Parbeer Grewal

Fact or Fiction: Does the Non-HIV/AIDS: Immunosuppressed Patient Need Pneumocystis Jiroveci Pneumonia Prophylaxis? An Updated Literature Review

Background: Pneumocystis jiroveci pneumonia (PJP) is a potentially fatal fungal infection occurring in immunocompromised patients. Objective: To determine whether PJP prophylaxis is required in the non-human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) immunocompromised patient and, if so, the optimal prophylactic therapy. Methods: A thorough literature review, with the appropriate MeSH terms, was conducted using PubMed, Medline, and The Cochrane Database. A number of cases describing PJP in patients with various systemic diseases and immunosuppressive medications, along with a Cochrane review, were highlighted. Results: Although there are a number of case reports in the literature, the only collagen vascular disease with an increased incidence of PJP is Wegener granulomatosis. Oral trimethoprim-sulfamethoxazole continues to be the prophylaxis of choice for PJP. Conclusion: There is currently no evidence to recommend PJP prophylaxis in the non-HIV/AIDS immunocompromised population. If physicians do decide to use prophylaxis, they should always weigh the benefits with the potential risks. Further studies are needed to better quantify the risks of PJP with immunosuppressive medications.

Acrokeratosis paraneoplastica (Bazex syndrome) presenting in a patient with metastatic breast carcinoma: possible etiologic role of zinc.

Background: Bazex syndrome (acrokeratosis paraneoplastica) is a rare paraneoplastic syndrome that usually occurs in males over 40 years old and is particularly associated with squamous cell carcinoma of the upper aerodigestive tract and adenopathy above the diaphragm. Objective: The objectives of our article are (1) to describe a unique case of acrokeratosis paraneoplastica and (2) to review the current literature regarding skin findings, commonly associated neoplasms, and treatment options relative to this condition. Patient: We describe a 68-year-old female with lobular breast carcinoma, complicated by local and distant recurrences, who presented with a 1-year history of prominent acral skin and nail changes. Results: Our patients clinical skin findings improved significantly following treatment and partial remission of her underlying malignancy. Conclusions: Our patient represents one of few females described with this syndrome, which is especially rare in association with lobular breast carcinoma. Further, the patients presentation is unique as she was discovered to demonstrate laboratory findings consistent with coexistent porphyria cutanea tarda and relative zinc deficiency.

Erythema induratum: case series illustrating the utility of the interferon-γ release assay in determining the association with tuberculosis.

Background: The interferon-γ release assay (IGRA) is a novel method for detecting previous sensitization to tuberculosis (TB). Despite having several advantages over the tuberculin skin test (TST), including higher specificity and no influence from past bacille Calmette-Guérin (BCG) exposure, there are a limited number of reports describing its application in patients with erythema induratum (EI)/nodular vasculitis (NV), which is usually but not always related to TB. Objectives: The aim of our case series was to evaluate the usefulness of the IGRA for determining a TB association in patients with EI/NV. Methods: Retrospective chart reviews were conducted on four patients diagnosed with EI/NV at our institution in whom an IGRA had been performed. Results: All four subjects had positive TST results. The IGRA was also positive and therefore supported a link with TB in two cases. One patient responded completely to anti-TB therapy, whereas the second was lost to follow-up. Both cases unrelated to TB, by virtue of negative IGRAs, demonstrated complete response to immunosuppressive therapy (methotrexate), with one individual having failed anti-TB therapy first. Conclusion: Our case series highlights the utility of the IGRA for establishing a TB association in patients with EI/NV. Although limited by a small sample size, we propose adjunctive use of this test at the time of EI/NV diagnosis, especially in the setting of previous BCG exposure, so that management can be tailored according to whether an underlying relationship with TB exists.

Is necrolytic migratory erythema due to glucagonoma a misnomer? A more apt name might be mucosal and intertriginous erosive dermatitis.

Background: In dermatology, many conditions are given names that ultimately prove to be a misnomer (eg, mycosis fungoides, pyogenic granuloma). For most misnomers, continued use of the inappropriate word(s) rarely results in a delay in diagnosis and/or treatment. An argument can be made that the term necrolytic migratory erythema (NME) due to glucagonoma results in a delay in diagnosis, often with fatal consequences. Objective: We reviewed the literature of the past 30 years concerning the dermatologic and histologic findings of NME in association with glucagonoma. The most striking feature evident in nearly all reported cases is the presence of mucosal lesions and annular, eroded, eczematous patches and plaques of intertriginous areas. Conclusion: We propose the renaming of the eruption associated with glucagonoma to one that emphasizes its unique localization to the mucosa and intertriginous areas: mucosal and intertriginous erosive dermatitis. It is hoped that this will lead to a more timely recognition of the condition and a possible improvement in prognosis.

Gorlin Syndrome Presentation and the Importance of Differential Diagnosis of Skin Cancer: A Case Report

In a busy community practice, clinical skin findings can often be misinterpreted. Skin cancers can sometimes mimic rashes like psoriasis, eczema or prurigo nodularis in both appearance and symptoms. Gorlin syndrome is one such genetic syndrome, characterized by the eruption of multiple and early onset basal cell carcinomas (BCCs), which can be mistaken for a rash. We describe a 68-year-old female who presented to the dermatology office with a previous history of over 30 BCCs that had been previously biopsied and/or surgically removed. However, the patient had been lost to follow up for several years and had not been seen by a skin specialist. In the interim, she had been misdiagnosed as having eczematous or psoriatic lesions by primary care providers. Patients with Gorlin syndrome are even harder to diagnose as their skin cancers often do not possess the classic features associated with a basal cell or squamous cell carcinoma. When in doubt, and especially if failing topical therapy, patients presenting with dermatological lesions should be properly referred to a specialist for further assessment and workup.

Psoriasis and Psoriatic Arthritis

Psoriasis is a common skin rash that affects almost 1 in 20 people in North America. Classically, psoriasis is seen on the skin as erythematous, well-demarcated plaques with silvery-white scale. However, there are other types of psoriasis as well: guttate, inverse, erythrodermic and pustular. Nail changes are also very common in all types of psoriasis and can help provide a clue to the diagnosis. Oftentimes, arthritis can coexist with psoriasis and cause major morbidity in psoriatic patients.

Inflammatory Bowel-Associated Spondyloarthropathy

Inflammatory bowel disease (IBD) is a common disease of the small and large intestine that can lead to severe morbidity and mortality in patients. There are many skin manifestations of IBD that can occur prior to, simultaneously with, or after the diagnosis. Erythema nodosum is manifested by tender subcutaneous nodules on the shins. Pyoderma gangrenosum causes large and painful skin ulcerations. Pyostomatitis vegetans can occur as small pustules in the oral mucosa. Other rare manifestations of IBD also include epidermolysis bullosa acquisita, Sweet’s syndrome, polyarteritis nodosa, metastatic Crohn’s, and nonspecific vesiculopustular reactions.