Naeem Raza

Presentation of early onset psoriasis in comparison with late onset psoriasis: a clinical study from Pakistan.

BACKGROUND Early onset psoriasis and late onset psoriasis are known to have different clinical patterns in Caucasian population. However, there is paucity of data among Asian patients. AIMS To compare the clinical presentation of early onset psoriasis with late onset psoriasis in Pakistani population. METHODS During the study period, participating dermatologists filled a pre-tested questionnaire for each patient with psoriasis on first encounter. The questionnaire incorporated information regarding clinical and demographic features of psoriasis including age of onset, clinical type of psoriasis, nail or joint involvement, and PASI score. Patients were then divided into early onset (age of onset < 30 years, group I) and late onset (age of onset > or =30 years, group II) psoriasis. RESULTS Five hundred and fifteen questionnaires were filled and returned for evaluation. There was no statistically significant difference in both groups with regards to gender, family history (P = 0.09), nail (P = 0.69) and joint (P = 0.74) involvement, disease severity (P = 0.68), and clinical type of psoriasis (P = 0.06). No significant difference between disease severities measured by PASI score was observed in the two groups (P = 0.68). Presence of nail involvement was associated with joint disease in both groups (odds ratio 2.8, confidence interval 1.9-4.1). CONCLUSION Patients with early and late onset psoriasis in Pakistani population do not show different clinical and demographic features contrary to the Western patients.

Lupoid cutaneous leishmaniasis: a report of 16 cases.

BACKGROUND Lupoid cutaneous leishmaniasis (CL) is known as the chronic form of CL. However, keeping its clinical presentation in view, there is a need to revisit this form of disease. AIMS To redefine/describe lupoid CL in view of clinical features. METHODS It was a case series seen in Muzaffarabad (Pakistan) from Jan 2006 to May 2008. All patients clinically suggestive and consistent with laboratory diagnosis of CL were registered. Patients of all age groups and either sex having cutaneous lesions resembling lupus vulgaris or lupus erythematosus on the face or elsewhere were included in the study. Those having chronic fluctuating/relapsing course or scarring within the lesions were also included. Various demographic features of the patients and clinical patterns were recorded. Descriptive statistics were used for analysis. RESULTS Of 254 registered patients of CL, 16 (6.3%) were diagnosed as lupoid CL. None of the patients had scarred lesions. Age ranged from 38 to 75 (55 + 15.11) years and duration of lesions varied from 4 to 32 (14.25 + 07.59) weeks. All patients had lesions over the face. Thirteen (81.25%) had a large solitary plaque extending over the nose and a large part of the cheeks and three (18.75%) had multiple lesions. Lesions were central/nasal in two (12.5%), unilateral/asymmetrical in four (25%) and bilateral/symmetrical in 10 (62.5%). Morphological patterns included erythematous/infiltrated (7), psoriasiform (6), ulcerated/crusted (2) and Discoid lupus erythematosus (DLE)[G1] like (1). CONCLUSION Lupoid CL is not strictly a chronic form of disease, which presents on the face from the very onset and shows no scarring or recurrence.

Constitutional and Behavioral Risk Factors for Chilblains: A Case-Control Study From Pakistan

OBJECTIVES To study constitutional and behavioral risk factors for chilblains in patients at Abbottabad and Sialkot, Pakistan. METHODS One hundred patients and matched controls completed a single-page, close-ended questionnaire which included demographic data and questions related to possible constitutional and behavioral risk factors for chilblains. Computer program SPSS-10 was used to manage and analyze the data. Risk factors were identified statistically by determining odds ratios and 95% confidence intervals using multivariate analysis. RESULTS There were an equal number of male and female respondents in each group. Age of the patients and controls ranged from 2 to 80 years with a mean of 24.51 +/- 16.02. Twenty-six patients and 3 controls had a positive family history for chilblains (odds ratio = 9.33); 42 patients and 14 controls reported a history of constipation (odds ratio = 2.69); 32 patients and 8 controls had a history of either numbness or tingling of fingers or toes (odds ratio = 2.93); 55 patients and 45 controls led sedentary lifestyles (odds ratio = 1.27); 85 patients and 58 controls consumed a low number of cups of tea daily (odds ratio = 3.20); 65 patients and 29 controls frequently washed their hands and/or feet (odds ratio = 4.93); and 56 patients and 33 controls had occasional sun exposure during winter months (odds ratio = 2.08). CONCLUSION Significant risk factors for the development of chilblains for people at Abbottabad and Sialkot included a history of chilblains in first-degree relatives, numbness and tingling sensations of fingers or toes, frequent hand or feet washing, and lower tea consumption during winter months.

Drug induced toxic epidermal necrolysis: two case reports

IntroductionAmong the various drug induced dermatological entities toxic epidermal necrolysis and Stevens-Johnsons syndrome occupy a primary place in terms of mortality. Prompt recognition of these conditions, immediate drug withdrawal and institution of appropriate treatment plays a vital role in reducing mortality. Drugs are by far the most common cause of toxic epidermal necrolysis, in which large sheets of skin are lost from the body surface making redundant the barrier function of the skin, with its resultant complications. The use of systemic corticosteroids in the treatment of toxic epidermal necrolysis has always been controversial, some consider corticosteroids life-saving while others believe that they increase mortality.Case presentationWe describe two cases of drug-induced toxic epidermal necrolysis, a male and a female, both caucasoids of Pakistani origin, one treated without any steroids and the other with them, who made complete recovery without any major complications or sequelae.ConclusionThe administration of systemic corticosteriods did not cause any major changes in outcome in our cases.

Dermatosis neglecta in a case of multiple fractures, shoulder dislocation and radial nerve palsy in a 35-year-old man: a case report

IntroductionDermatosis neglecta is an often misdiagnosed and under-diagnosed condition. In dermatosis neglecta, a progressive accumulation of sebum, sweat, keratin and other dirt and debris, occurs due to inadequate local hygiene resulting in a localized hyperpigmented patch or a verrucous plaque. Vigorous rubbing with alcohol-soaked gauze or soap and water results in a complete resolution of the lesion. This is the first case of dermatosis neglecta reported in a patient with multiple traumatic injuries.Case presentationWe report a case of a 35-year-old male Caucasian of Pakistani origin, with multiple fractures, neurological deficit and immobility sustained in a fall, leading to the development of dermatosis neglecta of the left hand.ConclusionEarly and prompt clinical recognition of this condition eliminates the need for aggressive diagnostic and therapeutic procedures.

Millipede Burn at an Unusual Site Mimicking Child Abuse in an 8-Year-Old Girl

An 8-year-old girl was seen with a 4-day history of painful swelling of her external genitalia. According to the mother, the child slept well at night on a raised bed, but woke up in the morning with the swelling. On examination, there was swelling and brownish red discoloration of the vulval region along with a small amount of desquamation. The clitoral region was markedly swollen, with deep red brown (mahogany) discoloration and a linear fissure (Figure 1). A mild mucopurulent discharge was noted in the vicinity. The area was tender to touch, and the child resisted examination. No abnormality of the vaginal opening was noted. At this point, the possibility of child abuse was considered, and she was admitted to the hospital. On further questioning, the mother remembered seeing a dead elongated insect in the child’s clothing that morning. The patient was treated with oral amoxicillin/ potassium clavulanate suspension and local application of a cream containing steroid and antibacterial agents. The lesion started to improve, with healing of the fissure, reduction of swelling and erythema, and formation of a mahogany colored crust over the clitoral region, thus confirming the suspicion of millipede burns (Figure 2). As the lesion was healing, depigmentation of the surrounding area was noted. Millipedes are elongated multisegmental arthropods belonging to class Diplopoda because they have 2 pairs of legs to each segment of the body. Some are bioluminescent and are very colorful, and are at times kept as pets. They range in length from as small as 3 mm to giants exceeding 270 mm found in tropical and subtropical regions. They feed on decaying vegetable material and are generally regarded as harmless; however, when acting defensively, some tropical species may cause harm to humans. Millipedes do not bite because they do not have biting jaws, but they secrete noxious substances like benzoquinone and hydroquinone from the repugnatorial glands present along the body segments. Contact of these substances with the skin produces a millipede burn characterized by burning sensation, edema, vesiculation, cracking of skin, and a yellow brown stain that may darken to a mahogany color. The extent of the injury depends on the specie of millipede and the extent of the contact to the patient. These arcuate burn-like lesions in children may be easily mistaken for signs of child abuse. Laboratory investigations are not helpful in making a diagnosis, and histologic evaluation reveals fullthickness epidermal necrosis. These changes are nonspecific, and the diagnosis depends on history and clinical findings.

Hearing improvement after stapedotomy using teflon loop prosthesis.

OBJECTIVE To assess hearing improvement after stapedotomy for otosclerosis using teflon loop prosthesis. DESIGN Quasy experimental study. PLACE AND DURATION OF STUDY January 2001 to May 2003 in the Otorhinolaryngology Department, CMH, Rawalpindi. PATIENTS AND METHODS Thirty diagnosed cases of otosclerosis were included in the study. Ear with greater air-bone gap was selected and stapedotomy was done using teflon loop prosthesis (size 4 - 4.5 mm). Mild vertigo occurred during immediate postoperative period, which subsided with Inj. Prochlorperazine. Patients were followed-up postsurgically at one month, two months, four months, six months and one year and postoperative air-bone gap was calculated. RESULTS Out of 30 cases, there were 24 males and 06 females. The age ranged from 18 to 50 years. Twenty-one (70%) patients had bilateral hearing loss and 09 (30%) had tinnitis also. Pre-operative audiograms showed conductive deafness. Carharts notch was present in 10 (33.3%) cases. Tympanogram revealed loss of stapedial reflex. Postoperatively good hearing improvement was seen in 56.7% (postoperative air-bone gap closure upto 10 dB), fair improvement in 30% (postoperative air bone gap closure from 11 to 20 dB) and poor results in 10% (postoperative air-bone gap more than 21 dB) cases. One patient developed dead ear. CONCLUSION Stapedotomy using teflon loop prosthesis for otosclerosis is an effective method to restore hearing. Complications are uncommon.

Ross syndrome with generalized anhidrosis and localized disabling compensatory hyperhidrosis.

Ann Saudi Med 28(1) January-February 2008 www.saudiannals.net 53 Ross syndrome is a progressive degenerative disorder of cutaneous sensory and autonomic innervation. Since Ross’ first description in 1958, approximately 40 cases have been described.1 It is clinically characterized by a triad of anhidrosis, tonic pupil and deep tendon areflexia. Anhidrosis may be acc companied by compensatory hyperhidrosis and other alterations of the autonomic nervous system.2,3 It has been suggested that sweating disorder results from progressive impairment of heat production and heat dissipation through both loss of sweating and loss of cutaneous blood flow regulation.1 The pathophysiology underlying Adie’s pupil is postcganglionic denervation of cholinergic fibers between the ciliary ganglion and the iris sphincter muscle. Initially there is dilatation of the pupil, but later, due to aberrant recinnervations of the iris or to the hypersensitive pupillary sphincter muscle, the pupil becomes constricted and tonic. In tonic pupils the near reaction is usually better than the light reaction accommodation reflex. Depression of deep tendon reflexes is due to dorsal root ganglionic degeneration or spinal interneuron loss. We report a patient with Ross syndrome who prec sented with generalized anhidrosis and socially disc abling localized compensatory hyperhidrosis along with tonic pupil and deep tendon hyporeflexia.