Nail Involvement in Leprosy: A Study of 300 Patients

Three hundred leprosy patients were recruited to study the pattern and frequency of nail changes. Nail changes, like longitudinal ridging in finger nails, transverse striations involving both finger and toe nails etc. which occurred with similar frequency in the PB and MB patients in comparison with the control group, were excluded from the analysis. Out of a total number of 150 PB patients, 84 (56%) showed nail changes. Fifty-eight (38.6%) patients showed changes in the finger nails, with an average of 3.2 involved nails per patient. Fifty-three (35.3%) patients showed changes in the toe nails, with an average of 3.0 nails per patient. The most common change observed was longitudinal melanonychia (32.4%) in the finger nails and longitudinal ridging (46.3%) in the toe nails.In comparison, 131/150 (87.3%) MB patients showed nail changes. Finger nail changes were seen in 102 (68%) patients with an average of 5.5 nails affected per patient. Changes in toe nails were seen in 116 (77.3%) patients, with an average of 6.0 nails involved per patient. The most common nail change observed was longitudinal melanonychia in 89/523, (17%) of the total involved finger nails and subungual hyperkeratosis in 164/702, (23.4%) of the total toe nails involvement. Out of a total of 32 colony patients, 31 (96.9%) showed nail changes both in finger and toe nails with an average of 7.9 and 8.4 affected nails per patient, respectively. The most common nail change observed was rudimentary nail(s) on fingers (29%) and toes (21.1%). Among MB patients, a significantly higher number had finger nail involvement in LL group. The frequency of nail involvement for both fingers and toes was significantly greater in LL as compared to BL group of patients. The frequency of nail involvement was significantly more in patients having disease for more than 5 years and in those having trophic changes secondary to loss of sensations and impaired circulation.

Tandem mass spectra of ammonium ion, metal ion and ligated metal ion adducts of acyclic sugar derivatives

The tandem mass (MS/MS) spectra of ammonium ion, metal ion and ligated metal ion adducts of chain-extended acyclic nitro-containing deoxyglucose and deoxygalactose derivatives have been studied. The ammonium adducts fragment primarily by elimination of ammonia followed by acetic acid, thus not giving much structural information. In contrast, cationization of these compounds by metal ions and ligated metal ions gave structurally informative and useful fragment ions on MS/MS. The metal ions and ligated metal ions play an important role in controlling and directing fragmentation. Retro-aldol fragmentation is facilitated by metal ions such as Li(+), Na(+), Ag(+) and Cu(+), whereas the adducts with higher alkali metal ions such as Rb(+) and Cs(+) fragment to give only the corresponding metal ions. The divalent metal ions such as Cu(2+) and Ba(2+) also induce retro-aldol fragmentation. However, the charge is carried by the aldehyde fragment in the case of Cu(2+) adducts, whereas the nitroalkane fragment carries the charge in the case of Ba(2+) adducts. Ligated metal ions such as ZnCl(+), CuCl(+), InCl(2) (+) and BaCl(+) also behave similarly and induce retro-aldol fragmentation in these acyclic sugars. Both the metal ion and ligated metal ion adducts can fragment by elimination of metal-containing neutral molecules.

Recurrence of stage I thymoma in sternum, 13 years after "complete" excision

Recurrence after complete excision of non-invasive thymoma is infrequent. We report a case of recurrent thymoma in the sternum in a 76-year-old man 13 years after complete surgical resection of stage I thymoma.

Leprosy and Psoriasis: An Enigmatic Relationship

The relationship between leprosy and psoriasis has been controversial since ancient times. Based on the fundamental importance of nerve involvement in the pathogenesis of leprosy and psoriasis, it has been hypothesized that leprosy patients may be protected from developing psoriasis. There are only sporadic reports of coexistence of these two diseases as evidence of this negative association. We report a 64-year-old male patient with borderline leprosy and psoriasis. Recent advances in the elucidation of pathogenesis of both diseases have contributed to the understanding of this enigmatic relationship. Various genetic, immunological, and structural alterations in leprosy and psoriasis as discussed could be responsible for the rare co-existence of these two diseases in a given patient.

Topical prostaglandin analog (PGE2) in vitiligo--a preliminary study

BACKGROUND

Several therapeutic options are available for the treatment of vitiligo, but none is uniformly effective. Prostaglandin has been shown to play a role in melanocyte proliferation and melanogenesis. Topical application of prostaglandin E2 (PGE2) over mice skin has been shown to increase melanocyte density.

AIM

To evaluate the role of topical PGE2 in the treatment of vitiligo.

METHODS

We enrolled 27 patients with limited vitiligo lesions in this study. Patients were instructed to apply a translucent gel containing 0.5 mg/3 g (166.6 micro g/g) PGE2 to depigmented skin.

RESULTS

Twenty-four patients were evaluated at the end of 6 months, as three patients withdrew for reasons unrelated to the study. At the end of treatment, 15 patients showed marked to complete repigmentation and three patients showed moderate repigmentation. The remaining six patients showed none to minimal repigmentation.

CONCLUSIONS

Marginal repigmentation with hyperpigmented borders was seen in the majority of lesions. Our results are encouraging and offer a new and potentially efficacious treatment for this pigmentation disorder.

Epidemiology of onychomycosis in patients with diabetes mellitus in India

BACKGROUND

The number of individuals diagnosed with diabetes mellitus is increasing worldwide. Although onychomycosis is often observed in diabetics, there have been no large studies of its epidemiology in this patient group in India.

METHODS

We studied the prevalence of onychomycosis in diabetics attending the Diabetes Clinic at the Postgraduate Institute of Medical Education and Research, Chandigarh, India, and compared it with that in a nondiabetic control group. A total of 400 diabetic subjects (237 males, 163 females), aged 48.8 +/- 0.5 years (mean +/- SD), were evaluated.

RESULTS

The prevalence of onychomycosis in the diabetic and control groups was 17% and 6.8%, respectively, the difference being statistically significant (P < 0.001). The presence of onychomycosis was found to correlate significantly with increasing age (P < 0.01) and male gender (P < 0.05) in both diabetic and control groups. From diabetics, yeasts were the most common isolate (48.1%), followed by dermatophytes and nondermatophyte molds in 37% and 14.8%, respectively. In the control group, the distribution of yeasts, dermatophytes, and nondermatophyte molds was 25%, 62.5%, and 12.5%, respectively. After controlling for age and sex, a stepwise logistic regression demonstrated that significant predictors for onychomycosis included the duration of diabetes (P < 0.01), absent or feeble peripheral pulses (P < 0.15), peripheral neuropathy (P < 0.05), and retinopathy (P < 0.001).

CONCLUSIONS

Diabetics were found to be 2.5 times more likely to have onychomycosis than the controls. Predisposing factors included increasing age, male gender, duration of diabetes, impaired peripheral circulation, peripheral neuropathy and retinopathy.

Combined 12-month WHO/MDT MB regimen and Mycobacterium w. vaccine in multibacillary leprosy: a follow-up of 136 patients

A total of 136 patients with BI > or = 2 having been followed up for at least 2 years or more were included in the analyses. Seventy-seven out of 136 patients had completed three years follow up. All patients were given WHO/MDT MB regimen for 12 months and additionally 4 doses of Mycobacterium w. vaccine at 3-month intervals. The age of the patients varied from 6 to 77 years (mean 34 +/- 11.3 years) and they had the disease varying from 3 months to 7 years (mean = 1.9 +/- 1.4 years). The mean of the BI before starting treatment was 3.6 +/- 1.3. At the end of 2 years follow-up, a total of 54 patients out of the 136 (39.7%) had become smear-negative. A larger proportion of patients, 39/46 (84.8%) with BI of < or = 3 had become smear-negative, whereas, only 10/32 (31.3%) patients with BI between 3.1 to 4 and 5/58 (8.6%) highly bacillated patients having initial BI > 4 had become smear-negative at the end of 2 years. Out of the 77 patients who were available for follow up at 3 years, 30/33 (90.9%) patients with BI of < or = 3, 15/20 (75%) patients with BI between 3.1 to 4 and 13/24 (54.2%) patients having initial BI > 4, respectively, had attained smear negativity. Reactions occurred more frequently after 6 months of therapy and over a period of time their frequency gradually decreased, however, they continued to occur even two years after RFT. During the course of MDT and thereafter in follow up 4.6% and 1.3% of the patients developed new deformities or an increase in the existing grade of deformities, respectively. Three relapses (2 in LL and 1 in BL) occurred in patients having initial BI of > 4. One patient relapsed in the second year and the other two relapsed in the third year of follow up and were successfully treated with reintroduction of the same MDT MB regimen. Local ulceration healing with scar formation and regional lymphadenopathy were the only local reactions to the vaccine seen in 47/136 (34.5%) patients. All the patients showed histopathological improvement in the form of a gradual reduction of granuloma fraction. Although the results of this limited period follow up are satisfactory, a long-term follow-up in larger number of patients will settle the issue of safety and efficacy of shortened MDT MB regimen and the place of immunotherapy with M. w. vaccine in multibacillary patients.

Fabric-staining properties and washability of a novel liposomal dithranol formulation

AIM

To test the staining potential of a novel liposomal dithranol gel on different types of fabrics and compare it with the only commercially available dithranol preparation in India, Derobin.

METHODS

Pure cotton, pure polyester and four blends of the two fabrics were tested for staining and washability.

RESULTS

Both products showed the least staining and spreading on pure cotton with progressively worse stains as the proportion of polyester in the fabric increased. When compared with each other the liposomal dithranol gel showed markedly lighter staining than Derobin on all fabrics. It also washed off completely with water whereas the Derobin stains could not be washed off, even with detergent.

CONCLUSION

The liposomal gel due to its superior staining properties may potentially increase the acceptability of dithranol amongst psoriasis patients.

Atopy and alopecia areata in North Indians

The study was undertaken with the aim of evaluating the effect of associated atopy on severity and age at onset of alopecia areata in north Indians. Presence of atopy was elicited by detailed history, examination and intracutaneous tests. Chi square test was carried out to evaluate statistical significance. One hundred patients (76 males and 24 females) with alopecia areata were evaluated. Historical evidence of atopy was present in 50 including patients alone (23), patients and first degree relatives (11) and first degree relatives alone (16). Intracutaneous tests were positive in 23 out of 50 patients tested randomly. There was a trend towards increasing frequency of severe alopecia as evidence of atopy became stronger e.g. both patient and first degree relatives with atopy or positive intracutaneous test but the results did not attain statistical significance. Similarly the age at onset and duration of alopecia areata was not significantly related to the presence of atopy. It is concluded that in north Indians with alopecia areata, the presence of atopy is not significantly associated with severe alopecia or onset at younger age.

KID syndrome: response to acitretin

KID syndrome is rare. We report a 17-year-old girl who presented with universally ichthyotic red hue on the face, trunk, and extremities along with deafness and keratitis since childhood. She was diagnosed with KID syndrome. Treatment with acitretin cleared the hyperkeratotic ichthyotic lesions with little effect on the cornea or hearing. Acitretin seems to be a promising new treatment in KID syndrome.

A novelliposomal formulation of dithranol for psoriasis: preliminary results

We have prepared a novel, aqueous gel-based, liposome-entrapped formulation of dithranol. Herein, we report preliminary observations on its efficacy, tolerability, and cosmetic acceptability in treating stable plaque psoriasis. Nineteen plaques of psoriasis in nine adult patients were treated for six weeks in a prospective, open-label trial. In five patients, there was total clearance of lesions, with more than 50% subsidence in a further two patients. Significantly, there were no reports of lesional or perilesional irritation, and only one patient showed faint brown staining of the skin, which was completely and rapidly reversible. These preliminary results indicate that our liposomal dithranol gel has potential advantages over presently available preparations of dithranol; these may translate into enhanced acceptance of this useful drug by patients and physicians.

Short-term methotrexate therapy in psoriasis: a study of 197 patients

Methotrexate (MTX) is one of the most effective antipsoriatic drugs available. Although it is undeniably hepatotoxic, it can be used safely in most patients with severe psoriasis if established guidelines are followed. Current opinion on the monitoring of hepatic damage is divided, however, and the need for repeated liver biopsies during MTX therapy is being re-examined. We have used MTX in a short-term protocol in our patients with psoriasis for the past 20 years, and have recently attempted to minimize or eliminate the need for liver biopsies using this regimen. Data on 244 psoriatics who were given MTX from 1981 to 2000 have been reviewed. Our protocol entailed the use of weekly oral MTX at the full therapeutic dose during episodes of peak disease activity, with tapering off of MTX when the disease subsided in response to treatment combined with natural/seasonal remission. Intensive topical and heliotherapy were encouraged throughout to facilitate the earliest possible drug withdrawal and the longest possible drug-free interval before the next relapse. Strict inclusion criteria were applied before starting MTX. A total of 243 cycles of MTX therapy have been given to 197 evaluable patients. More than 75% improvement occurred in 88% of patients in 8.5 +/- 5.1 weeks. The mean cumulative dose was 709.3 +/- 369.2 mg and the mean duration of follow-up was 16.5 +/- 9.1 months. Fifteen (6.1%) patients had serious adverse effects requiring the cessation of therapy. Only three patients had deranged liver function tests. Thirty-four pre-MTX and 13 post-MTX liver biopsies were taken, which revealed grade I or II changes that were nonprogressive. Our experience with short-term MTX therapy has enabled us to safely administer MTX to our patients with minimal recourse to liver biopsy. In developing countries, where advanced noninvasive methods for the assessment of liver damage are unaffordable or unavailable, this interrupted, short-term regimen may present an acceptable and safe method of using MTX in carefully selected patients with severe psoriasis.

Naevus sebaceous papilliferum

An unusual form--large linear lobulated--of naevus sebaceous on the ear is reported in a 40-year-old man. It simulated syringocystadenoma papillitferum clinically.

Multifocal bullous fixed drug eruption mimicking Stevens-Johnson syndrome

The overlapping clinical features of fixed drug eruption (FDE), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) make differentiation between them difficult, especially if FDE is multifocal and extensive. We present a case of multifocal bullous FDE mimicking SJS.

Pesticide (acephate) removal by GAC: a case study

Pesticides are persistent pollutants which need utmost attention in agricultural pollution. They usually accumulate in the food chain, and hence are hazardous in nature. The present study reports the performance of granular activated carbon (GAC) in the removal of acephate contained in the effluent of a nearby pesticide manufacturing industry. In the batch study, the optimum dose of GAC was found to be 85 gm/litre for almost 100% removal of acephate from its initial concentration of 2.9 mg/litre which was found in the industrial effluent under treatment. The adsorption kinetics were represented closely by Langmuir isotherm. The equilibrium time was found as 80 minutes. The adsorptive capacity of GAC for acephate (pesticide) was of the order of 0.04614 mg/gm. A column system was devised and designed based on bed depth-service time (BDST) approach with the experimental value of 'a' and 'b' as 6.125 and 47.75 respectively.

Pros and cons of antioxidant use during radiation therapy

Radiation therapy is one of the major treatment modalities in the management of human cancer. While impressive progress like more accurate dosimetry and more precise methods of radiation targeting to tumor tissue has been made, the value of radiation therapy in tumor control may have reached a plateau. At present, two opposing hypotheses regarding the use of antioxidants during radiation therapy have been proposed. One hypothesis states that supplementation with high doses of multiple micronutrients including high dose dietary antioxidants (vitamins C and E, and carotenoids) may improve the efficacy of radiation therapy by increasing tumor response and decreasing some of its toxicity on normal cells. The other hypothesis suggests that antioxidants (dietary or endogenously made) should not be used during radiation therapy, because they would protect cancer cells against radiation damage. Each of these hypotheses is based on different conceptual frameworks that are derived from results obtained from specific experimental designs, and thus, each may be correct within its parameters. The question arises whether any of these concepts and experimental designs can be used during radiation therapy to improve the management of human cancer by this modality. This review has analyzed published data that are used in support of each hypothesis, and has revealed that the current controversies can be resolved, if the results obtained from one experimental design are not extrapolated to the other. This review has also discussed the scientific rationale for a micronutrient protocol that includes high doses of dietary antioxidants (vitamin C, vitamin E succinate and natural beta-carotene) which can be used adjunctively with radiation therapy.