Nadir Goksugur

Basic histological structure and functions of facial skin

The skin and its appendages that derive from the epidermis (hair follicles, sweat glands, sebaceous glands, nails, and mammary glands) establish the integumentary system. Histologically, skin has two main layers-the epidermis and the dermis-with a subcutaneous fascia called the hypodermis, which lies deep in the dermis. The epidermis is formed of four to five layers of cells made mostly out of keratinocytes, along with three other different and less abundant cells. The dermis underlies the epidermis. The hypodermis is a looser connective tissue that is located beneath the dermis. It blends to the dermis with an unclear boundary.

Carbamazepine-induced hypogammaglobulinemia

Carbamazepine is used to control seizures. Its common side effects are sleep disorders, anorexia, nausea, vomiting, polydipsia, irritability, ataxia, and diplopia. Involvement of the immune system is rare, and few cases of decreased immunoglobulin levels have been reported. We describe a patient with low immunoglobulin levels due to carbamazepine use who presented with recurrent urinary tract infection. Intravenous immunoglobulin was administered, and immunoglobulin levels increased to safer levels after discontinuation of carbamazepine. Previous reports describe severe infection after carbamazepine-induced hypogammaglobulinemia. Therefore, in patients using antiepileptics, particularly carbamazepine, serum immunoglobulin levels should be checked in those with recurrent infections.

Tongue hyperpigmentation during interferon therapy

Dear Editor, Chronic hepatitis C virus (HCV) infection has been reported in association with some cutaneous disorders such as lichen planus, vasculitis and porphyria cutanea tarda. Also, there have been many cutaneous side-effects of interferon (IFN) treatment such as vasculitis, transient alopecia and trichomegaly. It seems that combination IFN and ribavirin (RBV) causes more toxic skin reactions than IFN alone. Here, we report a woman who developed tongue hyperpigmentation during pegylated (PEG)-IFNa2b and RBV treatment for HCV infection. Mucosal, especially the tongue hyperpigmentation associated with IFN and RBV treatment for HCV infection is rare and has been reported in only 15 patients to date. A 54-year-old woman had been diagnosed with chronic active hepatitis C 2 months prior. The liver biopsy was done and histological activity index (HAI) was 11 and fibrosis score was 2. PEG-IFN-a2b (1.5 mcg ⁄kg once weekly) and RBV (1 g daily) treat-

Prevalence and risk factors of asthma and allergic diseases among schoolchildren in Bolu, Turkey

Aim: In this study we aimed to detect the prevalence and risk factors of asthma and allergic diseases in children aged between 7 and 14 years old at rural and urban areas of Bolu, Turkey.

Hand, Foot, and Mouth Disease

A 4-year-old boy presented with a 5-day history of mild fever and malaise and a 3-day history of a vesicular rash involving his hands, feet, tongue, and buttocks. Goksugur N., Goksugur S. N Engl J Med 2010;362:e49, April 8, 2010

Tear and serum vitamin D levels in children with allergic rhinoconjunctivitis

BACKGROUND Although solid cohort studies confirmed a preventative role for the anti-oxidant vitamin D in allergic asthma, a limited number of studies focused on allergic rhinoconjunctivitis (ARC). Here, we aimed to determine 25-hydroxycholecalciferol levels in tear and serum in young allergic rhinoconjunctivitis patients as compared to their apparently healthy matched controls. METHODS In total, 22 children with allergic rhinoconjunctivitis and 31 healthy control subjects underwent serum total IgE and 25-hydroxycholecalciferol measurements. Tear levels of 25-hydroxycholecalciferol were also determined in both groups. RESULTS The mean serum total IgE level in the ARC group (143.6±132.8IU/ml) was significantly higher than that in the control group (54.8±44.1IU/ml; p=0.03). Serum 25(OH)D levels were significantly higher in the ARC group (34.1±12.7ng/ml) than in the healthy controls (21.8±11.3ng/ml; p=0.001). CONCLUSIONS To our knowledge, this is the first reported study to show an association between serum 25-hydroxycholecalciferol and ARC in a childhood group. Higher levels of serum 25-hydroxycholecalciferol in children with allergic rhinoconjunctivitis may indicate a possible aetiopathogenic mechanism in the development of allergic rhinoconjunctivitis. This is also the first report to examine tear fluid vitamin D levels in paediatric ARC patients.

Neurofibromatosis of nipple-areola complex.

Neurofibromatosis type I or von Recklinghausen disease is an autosomal-dominant condition with well-known clinical signs, including café au lait patches, axillary freckling, Lisch nodules, and multiple neurofibromas. A 41-year-old woman presented to our unit with severe neurofibromatosis of nipple-areola complex (NAC) like a bunch of grapes, associated with multiple neurofibromas of the trunk and limbs (Fig. 1a). Bilateral bunch of neurofibromas arising from the NAC associated with numerous cutaneous neurofibromas are illustrated in a reconstructed axial MRI image with VRD (volume rendering display) technique (Fig. 1b). Neurofibromas are characteristically distributed all over the trunk, head and neck area. Massive neurofibromatosis of the breast rarely invades all breast tissue and deforms the NAC as in our case. Craniocaudal mammographic projections of right and left breast demonstrate well-defined, noncalcificated, multilobular masses originating from the NAC (Fig. 1c). In MRI, solid lesions with lobulated contours arising from the NAC are homogenously hyperintense on axial T1 weighted and heterogenously hyperintense on axial T2 weighted images compared with striated muscle. Several nodular cutaneous lesions having similar signal characteristics are demonstrated as well (Fig. 1d).

The blueberry sign

Cryotherapy is an effective treatment modality for various skin diseases. It is most commonly used to destroy viral warts, actinic keratosis, and seborrheic keratosis. Although cryotherapy is a relatively safe procedure, it can have a wide variety of side effects. A 14-year-old boy presented with a wart over the dorsum of his right hand. The lesion was treated with two freeze–thaw cycles of cryotherapy using an open-spray technique with freeze time of 15 s. A painful, blue–black, hemorrhagic blister developed over the posterior of the right hand on day 3 of treatment (Fig. 1). Because it so closely resembled a blueberry fruit (Fig. 2), we named this phenomenon the blueberry sign. Neither the patient’s history nor laboratory investigations revealed any systemic disorder, and the lesion healed completely.

Giant Chondroid Syringoma of the Breast

*Department of Dermatology, Medical Faculty, Abant Izzet Baysal University, Bolu, Turkey; Department of Radiology, Medical Faculty, Abant Izzet Baysal University, Bolu, Turkey; Department of Chest Disease, Medical Faculty, Abant Izzet Baysal University, Bolu, Turkey; Department of Otorhinolaryngology, Bolu Koroglu State Hospital, Bolu, Turkey; Department of Pathology, Medical Faculty, Abant Izzet Baysal University, Bolu, Turkey

Hunting Sarcoptes scabiei—dead or alive!

A 13-year-old boy presented with a 3-week history of generalised pruritus, which worsened at night. Physical examination revealed small non-specifi c papules, vesicles, crusts, eczematisations and lichenifi cations, as well as excoriations from scratching. Diagnosis of scabies was confi rmed after identifi cation of a burrow between the patient’s fi ngers. The patient was successfully treated by application of 5% permethrin cream. Females of Sarcoptes scabiei var hominis spread and cause the disease, burrowing into the stratum corneum of the epidermis at a rate of 0·5–5·0 mm per day, where it feeds and lays eggs. Burrows are rarely visible, appearing as greyish-white or pink, scaly, threadlike lines arranged in a zigzag or twisted pattern. The burrows are 0·5 to 1 cm long and are most commonly seen on the fi ngers, wrists, or penis. A diagnosis of scabies is typically confi rmed by the identifi cation of a mite, mite parts, eggs, or waste products (scybala) during microscopic examination of a skin scraping. With a great deal of care, mites can be removed from burrows with a lancet—it is usually the black dot at the end of the tunnel—and viewed under a microscope (fi gure; webvideo). Finding S scabiei dead or alive in a patient’s epidermis provides a defi nitive diagnosis of scabies, although in our opinion, the retrieval of a live specimen off ers a more interesting and educational experience, especially for resident doctors and medical students.