Erythroderma: a comparison between HIV positive and negative patients

Background Erythroderma has protean underlying causes. There have been isolated case reports suggesting an association between erythroderma and the human immunodeficiency virus (HIV).

OBJECTIVE

To describe and characterize further the prevalence, etiology, and metabolic sequelae of erythroderma in HIV positive and negative patients. In a subset of patients, clinicopathologic correlation was performed.

METHOD

One hundred and thirty-eight consecutive patients were prospectively recruited over a one and a half year period at the skin clinic of King Edward VIII Hospital. Demographic, clinical, biochemical, and histologic data were recorded.

RESULTS

Seventy-five per cent of the patients were black, 22.5% Indian, and 2.5% white. The men to women ratio was 1.9 : 1. The mean age was 34. 7 years (range, 1 month to 85 years). Forty-three per cent of patients were HIV positive, of whom 90% were black. The commonest causes of erythroderma in the total sample were atopic dermatitis (23.9%), psoriasis (23.9%), and drug reactions (22.5%). The commonest cause in the HIV positive group was drug reactions (40.6%), the commonest being ethambutol (30.8%). HIV positive patients had a significantly lower (P < 0.05) white cell count (7.6 vs. 10.5 x 109 /L), hemoglobin (11.1 vs. 12.6 g/dL), platelets (278.3 vs. 378.0 x 109 /L), and albumin (25.4 vs. 28.7 g/L) and significantly higher serum urates (0.6 vs. 0.4 mM/L) than HIV negative patients. HIV positive patients did not have a significant increase in the number of episodes of erythroderma. Clinicopathologic correlation was greatest with psoriasis in the HIV negative group and with psoriasis and drug reactions in the HIV positive group.

CONCLUSIONS

A large proportion of erythrodermic patients in this study were HIV positive. Inflammatory dermatoses were the commonest cause of erythroderma in all the patients studied. Drug reactions were the commonest cause in HIV positive patients. In the young black patient, erythroderma may be a marker for HIV infection.

Onychomycosis: predisposed populations and some predictors of suboptimal response to oral antifungal agents

The population groups predisposed to onychomycosis and factors associated with a poor response to antifungal therapy may be subdivided into (a) genetic, (b) environmental, (c) systemic conditions, (d) local nail characteristics, and (e) other miscellaneous items. By paying attention to the scenarios that may lead to a suboptimal response to the therapy and a higher probability of relapse of the onychomycosis, it may be possible to improve the overall cost-effectiveness of treatments for onychomycosis. Besides attempting to achieve a cure when treating onychomycosis it is important to take steps to prevent reinfection with fungal organisms.

rRNA Gene Internal Transcribed Spacer 1 and 2 Sequences of Asexual, Anthropophilic Dermatophytes Related to Trichophyton rubrum

The ribosomal region spanning the two internal transcribed spacer (ITS) regions and the 5.8S ribosomal DNA region was sequenced for asexual, anthropophilic dermatophyte species with morphological similarity to Trichophyton rubrum , as well as for members of the three previously delineated, related major clades in the T. mentagrophytes complex. Representative isolates of T. raubitschekii , T. fischeri , and T. kanei were found to have ITS sequences identical to that of T. rubrum . The ITS sequences of T. soudanense and T. megninii differed from that of T. rubrum by only a small number of base pairs. Their continued status as species, however, appears to meet criteria outlined in the population genetics-based cohesion species concept of A. R. Templeton. The ITS sequence of T. tonsurans differed from that of the biologically distinct T. equinum by only 1 bp, while the ITS sequence of the recently described species T. krajdenii had a sequence identical to that of T. mentagrophytes isolates related to the teleomorph Arthroderma vanbreuseghemii .

Combined distal and lateral subungual and white superficial onychomycosis in the toenails

BACKGROUND

The 5 main types of onychomycosis are distal and lateral subungual onychomycosis (DLSO), white superficial onychomycosis (WSO), proximal subungual onychomycosis (PSO), Candida onychomycosis, and total dystrophic onychomycosis (TDO) (primary or secondary type). In the literature there is infrequent discussion about 2 types of onychomycosis present in the toenails of the same individual.

OBJECTIVE

We attempted to determine the prevalence and etiologic organisms of DLSO and WSO occurring in the same individual.

METHODS

We surveyed 4411 subjects presenting to dermatology offices for causes other than the management of onychomycosis. In each patient the toenails were examined. If they appeared abnormal, nail material was obtained for mycologic evaluation; partitioned sampling was performed when more than one type of onychomycosis was present.

RESULTS

In our series, 39 (0.9%) of 4411 patients had the combination DLSO and WSO, compared with 417 (9.4%) and 111 (2.5%) who had DLSO and WSO, respectively. After controlling for age and sex in the general population, the projected prevalence rates of DLSO, WSO, and combined DLSO and WSO in the province of Ontario, Canada were 7.1%, 1.5%, and 0.5%, respectively. The combination of DLSO and WSO in the toenails of an individual occurred more frequently than that predicted by chance alone (P <.0001). Nine (0. 2%) of 4411 subjects had DLSO and WSO on the same nail. In 23 (59%) of 39 subjects both the DLSO and WSO were associated with Trichophyton mentagrophytes. In the remaining 16 subjects other organisms cultured were T rubrum, Acremonium spp, Aspergillus spp, Fusarium oxysporum, and Onychocola canadensis. In 33 (84.6%) of 39 subjects with the combination of DLSO and WSO on the toenails, the same fungal organism was associated with both the DLSO and WSO.

CONCLUSION

When both DLSO and WSO are concurrently present in the toenails of an individual, partitioned sampling (ie, sampling for each of the two types of onychomycosis) may provide us with a better understanding of the different organisms associated with the onychomycosis and the relationship between the two types of onychomycosis.

An IgM monoclonal antibody to Japanese encephalitis virus recognizing a cross-reactive epitope on nuclear histones

An IgM class of monoclonal antibody (MAb) raised against 'envelope' (E) glycoprotein of Japanese encephalitis (JE) virus, cross reacted with nuclear histones, in addition to recognizing the viral antigen present in the cytoplasm of infected cells by indirect fluorescent antibody (FA) technique. The experiments on histone depletion by the acid treatment of uninfected PS (porcine kidney) cells, revealed the loss of nuclear immunofluorescence (IF) which was regained after the reconstitution of acid treated cells with histones, prior-to reacting with MAb NHA-2. The IgM MAb recognized specifically the viral antigens expressed on the surface of JE virus infected PS cells by a modified indirect FA. The adsorption of MAb NHA-2 with calf thymus histones (type II-AS) showed a comparative higher drop in the reactivity to JE virus (54.2% reduction) as compared to that against uncomplexed histones (33.3%) by ELISA, thus indicating a higher MAb affinity to the former. In contrast, the adsorption of MAb with chicken RBC nuclei resulted in comparatively more reduction in the reactivity to the uncomplexed histones (52.4% reduction) as against JE virus (37.5%), suggesting that DNA plays some role in modifying and presenting these epitopes. The cross-linkage of epitopes by glutaraldehyde treatment of JE virus antigen and histones showed a 2-fold and higher rise in the MAb reactivity as against those with unfixed or methanol fixed antigens (no cross-linkage), suggesting that the epitope is conformation dependent. Thus, histones seem to share a partial conformational homology with 'E' glycoprotein of JE virus and immune reaction with histones might lead to an autoimmune disorder.

Role of imaging in pediatric respiratory diseases

Both medical and surgical diseases commonly affect the pediatric respiratory system. Imaging has a crucial role to play in their management. Plain chest radiograph is still the single most important investigation. However, at times further workup is essential and then CT, MR imaging and other modalities provide detailed findings. Pediatric radiologist should be aware of the advantages and the limitations of each imaging technique so as to be able to use these judiciously, without duplicating information and at the minimum cost and radiation to the patient.

Primary embryonal rhabdomyosarcoma of the diaphragm in a child: case report

Primary rhabdomyosarcoma of the diaphragm presenting as an epigastric mass is extremely rare, with only three published cases. We highlight the unique imaging features in a 2(1)/(2)-year-old boy which predicted the correct anatomical site preoperatively. Awareness of this rare tumour and its imaging characteristics should help in differentiating it from other more common tumours in this location, especially primary hepatic tumours.

Effects of a composite Indian herbal preparation on combat effectiveness in low-intensity-conflict operations

The efficacy of a composite Indian herbal preparation (CIHP) in sustaining the mental performance of soldiers engaged in prolonged low-intensity-conflict operations has been evaluated. For this purpose, a cohort of 56 soldiers acted as volunteers in combat situations. After recording their initial responses to psychological tests such as the d2 test, the trail-making test, the serial addition test, the short-term memory test, and the Institute for Personality and Ability Testing Anxiety Scale, they were randomly given either CIHP or placebo in a double-blind fashion for 8 days while they performed their usual combat duties. The final 3 days of assignments included physically exhausting and life-threatening events. On day 8, they were withdrawn from combat duties and the psychological tests were readministered immediately. After 7 days of rest, the tests were repeated once again. The results indicate comparatively better performance immediately after the mission by the CIHP group. CIHP was effective at sustaining the mental abilities of soldiers in a low-intensity-conflict environment.

Pre-operative management of congenital choledochal cyst with ultrasound-guided percutaneous choledochalcystostomy

Choledochal cyst is a rare congenital anomaly of the biliary system, presenting in infancy. Two cases of choledochal cyst (one infected) with grossly deranged liver function tests and associated biliary atresia, which were successfully managed pre-operatively by sonoguided percutaneous choledochalcystostomy, are reported here. The use of this technique in the treatment of patients such as these is proposed.

Antibiotic prophylaxis in elective cholecystectomy: a randomized, double blinded study comparing ciprofloxacin and cefuroxime

A prospective, randomised and double blind study was undertaken to compare the prophylactic efficacy of ciprofloxacin and cefuroxime in 155 patients undergoing elective cholecystectomy. Patients with past history of jaundice or presence of jaundice, diabetes mellitus, common bile duct stones and previous biliary tract surgery were excluded. Patients were allocated to the following groups: group A-no antibiotic (n = 30); group B-ciprofloxacin (200 mg i/v before surgical incision and a second dose after 12 hrs) (n + 45); group C-ciprofloxacin given only post operatively (200 mg i/v, 12 hourly X 2 days followed by oral 500 mg twice daily X 3 days) (n = 35); group D-cefuroxime (750 mg i/v before surgical incision and a second dose after 12 hrs) (n = 45). Efficacy of the antibiotic was defined as a patient being free of post operative wound infection. Maximum numbers of infection occurred in group A (26.67%) and group C (25.71%). The incidence of wound infection was significantly lower when ciprofloxacin was used as prophylaxis (group B) than when used post operatively (group C) only (P < 0.05). Patients who received ciprofloxacin (group B) and cefuroxime (group D) as prophylaxis had significantly reduced incidence of infection (4.44% and 6/67% respectively); no statistically significant difference was found between these groups. Ciprofloxacin could be used as prophylactic antimicrobial in elective cholecystectomy in developing countries because of its effectiveness, economy and ready availability.

Pre-natal echocardiographic diagnosis and neonatal balloon dilatation of severe valvar pulmonic stenosis

A case is presented below where pre-natal echocardiographic diagnosis of critical pulmonic valvar stenosis was made at 36 weeks of gestation. In view of the severe heart failure, successful balloon valvotomy was performed on day 4 of life. The child was asymptomatic at one month follow-up.

Itraconazole oral solution for the treatment of tinea capitis using the pulse regimen

A 7-year-old boy with Trichophyton tonsurans tinea capitis was cured following the administration of itraconazole oral solution. He had difficulty swallowing tablets or capsules, so the availability of the oral solution was particularly advantageous. The itraconazole was given once daily in a fasting state at a dosage of 3 mg/kg/day as a pulse lasting 1 week. The first two pulses were separated by 2 weeks and the second and third pulse by 3 weeks. The decision whether or not to administer the third pulse was guided by the presence of clinical symptoms and signs of tinea capitis just prior to the scheduled administration. The availability of the oral solution will enable more young children to be considered for treatment of tinea capitis with itraconazole than was possible when only tablets or capsules were available.

Total colonic aganglionosis: diagnosis and management in a 12-year-old boy

Total colonic aganglionosis (TCA) is an unusual form of Hirschsprung's disease, and most of these present within the first few weeks and nearly all by the end of the first year of life. Very few cases presenting in older childhood or adulthood have been reported. Without a high index of suspicion these cases can easily be missed and, therefore, patients undergo repeated laparotomies for subacute intestinal obstruction without relief of symptoms. The diagnosis is suspected on operative findings and confirmed by histological evaluation of seromuscular biopsy specimens. Proper diagnosis will prevent loss of bowel length caused by inadvertent resection and will help in performing an optimal procedure to treat these patients. Discussed herein is another case of TCA in a 12-year-old boy with review of relevant literature.

Safety of itraconazole in diabetic patients

BACKGROUND

Onychomycosis and dermatomycoses can result in serious complications in patients with underlying chronic diseases such as diabetes. To avoid these complications, these dermatological disorders need to be treated efficiently, for example with the triazole antifungal itraconazole. Itraconazole can inhibit the metabolism of drugs by CYP 3A4 and therefore might affect the efficacy of antidiabetic agents.

OBJECTIVE

To investigate this, we assessed the safety of itraconazole in diabetic patients with onychomycosis or dermatomycoses.

METHODS

We reviewed pharmacokinetic and safety data from clinical trials and postmarketing surveillance over the past 10 years.

RESULTS

Postmarketing surveillance (a review of all adverse-event reports in patients receiving itraconazole concomitantly with insulin or an oral antidiabetic agent) revealed 15 reports suggestive of hyperglycemia and 9 reports suggestive of hypoglycemia; in most patients, no change in antidiabetic effect was reported. From clinical trials including a total of 189 diabetic patients treated with itraconazole for various infections (mainly systemic infections and vaginal candidiasis), only one itraconazole-related adverse event was recorded; this was a case of aggravated diabetes in a renal transplant recipient who was also receiving cyclosporine. Adverse effects due to drug-drug interactions are not expected in diabetic patients receiving oral antidiabetic agents that are not metabolized through the CYP 3A4 system (e.g. tolbutamide, gliclazide, glibenclamide, glipizide and metformin).

CONCLUSION

Itraconazole can be used safely and efficiently for the treatment of dermatological disorders in diabetic patients.

Drug interactions with itraconazole, fluconazole, and terbinafine and their management

A drug interaction develops when the effect of a drug is increased or decreased or when a new effect is produced by the prior, concurrent, or subsequent administration of the other. Before prescribing a drug, it is important to obtain a thorough drug history of the prescription and nonprescription medications taken by the patient. The nonprescription medications may include items such as nutritional supplements and herbal medications. The risk of side effects is an inevitable consequence of drug use. The frequency of adverse reactions is increased in those patients receiving multiple medications. Drug interactions reported in animal or in vitro studies may not necessarily develop in humans. When drug interactions are observed with a particular agent, it cannot be automatically assumed that all closely related drugs will necessarily produce the same interaction. However, caution is advised until sufficient experience accrues. The prescriber should not overestimate or underestimate the potential for a given drug interaction on the basis of personal experience alone. Drug interactions will not necessarily occur in every patient who is given a particular combination of drugs known to produce an interaction. For a clinically significant drug interaction to be manifest, several other factors may be relevant other than just using the two drugs. In many instances drug interactions can be predicted and therefore avoided if the pharmacodynamic effects, the pharmacokinetic properties, and the mechanisms of action of the 2 drugs in question are known. In the case of contraindicated drugs, it may be possible to use an alternative agent.

Intermittent short duration therapy with fluconazole is effective for tinea capitis

We have demonstrated in an open multicentre investigation that oral fluconazole 6 mg/kg daily for 2 weeks, followed, if clinically indicated four weeks from the start of therapy, by an extra week of treatment at the same dosage, may be effective and safe in the treatment of tinea capitis. Of a total of 48 patients, there were 42 evaluable children < 18 years old (19 boys, 23 girls; mean age 6.2 years, range 1.5-16). The causative organisms were Trichophyton tonsurans (38 subjects) and T. violaceum (four). In the 42 evaluable patients, a 2-week course of fluconazole was administered in 21, with the remainder requiring 1 additional week of therapy. At follow-up 12 weeks from the start of therapy, mycological and clinical cure was recorded in 37 of the 42 evaluable patients (88.1%, 95% confidence interval 83.1-93.1%). The treatment was well tolerated, with no clinical adverse effects. This regimen appears to be effective and safe, and is associated with high compliance. The preliminary results of the investigation need to be evaluated in a larger sample of patients, and in tinea capitis caused by zoophilic species.

Association with the cellular export receptor CRM 1 mediates function and intracellular localization of Epstein-Barr virus SM protein, a regulator of gene expression

Splicing and posttranscriptional processing of eukaryotic gene transcripts are linked to their nuclear export and cytoplasmic expression. Unspliced pre-mRNAs and intronless transcripts are thus inherently poorly expressed. Nevertheless, human and animal viruses encode essential genes as single open reading frames or in the intervening sequences of other genes. Many retroviruses have evolved mechanisms to facilitate nuclear export of their unspliced mRNAs. For example, the human immunodeficiency virus RNA-binding protein Rev associates with the soluble cellular export receptor CRM 1 (exportin 1), which mediates nucleocytoplasmic translocation of Rev-HIV RNA complexes through the nuclear pore. The transforming human herpesvirus Epstein-Barr virus (EBV) expresses a nuclear protein, SM, early in its lytic cycle; SM binds RNA and posttranscriptionally activates expression of certain intronless lytic EBV genes. Here we show that both the trans-activation function and cytoplasmic translocation of SM are dependent on association with CRM 1 in vivo. SM is also shown to be associated in vivo with other components of the CRM 1 export pathway, including the small GTPase Ran and the nucleoporin CAN/Nup214. SM is shown to be present in the cytoplasm, nucleoplasm, and nuclear envelope of transfected cells. Mutation of a leucine-rich region (LRR) of SM inhibited CRM 1-mediated cytoplasmic translocation and SM activity, as did leptomycin B, an inhibitor of CRM 1 complex formation. Surprisingly, however, leptomycin B treatment and mutation of the LRR both led to SM becoming more tightly attached to intranuclear structures. These findings suggest a model in which SM is not merely a soluble carrier protein for RNA but rather is bound directly to intranuclear proteins, possibly including the nuclear pore complex.

Cardiac function in hypothyroid children: effect of replacement therapy

OBJECTIVE

To evaluate prospectively cardiac function in children with primary hypothyroidism before and after replacement therapy with L-thyroxine.

DESIGN

Prospective clinical and laboratory cardiac evaluation of children with hypothyroidism before and after therapy.

SETTING

Hospital based.

SUBJECTS

20 consecutive children aged 6 months - 14 years with primary hypothyroidism.

METHODS

Assessment of cardiac status by clinical, radiological, ECG, echocardiography, M-mode and 2 dimensional echo-Doppler study and phonocardiography for systolic and diastolic functions and structural anomalies.

RESULTS

Indices of myocardial contractility like ejection fraction (EF), velocity of circumferential fibre shortening (VCF) did not change with therapy. However, systolic time intervals, both left ventricular (before therapy 0.32+/-0.03 msec; after therapy 0.25+/-0.03 msec; p <0.001) showed a significant change. In diastolic functions, isovolumic relaxation time fell from 62+/-9 msec before therapy to 50+/-5 msec after therapy (p <0.001). Pericardial effusion was found in 10 children before treatment which disappeared in 7 following therapy.

CONCLUSION

Subtle evidence of alteration of myocardial function is thus seen in children with primary hypothyroidism which reverses with treatment.

Non-randomized comparison of surgical modalities for paranasal sinus mycoses with intracranial extension

Mycotic infections of paranasal sinuses are frequently reported in southern Asia. Aspergillus and Mucor species are the predominant ones. Intracranial extension of paranasal sinus mycoses is a difficult problem to manage. We report 18 cases of paranasal sinus mycoses with intracranial extensions. The commonest manifestations were nasal discharge (67%), nasal obstruction (50%), ocular symptoms such as proptosis (44%), telecanthus (39%) and ophthalmoplegia. Computerized tomography scans were found to be quite informative regarding the nature and extent of the disease (100% sensitivity and 78% specificity). A combined intracranial-extracranial approach (six cases) gave a distinct advantage over only adopting an extracranial approach (12 cases). A 17% incidence of CSF leak was noted by adopting only an extracranial approach as well as a recurrence in four cases out of the 12 that were treated using this method (P < 0.05). A slight increase in morbidity was associated with the combined intracranial-extracranial treatment, but no recurrence or significant complications were noted in this approach.