Mary Gail Mercurio

Cutaneous photosensitivity diseases induced by exogenous agents

Cutaneous photosensitivity diseases may be idiopathic, produced by endogenous photosensitizers, or associated with exogenous photosensitizers. Those caused by exogenous agents include phototoxicity, photoallergy, and the exacerbation or induction of systemic disorders in which photosensitivity is a prominent clinical manifestation. Phototoxic disorders have a high incidence, whereas photoallergic reactions are much less frequent. The action spectra for most phototoxins and photoallergens lie in the UVA range. Phototoxic and photoallergic reactions can be distinguished on the basis of pathogenesis, clinical characteristics, diagnosis, and management. Drugs capable of causing phototoxic reactions include psoralens, porphyrins, coal tar, antibiotics, and nonsteroidal antiinflammatory agents. Drugs capable of causing photoallergic reactions include topical antimicrobial agents, fragrances, sunscreens, nonsteroidal antiinflammatory agents, plants, and psychiatric medications. Drug-induced systemic diseases in which photosensitivity is a prominent component include drug-induced lupus erythematosus, porphyria, and pellagra.

Outbreak of Mycobacterium chelonae Infection Associated with Tattoo Ink

BACKGROUND In January 2012, on the basis of an initial report from a dermatologist, we began to investigate an outbreak of tattoo-associated Mycobacterium chelonae skin and soft-tissue infections in Rochester, New York. The main goals were to identify the extent, cause, and form of transmission of the outbreak and to prevent further cases of infection. METHODS We analyzed data from structured interviews with the patients, histopathological testing of skin-biopsy specimens, acid-fast bacilli smears, and microbial cultures and antimicrobial susceptibility testing. We also performed DNA sequencing, pulsed-field gel electrophoresis (PFGE), cultures of the ink and ingredients used in the preparation and packaging of the ink, assessment of source water and faucets at tattoo parlors, and investigation of the ink manufacturer. RESULTS Between October and December 2011, a persistent, raised, erythematous rash in the tattoo area developed in 19 persons (13 men and 6 women) within 3 weeks after they received a tattoo from a single artist who used premixed gray ink; the highest occurrence of tattooing and rash onset was in November (accounting for 15 and 12 patients, respectively). The average age of the patients was 35 years (range, 18 to 48). Skin-biopsy specimens, obtained from 17 patients, showed abnormalities in all 17, with M. chelonae isolated from 14 and confirmed by means of DNA sequencing. PFGE analysis showed indistinguishable patterns in 11 clinical isolates and one of three unopened bottles of premixed ink. Eighteen of the 19 patients were treated with appropriate antibiotics, and their condition improved. CONCLUSIONS The premixed ink was the common source of infection in this outbreak. These findings led to a recall by the manufacturer.

Characteristic purpura of the ears, vasculitis, and neutropenia–a potential public health epidemic associated with levamisole-adulterated cocaine

BACKGROUND Dermatologists at the University of California, San Francisco recently reported two patients in the online Journal of the American Academy of Dermatology with purpura presumably induced by levamisole in contaminated cocaine. Levamisole-induced vasculitis and neutropenia has been reported elsewhere in the United States and Canada. Up to 70% of cocaine in the United States could be contaminated. OBJECTIVE We sought to describe similar cases of vasculitis associated with cocaine use. METHODS This is a retrospective case series. RESULTS We report 6 remarkably similar patients seen over just the past few months with retiform purpura on the body and tender purpuric eruptions, necrosis, and eschars of the ears after cocaine use in New York and California. All of these patients had positive perinuclear antineutrophil cytoplasmic antibody values and 3 of the 6 also had an associated neutropenia. Direct immunofluorescence studies suggested an immune complex-mediated vasculitis. LIMITATIONS This case series is descriptive in nature and, because testing is not easily performed, we did not test for levamisole in the serum or blood to prove this is the causative agent. CONCLUSION It appears the use of cocaine is associated with the peculiar clinical findings of ear purpura, retiform purpura of the trunk, and neutropenia. We believe this case series may represent the tip of the iceberg as a looming public health problem caused by levamisole. Although the direct causal relationship may be difficult to establish, the astute dermatologist or primary care physician should be able to recognize the characteristic skin lesions and should be wary of the potential development of agranulocytosis.

Minocycline-Induced Drug Hypersensitivity Syndrome Followed by Multiple Autoimmune Sequelae

BACKGROUND Drug hypersensitivity syndrome (DHS) is a severe, multisystem adverse drug reaction that may occur following the use of numerous medications, including anticonvulsants, sulfonamides, and minocycline hydrochloride. Long-term autoimmune sequelae of DHS have been reported, including hypothyroidism. OBSERVATIONS A 15-year-old female adolescent developed DHS 4 weeks after starting minocycline therapy for acne vulgaris. Seven weeks later she developed autoimmune hyperthyroidism (Graves disease), and 7 months after discontinuing minocycline therapy she developed autoimmune type 1 diabetes mellitus. In addition, she developed elevated titers of several markers of systemic autoimmune disease, including antinuclear, anti-Sjögren syndrome A, and anti-Smith antibodies. CONCLUSIONS Minocycline-associated DHS may be associated with multiple autoimmune sequelae, including thyroid disease, type 1 diabetes mellitus, and elevated markers of systemic autoimmunity. Long-term follow-up is needed in patients with DHS to determine the natural history of DHS-associated sequelae.

Treatment of Human Papilloma Virus in a 6-Month-Old Infant with Imiquimod 5% Cream

A healthy female infant was diagnosed with genital warts at six months of age. She was the product of an uncomplicated vaginal delivery to a mother who was diagnosed with genital warts during the pregnancy, but did not undergo any treatment. The infant’s warts were clinically resolved following a three week course of 5% imiquimod cream, an immunomodulating agent that has been demonstrated to be a potent inducer of several cytokines promoting an antiviral cell‐mediated immune response.

Hirsutism: Diagnosis and management.

BACKGROUND Hirsutism is defined as excess hair growth in androgen-dependent areas of the body in women. OBJECTIVE This article provides an updated review of hirsutism, focusing on the etiologies, clinical features, approach to diagnostic evaluation, and treatment options. METHODS The PubMed database was searched for English-language articles published from 1981 to the present, using the terms hirsutism, polycystic ovarian syndrome, congenital adrenal hyperplasia, hirsutism diagnosis, and hirsutism treatment. Reference lists from review articles on hirsutism during this time period were also examined. RESULTS While there are many causes of hirsutism, the majority of patients have a benign process that may be idiopathic. In some circumstances, hirsutism is a sign of functional ovarian hyperandrogenism or congenital adrenal hyperplasia. Even more rarely, it is the presenting sign of an internal malignancy. CONCLUSIONS Hirsutism clinically presents in women as excessive hair growth in androgen-dependent areas. It is a particularly important diagnosis to make, because it often significantly affects a womans perception of her femininity and less commonly can be a sign of an underlying malignancy or a cutaneous manifestation of a condition with significant cardiovascular or other morbidity. A variety of treatments exist to help minimize the appearance of unwanted hair.

Congenital Leukemia Cutis

Abstract:  We describe a premature neonate who was born with pancytopenia and a single subcutaneous nodule on her right lower extremity. A biopsy specimen from the nodule demonstrated a dense infiltrate of pleomorphic mononuclear cells that extended throughout the dermis and into the subcutaneous tissue. Immunohistochemical stains and bone marrow examination confirmed a diagnosis of acute myelogenous leukemia. Cytogenetic studies on peripheral blood by G‐banding analysis revealed an abnormal karyotype of 46, XX, ins[inv(10)(p11.2q22.2);11](q22.2;q13.2q23.2). A split in the mixed lineage leukemia gene was identified by fluorescence in situ hybridization. Induction chemotherapy was started but was complicated by multiorgan failure. The patient died on the eleventh day of life. As leukemia cutis more typically presents as multiple infiltrative papules, nodules, or plaques, we stress the importance of including leukemia in the differential diagnosis of a solitary nodule in a neonate.

Medical and surgical approaches to vulvar intraepithelial neoplasia

Vulvar intraepithelial neoplasia (VIN) is a precursor to invasive vulvar carcinoma. The two major types of VIN, usual and differentiated, differ in epidemiology, pathogenesis, clinical manifestations, pathology, and malignant potential. Usual VIN commonly occurs in younger women. It is associated with human papillomavirus and tends to have multifocal and multicentric involvement. Differentiated VIN is frequently associated with benign vulvar dermatoses such as lichen sclerosus and lichen simplex chronicus. It occurs in older women and typically is unifocal and unicentric. Clinicians must have a high suspicion for VIN, which is diagnosed by biopsy. Surgical excision has been the standard treatment in order to prevent progression to invasive disease. The objectives of treatment have expanded to include preservation of normal vulvar function and anatomy. Therefore, management options are being investigated, including topical therapy, laser excision and vaporization, and photodynamic therapy. All can be effective in both eliminating disease and maintaining relatively normal‐appearing and functioning anatomy.

Malignant tumors of the penis.

BACKGROUND Although penile cancer is rare in developed countries, it occurs more frequently in other parts of the world and causes significant morbidity and mortality. OBJECTIVE To review the current literature on the pathogenesis, risk factors, clinical presentation, staging, and treatment of premalignant and malignant tumors of the penis. MATERIALS AND METHODS A literature review using PubMed was conducted searching for articles on penile malignancies. RESULTS The majority of penile cancers are in situ or invasive squamous cell carcinomas, although other rare tumors of the penis occur, such as melanoma, basal cell carcinoma, extramammary Pagets disease, and soft tissue sarcomas. CONCLUSION Physicians should be aware of the risk factors and clinical presentation of penile malignancies because early diagnosis is essential in effective management and cure. Accurate staging is imperative for risk stratification and treatment planning. Depending on the type of tumor, size of tumor, location, staging, and grading, treatment modalities vary and may include topical chemotherapy, surgical excision, Mohs micrographic surgery, laser excision or ablation, systemic chemotherapy, and radiotherapy.

Tinea capitis : Fluconazole in trichophyton tonsurans infection

Abstract: Tinea capitis is the most common dermatophyte infection in children. Trichophyton tonsurans is the most common etiologic agent in the United States, and for more than four decades the standard therapy has been griseofulvin. The availability of newer, and often more effective, antifungal drugs creates the opportunity for choice and the ability to optimally tailor treatment for a particular patient. Fluconazole is an azole antifungal drug available in a pleasant, well‐tolerated, liquid formulation ideal for the pediatric population. It has a good safety profile and is approved in the United States for use in children, although not for tinea capitis. We present five patients with tinea capitis successfully treated with fluconazole.