.