Roberta Bilenchi

Geriatric teledermatology: store-and-forward vs. face-to-face examination

Background  Telemedicine could be useful in countries like Italy to meet the needs of elderly patients and in particular in those in precarious general conditions, for whom travelling even short distances can pose considerable practical and economical difficulties.

Cutaneous metastases from adenocarcinoma of the rete testis.

Abstract:  Adenocarcinoma of the rete testis (ACRT) is extremely rare and has only been the subject of sporadic case reports, in most of which the neoplasm manifested as a scrotal mass with diffuse enlargement of the testis. Only a few cases of scrotal infiltration by a contiguous ACRT have been described. To our knowledge, none have reported distant skin metastases. We report a case of ACRT presenting with suprapubic skin metastases. The diagnosis was based on clinical and histopathological findings and supported by the results of immunohistochemical and ultrastructural studies. We discuss the differential diagnosis to this rare entity, which include metastatic adenocarcinoma, serous tumor of the testis, and mesothelioma of the tunica vaginalis.

Non-infectious inflammatory genital lesions

The genitalia may be the site of non-infectious inflammatory lesions that are generally manifested as balanoposthitis and vulvovaginitis. In men, these forms constitute 50% of all balanoposthitis forms, and in women, vulvovaginitis frequency is even higher. They consist of genital locations of general skin diseases, such as psoriasis, lichen planus, lichen sclerosus, and other clinical entities with their own physiognomy, such as Zoons balanitis-vulvitis. Diagnosis of genital non-infectious inflammatory lesions is usually made on clinical criteria. A biopsy is only necessary for the identification of clinical conditions that may simulate inflammatory form but are actually premalignant processes.

Human papillomavirus reactivation following topical tacrolimus therapy of anogenital lichen sclerosus.

SIR, In recent years, there have been many reports of cases of lichen sclerosus (LS) successfully treated with topical tacrolimus 0Æ1%. It is therefore disconcerting that most of these articles mention the risk of viral infections of the skin in patients using topical tacrolimus but do not consider the possibility of increased risk of squamous cell carcinoma. We recently observed the appearance of condylomata in a man (patient A) and a woman (patient B) with anogenital LS during topical treatment with tacrolimus (Fig. 1). Patient A was an otherwise healthy 51-year-old man with an 8-year history of penile LS, diagnosed clinically and histopathologically. Topical steroids only provided temporary relief and since April 2002 only emollient preparations had been applied. In December 2005, twice daily topical treatment with 0Æ1% tacrolimus ointment began. Slight improvement of LS plaques was observed after 3 months of treatment but 1 month later penile condylomata manifested. Biopsy showed histological signs suggesting condylomatosis without dysplasia. Polymerase chain reaction (PCR) typing of the virus was positive for human papillomavirus (HPV) 11. The condylomata were treated with liquid nitrogen. Follow-up is still in course: the patient is applying emollients and there are no signs of recurrent condylomata. Patient B was a 75-year-old diabetic woman with a 20-year history of pruritus, burning, dyspareunia and vulval erosions. In February 2006 she was diagnosed as having LS, based on clinical and histopathological data. After 2 weeks of topical clobetasol propionate treatment with slight improvement of symptoms she presented vulvovaginal candidosis. Cessation of this topical steroid treatment caused a flare of the LS and, for this reason, twice daily topical treatment with 0Æ1% tacrolimus ointment was tried. The patient reported a slight burning sensation after the first applications and then partial relief of symptoms. After 2 months of topical tacrolimus treatment, anal condylomata appeared and were confirmed histologically. PCR typing of the virus was positive for HPV 6. Colposcopy and Pap test were negative. The condylomata are still under treatment with liquid nitrogen. Neither patient had a history of condylomatosis, and both were claimed to be monogamous. As both were negative for condylomatosis before tacrolimus was prescribed, we interpreted the condylomata as due to reactivation of latent HPV infection in response to local immunosuppression. Like all local immunosuppressants, tacrolimus, which suppresses activation of T lymphocytes by inhibiting transcription of interleukin 2 and other cytokines, may be accompanied by infections at the site of application. Recurrence of condyloma acuminata in patients with vulval psoriasis treated with topical tacrolimus was recently described by Amstey and there have been other reports of viral infections arising in patients treated with this drug. Lonsdale-Eccles and Velangi reported a woman with herpes simplex of the vulva associated with the use of topical tacrolimus but, as far as we know, none of these previously reported patients had LS. It is well-known that genital squamous cell carcinoma is an established risk in the context of a chronic inflammatory scarring dermatosis such as LS and although it is not known whether the use of topical immunosuppressants in LS increases the risk of malignant progression, this risk needs to be considered more carefully for tacrolimus and other topical calcineurin inhibitors, which are relatively new agents that have not yet stood the test of time. In our opinion, HPV infections in patients with LS could be synergic with the chronic inflammation of the disease, contributing to malignant transformation. We also think that ‘nononcogenic low-risk’ HPVs (types 6 and 11, as in our patients) could be dangerous in patients with LS. In conclusion, although there is currently no evidence of a causal relation between application of tacrolimus and reactivation of latent anogenital HPV infection, patients with LS should be carefully assessed before prescribing this immunosuppressant and throughout its use. In general terms, topical calcineurin inhibitors should be used after the failure of an initial steroid treatment and not as a first-line therapy on a

Floppy eyelid syndrome associated with obstructive sleep apnoea

Floppy eyelid syndrome (FES), initially reported by Culbertson and Ostler in 1981, is a rare disorder of unknown aetiology, often described in association with other systemic conditions, manifesting as an easily everted, floppy upper eyelid, upper papillary conjunctivitis and nonspecific irritative symptoms. We report a 45-year-old obese woman with intense conjunctival hyperaemia and papillary hypertrophy whose left upper eyelid was pulpy and easily everted (Fig. 1). Biopsy showed thickening of the epithelium with a mild chronic lymphocytic tarsal infiltrate (Fig. 2). Giemsa-orcein staining revealed a marked decrease in the tarsal elastic network with fragmentation and loss of elastic fibres. Ultrastructural study confirmed changes in tarsal elastin, which appeared disorganized and focally disrupted, with a reduced

Sexually transmitted scabies in elderly people

about nosocomial outbreaks of scabies in elderly people. Persons over the age of 65 years are usually defined as ‘elderly’ but we would like to emphasize that most of them are still sexually active. The elderly population shares the full spectrum of sexually transmitted diseases (STDs) with the general population and their incidence is significant for newly acquired diseases and complications of previous infections (particularly syphilis 2 and human immunodeficiency virus (HIV) 3 ). Working in an STD practice, we have often encountered elderly persons with scabies and their history sometimes reveals that they had been infected during sexual intercourse. In our opinion, scabies in the elderly may therefore also be considered an STD and not exclusively a nosocomial disease. A 77-year-old man who had been diagnosed with prurigo nodularis and treated with topical and systemic corticosteroids was referred to us with penal and scrotal papules (fig. 1). We suspected scabies and microscopic examination of skin flakes obtained by scraping was positive. As he had had sexual intercourse with prostitutes, we performed tests for HIV and other STD laboratory diagnostic tests, including serological tests for syphilis (venereal disease research laboratory (VDRL), treponema pallidum haemagglutination (TPHA), fluorescent treponemal absorption (FTAabs)) and hepatitis B surface antigen (HBsAg) enzyme linked immuno sorbent assay (ELISA) as well as polymerase chain reaction (PCR) for hepatitis C. All were negative. We prescribed benzylbenzoate for the patient and his wife, who refused to be examined. This case is not isolated. In the period 1990–2004 we have seen 1652 elderly patients, both males and females, in our STD clinic. The most frequent pathology (1105 cases) has been scabies followed by condylomatosis (224 cases), pubic pediculosis (132 cases), and genital herpes (105 cases). We also observed 61 cases of syphilis (primary lesions in 28, and serological positivity in 33 cases), and 35 cases of gonorrhoea. In 13 cases, an HIV test, performed with tests for STDs and routine procedures, was positive. Scabies was diagnosed and confirmed by positive microscope examination in 997 patients. Only in 265 cases, including the present one, did medical history indicate sexual transmission. We believe that this is an underestimate, as we have noted that elderly patients are often more reluctant to report having had sexual intercourse at risk than young people. We agree with Gimènez Garcìa et al . that atypical presentations of scabies may be encountered in the elderly. 1,4

Discoid lupus erythematosus of the vulva

Genital involvement is a rare manifestation in discoid lupus erythematosus (DLE) and systemic lupus erythematosus (SLE), and there are few reports on vulvar clinical features. We describe a 41-year old Caucasian woman with bilateral vulvar DLE. Although vulvar lesions in lupus are probably more common than is realized, the present report is the first case of genital DLE documented in a female.

Temporal lobe abnormalities in neurosyphilis

A 28-year-old woman presented with a 5-month history of cognitive and behavioural disturbances. Her past history was unremarkable, and she had no family history of neurological disorders. On examination, she showed temporospatial disorientation, ideomotor apraxia, gait ataxia, dysarthria, anisocoria and reduced pupillary light responses. Routine blood tests were normal. MR scan of brain showed T2/FLAIR temporal hyperintensities (figure 1). Cerebrospinal fluid (CSF) analysis showed …

Sexually transmitted diseases in elderly people: an epidemiological study in Italy.

days) to describe antibiotic use in this study. An antibiotic course was defined as one that was 5 days or longer. Benoit et al. also used the Resource Utilization Group III (RUG III) system to account for differences in functional status in the study population. They found that, for all 73 facilities, the pooled mean number of antimicrobial courses per 1,000 resident care days was 4.8 but that the range of facilityspecific incidence of use was wide (0.4–23.5). Multiple factors were found to be significantly associated with higher antimicrobial use, including presence of a foley catheter, greater likelihood of discharge from the nursing home (surrogate for rehabilitation), residents in RUG groups with higher resource utilization, a higher case mix index (CMI), and certain medical problems (lung disease, dementia, and cancer). My major concern with this article is that the authors failed to mention two studies that my colleagues and I published that used the RUG II classification as well as an evaluation of infection rates to assess antimicrobial use in nursing homes. These studies have relevance to the study by Benoit et al. In the first study, antibiotic use and cost parameters were evaluated in one 433-bed nursing home in Syracuse, New York. This study used the CMI of the RUG II classification scheme, an earlier version of the RUG system, which divided the nursing home population into 16 mutually exclusive groups. The nursing home studied was unique in that it had 10 individual units that differed significantly based on average CMI and only six physicians were involved with care and were assigned to specific units. This situation allowed for an evaluation of antibiotic use according to unit and to physician. There was a significant difference in courses started per 1,000 resident care days between the 10 units and between the six physicians. There was also a significant positive correlation between infection rate and courses started per 1,000 resident care days, but there was no correlation between unit-specific CMI and infection rate. After controlling for CMI and a cost indicator, the variation in infection rate explained 65% of the variability in courses started per 1,000 resident care days. The other study was conducted in 11 nursing homes in the Buffalo, New York, area during a 1-year period using antibiotic use and cost parameters and CMI of the RUG II. This study focused on facility level parameters rather than individual resident parameters. There was significant variation in all of the antibiotic indicators between the 11 nursing homes, but there was no correlation between mean facility CMI and mean facility infection rate. However, there was a trend toward a significant correlation between mean facility CMI and mean facility antibiotic courses started per 1,000 resident care days. Variation in mean facility infection rate explained 66% of the variation in mean facility courses started per 1,000 resident care days (Po.001). In a multivariate analysis, mean facility infection rate (P 5.003) and mean facility CMI (P 5.046) were predictors of mean courses started per 1,000 resident care days and explained 83% of the variation in this parameter. This was the first evidence that functional status is associated with antibiotic prescribing in the nursing home setting. Lastly, there is evidence that the RUG classification scheme may be a useful method of stratifying nursing homes in terms of risk of infection. A prospective study of infection rates was performed in 16 nursing homes in upstate New York in the late 1990s. There was a significant correlation between RUG II category and infection rate; residents in the clinically complex and special care categories had significantly higher infection rates than the reference group (behavioral category). This study suggests that it may be possible to use the CMI or the proportion of residents in specific RUG categories to stratify nursing homes into risk categories for infection. It is clear from the findings of Benoit et al. and the other studies discussed above that it is critical that functional status be accounted for when assessing antibiotic prescribing in the nursing home setting. Being able to monitor antibiotic prescribing accurately while controlling for functional status in the nursing home setting is an important first step in developing benchmarks and for evaluation of appropriateness of antibiotic therapy. Because published antibiotic use and cost indicators can detect significant variation in prescribing at the facility level, one potential initial approach to evaluating appropriateness of antibiotic prescribing would be to stratify homes based on the degree of risk for infection based on RUG classification and focus the evaluation on nursing homes that have high rates of prescribing relative to benchmarks.

Keratotic Horn on Left Fifth Fingertip: Congenital Ectopic Nail Misdiagnosed as a Common Wart

Abstract:  The term “ectopic nail” refers to nail tissue found in a location other than in the normal nail bed. Here we report a 9‐year‐old girl with an asymptomatic keratotic “horn” on the tip of her left fifth finger. Present since the age of 1 month, it was misdiagnosed as a common wart and treated using liquid nitrogen cryotherapy without benefit.