Virendra N. Sehgal

Changing pattern of cutaneous tuberculosis: a prospective study

ABSTRACT: During the past 3 years, we have seen a changing pattern of cutaneous tuberculosis, in which its incidence was recorded to show an upward trend affecting predominantly the adult men. The latter was true in reinfection‐lupus vulgaris and tuberculosis verrucosa cutis, whereas a substantial number of children were victims of reactivation‐scrofuloderma. The duration of the disease was usually short in reactivation tuberculosis. Its clinical expression, however, conformed largely to the ritual text except that apple‐jelly nodules were infrequently demonstrated. Similarly, the morbidity was low. The affliction of the extremities in lupus vulgaris, in particular, was a contrasting feature. The histopathology invariably either confirmed or supplemented the clinical impression. The ultimate confirmation of cutaneous tuberculosis was done only by the demonstration of Mycobacterium tuberculosis in smears, or its recovery in vitro. In view of the limitations of the preceding parameters, the diagnosis may reasonably be made based on the history and evolution of the disease, cardinal morphologic features of reinfection and reactivation tuberculosis, and histopathologic characteristics. A response to antitubercular drugs may be of assistance.

Histoid Leprosy: A Prospective Diagnostic Study in 38 Patients

Histoid leprosy is a fascinating expression of multibacillary leprosy, the incidence of which was 3.6%. It was seen predominantly in males of the younger age group, who were on inadequate and irregular dosage of diaminodiphenyl sulfone. Papules, cutaneous and/or subcutaneous nodules and plaques appearing over apparently normal skin were its exquisite prospective clinical features. It was invariably supported by enormous, uniformly solid staining discrete bacilli from the lesions, in contrast to their virtual absence from the surrounding normal-appearing skin. Encapsulated tumorous mass, formed primarily by spindle-shaped histocytes, displayed either in intertwining, criss-cross or whorled fashion in haematoxylin-eosin-stained sections, were supplementary. The morphology of acid-fast bacilli was, however, similar to skin-slit smears.

Reactions in leprosy--a prospective study of clinical, bacteriological, immunological and histopathological parameters in thirty-five Indians.

The clinical manifestations of types I (lepra) and II (ENL) reactions are now well‐appreciated. The correlation of clinical expression to bacterial index, lepromin response and histological features has hardly been attempted. In a study of 35 reaction patients, 18 type I (lepra) and 17 type II (ENL), the preceding parameters were studied in detail. Their incidence among leprosy patients was 20%. Males in the age group 20–30 years were frequently affected, the ratio of males to females being 6:1. The mean age at onset in type II (ENL) was younger than in type I (lepra) reactions. However, the duration of the reactions was variable. They were frequently precipitated by antileprosy drugs. The clinical features were cardinal. The bacteriological features reflected wide variations, but were considered imperative. Early Fernandez and Late Mitsuda reactions were useful adjuvants for monitoring progress. The utility of changing microscopic pathology in determining the swing towards the lepromatous or tuberculoid end of leprosy spectrum are emphasized.

Lupus vulgaris, caries of the spine and lichen scrofulosorum : an intriguing association

An unusual association of lupus vulgaris, caries of the spine and lichen scrofulosorum is reported in a young boy. An attempt has been made to explain these findings on the basis of the immunoprorile, which indicated unstable immune responses.

Isotretinoin – unapproved indications/uses and dosage: a physician's reference

Isotretinoin (13-Cis-retinoic acid), the harbinger of the revolution in systemic retinoid therapy, is the most popular first generation retinoid, chiefly recognized for its use in nodulocystic acne. Ever since its approval in 1982 for use in severe acne by the United States’ Food and Drug Administration (FDA), it has been used extensively worldwide. Over the years the drug has proved to be useful in multifarious chronic, progressive, recalcitrant dermatological disorders other than acne. Although technically “off-label” uses these reports have rekindled hope for the therapy of such skin disorders, which have no other tenable therapeutic solution. The present appraisal attempts to highlight these “off-label” uses of isotretinoin, which after further research may form a significant component in the therapeutic armamentarium of these hitherto therapeutically frustrating disorders.

Unusual Clinical Manifestations of Cutaneous Tuberculosis

Two unusual patients with multifocal guttate tuberculosis verrucosa cutis and necklace lupus vulgaris are described. An endeavour was made to explain these manifestations through percentages of T‐lymphocytes T4 and T8 in the peripheral blood. Mantoux tests indicating cell‐mediated immunity were strongly positive in both cases; leucocyte migration inhibition test (LMIT) values were, however, relatively low. The latter result also indicates good cell‐mediated immunity.

Tissue Section Donovan Bodies – Identification through Slow-Giemsa (Overnight) Technique

Slow-Giemsa (overnight) tissue section staining technique is described. It was found to be 100% successful in different variants of donovanosis. This method, though time-consuming, is much superior to often used tissue smears, and should be employed for its ultimate confirmation.

Adult onset pityriasis rubra pilaris.

Pityriasis rubra pilaris (PRP) has always been an intriguing topic ever since its inception. It is a group of chronic disorders characterized by reddish orange plaques with pityriasiform scaling showing follicular keratoses, palmoplantar keratoderma, and sometimes, erythroderma. It occurs all over the world but with racial variations. Its incidence might vary and the age at onset, behavior, clinical appearance, and prognosis are considered to be very important for its classification. It may manifest either as Type I classical adult onset PRP, Type II atypical adult (onset) PRP, or Type VI PRP (HIV-associated PRP pityriasis rubra pilaris) in contrast to classical juvenile (Type III) and circumscribed juvenile (Type IV) encountered among children. Its diagnosis is largely clinical with microscopic pathology being a useful supplement, but it continues to be a therapeutic dilemma. We review the epidemiology of adult onset PRP here and take stock of the prevalent treatment options.

Fixed Drug Eruptions: A Study of Epidemiological, Clinical and Diagnostic Aspects of 89 Cases from India

Fixed drug eruption incidence was 0.3% of outpatients. It affected individuals of both sexes in their 3rd and 4th decades, with a preponderance of males. Literary index and occupation were inconsequential. High index of suspicion for an etiologic drug was cardinal and was invariably supported by history. The clinical features of FDE were characteristic; it affected the upper and lower extremities, trunk, and lower lips. The diagnosis was confirmed by provocation test in 86 and cross‐sensitivity in 11 patients. Analgesics and chemotherapeutic agents were primarily responsible for FDE in this population.

Clinicopathology and immunohistochemistry of genital warts.

ABSTRACT: Genital warts are a fairly common sexually transmitted disease and often affect young, illiterate subjects of poor socioeconomic status in India. The mean incubation period was 2.4 months, and the duration varied from 10 days to 4 years. Hyperplastic sessile, verruca vulgaris‐like, and flat variants of warts were seen in that sequence, with distinct clinical features. The epidermal and the dermal changes were largely identical; however, the flat type in the epidermal changes were inconspicuous. Koilocytosis was a pathogno‐monic feature in 28, whereas human papilloma virus (HPV) antigens were detected through peroxidase‐antiperoxidase technique in 18 patients.