'Monkeypox 2.0': Case series on a reconditioned virus causing sexually transmissible disease in urban population

BACKGROUND

MPOX (Monkeypox) viral infection, a zoonotic disease previously confined to the African sub-continent, has caught attention worldwide recently due to its resurgence in a new 'avatar' among urban communities. Dermatologists in the U. A. E. started to see patients with fever and a self-limiting pustular necrotic rash that was negative for all other infectious investigations.

METHODS

We performed a prospective observational multicenter clinical study of the demographics, skin manifestations, and outcomes of patients presenting with necrotic pustular lesions and/or fever.

RESULTS

35 cases of PCR confirmed MPOX cases, mostly in the expatriate population, were followed up and found to have high-risk heterosexual contact on an average of 1 week prior to disease onset. We found that they have characteristic annular pustular lesions with necrotic center or "Smoke ring pustules' in all cases. Lesion tenderness and predilection for the lower abdomen, pubic area, and genitalia were observed. Most cases were systemically stable, with fever lasting for an average of 4 days and elevated CRP levels. Genital lesions were prone to secondary bacterial infections. The disease was severe, with larger annular plaques in one of our patients found to be living with HIV.

CONCLUSIONS

The overall prognosis in healthy individuals is good, with lesions healing within an average of 2 weeks without scarring. 'New world MPOX' should be unclassified from zoonosis to a sexually transmitted infection (STI) capable of transmission in an urban population. Our findings can help in early clinical suspicion and differentiation from other STI's for primary and secondary health care physicians.

Bullous Mastocytosis: A Rare Variant of Diffuse Cutaneous Mastocytosis

Mastocytosis is a disease of the mast cells caused by an increase in the number of mast cells due to abnormal proliferation. The disease is associated with a mutation in the c-kit gene, which is a key factor in the development of mast cells. Mastocytosis is classified into two main groups, namely, cutaneous and systemic mastocytosis, based on the site of mast cell accumulation. In cutaneous mastocytosis, the cells purely gather in the skin. In contrast, systemic mastocytosis must affect an internal organ, including the bone marrow, lymph nodes, liver, spleen, and/or the gastrointestinal tract with or without skin involvement. Cutaneous mastocytosis has four distinct presentations, including urticaria pigmentosa, cutaneous mastocytoma, diffuse cutaneous mastocytosis, and telangiectasia macularis eruptive perstans listed from most to least common. This case report presents a rare bullous variant of diffuse cutaneous mastocytosis.

Healthcare Resource Utilization and Direct Cost of Patients with Atopic Dermatitis in Dubai, United Arab Emirates: A Retrospective Cohort Study

Introduction

Atopic dermatitis (AD) data are scarce in Dubai [United Arab Emirates (UAE)]. Therefore, this study aimed at understanding real-world healthcare resource utilization (HCRU) and related costs, specialties, treatment landscape, consultation-based prevalence and incidence, and patient characteristics.

Methods

This retrospective, longitudinal, insurance e-claims (Dubai Private Insurance-insured expatriates) database studied AD in Dubai between 1 January 2014 and 31 March 2020. Two cohorts of patients based on treatment status as the eligibility criteria were selected from 442,956 patients with at least two AD diagnosis claims: treated AD [mild to moderate (10,134 patients) and moderate to severe (3515 patients)] and untreated or on drugs not included in the treated AD cohort (10,806 patients).

Results

Across treated AD (mild to moderate and moderate to severe) and untreated AD cohorts, mean age was ~ 29 years; the majority were from dermatology (65-44%) and pediatrics (29-32%) specialty. Key HCRU cost contributors were hospitalizations and outpatient visits in both the treated AD groups. Mean annual disease-specific HCRU cost per patient was highest for the moderate-to-severe treated (531.5 USD) cohort, followed by the mild-to-moderate treated (378.4 USD) cohort, and lowest for the untreated (144.0 USD) cohort; patients with AD with any infection, asthma, or allergic rhinitis showed a similar trend. However, AD-diagnosed patients with Staphylococcus infection had the highest mean HCRU cost among the mild-to-moderate treated AD cohort, followed by the moderate-to-severe treated AD cohort.

Conclusion

This study indicated AD to be a common skin disease with a prevalence rate of 4-5% in Dubai (UAE), with the majority of patients (about 90%) being treated by specialists. However, there is a significant underuse of newer innovative therapies (including biologics). Also, disease severity (moderate-to-severe AD) was associated with high direct medical cost, which could be controlled by early intervention. Furthermore, AD treatment choice could focus on major direct HCRU cost contributors such as hospitalizations, comorbid conditions, and infections.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-022-00769-z.

Necrolytic migratory ulceration

Endocrine tumors of the gastroenteropancreatic system associated with specific skin manifestations are rare. We report a 53-year-old female who presented with migratory annular and arcuate ulcers on her limbs. Histopathology was similar to necrolytic erythema family which includes necrolytic migratory erythema (NME). Though initial CT scans were normal, follow up scans revealed multiple mass lesions in the tail of pancreas. Her skin lesions responded to oral zinc sulphate and monthly injections of octreotide. Prior to planned FNAC from the mass lesion, patient developed altered sensorium and succumbed to the disease. This case report seems to differ from NME clinically, due to unique finding of deep migrating ulcers which heal with scarring. 'Necrolytic migratory ulceration' thus appears to be a new paraneoplastic manifestation, secondary to pancreatic malignancy.

Localized psoriasis herpeticum: Case report and review of literature

Kaposi's varicelliform eruption (KVE) is a widespread cutaneous eruption caused by viruses, especially herpes simplex virus in patients with pre-existing dermatoses. “Psoriasis herpeticum” refers to the rare occurrence of KVE in patients with psoriasis. We report a case of KVE localized to the face in a patient with exfoliative dermatitis secondary to psoriasis. This case is being reported to make the treating clinician aware of the possibility of KVE in patients with psoriatic erythroderma.

Determinants of quality of life in psoriasis patients: a cluster analysis of 50 patients

BACKGROUND

Although psoriasis generally does not affect survival, it certainly has a number of major negative effects on patients, demonstrable by a significant detriment to quality of life.

AIMS

We have done a study with the objective of assessing the clinical variables adversely affecting quality of life in patients diagnosed with psoriasis.

MATERIALS AND METHODS

This study is a cluster analysis of 50 consecutive consenting patients with psoriasis, of both sexes, aged over 18 years, attending the dermatology outpatient department of a tertiary care center. We measured the clinical severity using psoriasis area severity index and health-related quality of life using psoriasis disability index (PDI). Statistical analysis was performed using unpaired independent student's t-test, analysis of variance (and Scheffe's post hoc test as appropriate) and Pearson's correlation coefficients.

RESULTS

There was a significant correlation between the physician-rated severity of psoriasis and the extent of impact of psoriasis on physical disability as measured by the PDI. We have identified that a younger age at onset of disease and self-reported stress exacerbators suffer greater disability in most aspects of quality of life.

CONCLUSIONS

On the basis of this study, we would recommend that psoriasis patients especially with severe disease require a more holistic treatment approach that encompasses both medical and psychological measures.

Adult T-cell leukemia/lymphoma: a retroviral malady

Adult T-cell leukemia/lymphoma (ATLL) is an aggressive leukemia/lymphoma of mature T-lymphocytes caused by human T-cell lymphotropic virus type 1 (HTLV-1). At a tertiary healthcare center in South India, a 58-year-old female presented with multiple erythematous, crusted, and umbilicated papules over the body along with cervical lymphadenopathy. The skin biopsy was consistent with cutaneous T-cell lymphoma. Although she responded initially to chemotherapy, the disease relapsed after 3 months, and she developed disseminated infiltrated skin lesions, generalized lymphadenopathy, and leukemia. Due to the unusual clinical findings we did HTLV-1 Enzyme-linked immunosorbent assay (ELISA), which turned out to be positive in high titers. Her mother had died at an early age from a hematological malignancy and her daughter was also found to be seropositive. To the best of our knowledge, this is the first case to be reported from India of the chronic type of ATLL associated with mother-to-child transmission of HTLV-1 in two generations. This case also emphasizes that the chronic type of ATLL can occur in nonendemic areas like India and should be suspected in nonresponding cases of mycosis fungoides. It should be kept in mind that the chronic type often presents without hypercalcemia or the characteristic ‘flower cells’ in the peripheral smear.

Interesting effect of Malassezia spp. infection on dermatoses of other origins

BACKGROUND

Tinea versicolor (TV) is a superficial fungal infection affecting as many as 40% of the population in the tropics. We noticed an unusual affect of TV on dermatoses of other origins.

METHODS

In this prospective clinical study, we examined patients attending our dermatology outpatient department over a period of one year for coexistence of TV with any unrelated dermatoses. We confirmed the diagnosis of TV by microscopy of skin scrapings. Skin biopsy was performed when necessary to confirm the diagnosis of associated dermatoses.

RESULTS

We describe four cases in which unrelated dermatoses (viral exanthem, acute generalized exanthematous pustulosis, polymorphous light eruption, and irritant contact dermatitis) specifically spared sites affected with TV.

CONCLUSIONS

Recent research has elucidated the immunomodulatory properties of Malassezia spp. in vitro. Our cases serve as possible in vivo models illustrating such properties. Further studies based on these reports could lead to the isolation of molecules from Malassezia, which may have potential use in anti-inflammatory drug formulations.

Purpuric macules with vesiculobullous lesions: a novel manifestation of Chikungunya

BACKGROUND

Chikungunya (CHIK) is an emerging viral disease with a myriad of cutaneous manifestations.

AIMS

The aim of our study was to document the morphology and evolution of skin lesions in cases presenting with fever, purpuric macules and vesiculobullous lesions, to confirm its causative relationship with CHIK, and to investigate further in order to delineate possible mechanisms of bulla formation in these cases.

MATERIALS AND METHODS

A prospective, descriptive hospital-based study was carried out at a tertiary health care centre in Kerala. A total of 10 patients were enrolled in the study and investigated.

RESULTS

All cases had morbilliform eruption prior to onset of purpuric macules. Eight cases developed vesiculobullous lesions that arose either de novo or over a part or whole of the purpuric macules. Skin lesions resolved within an average of 7.6 days leaving post-inflammatory hypopigmentation. IgM CHIK enzyme-linked immunosorbent assay (ELISA) was positive in all 10 patients. Tzanck smear from the bullae showed lymphocytes in most cases along with acantholytic cells, necrotic keratinocytes or occasional neutrophils. Skin biopsy showed intraepidermal or subepidermal bullae. Immunohistochemistry revealed predominantly CD8 positive T lymphocytes in the infiltrate. The prognosis was good with supportive management alone.

DISCUSSION

The clinical features in our cases are comparable to the 3 previous reports of vesiculobullous lesions in CHIK affected infants. Based on the current evidence, we hypothesize that at least 2 mechanisms are at play for these skin lesions; CHIK virus induced keratinocyte necrosis followed by a cytotoxic immune response, and possible modulation of rash by drugs.

CONCLUSION

With severe epidemics of CHIK spreading from Asia and Africa to the Western hemisphere, we must consider bullous CHIK as a differential diagnosis in cases with fever and purpuric and vesiculobullous lesions.

Sub-polar lepromatous leprosy localized to the face

Leprosy is an infectious disease characterized by a wide spectrum of clinical manifestations, ranging from tuberculoid to lepromatous disease with immunologically unstable borderline forms in between. In clinical practice cases often do not conform to a classical textbook description, which may lead to misdiagnosis if not properly investigated. A 22-year-old patient presented to us with erythematous plaques localized to the face. Slit skin smear for Mycobacterium leprae was positive from lesional as well as non-lesional skin. A biopsy from a plaque showed diffuse atrophy of the epidermis with a subepidermal cell free zone (grenz zone). The cellular infiltrate was composed of foamy macrophages admixed with lymphocytes in the dermis. Fite-Faraco staining revealed clumps of acid-fast bacilli within the macrophages. Based on the skin smear and histopathology findings, a diagnosis of sub-polar lepromatous leprosy was made and the patient was started on multidrug therapy. The exact pathogenesis of localized multibacillary disease is not known. Our case highlights the importance of skin smear and biopsy in all suspected cases of Hansen disease. We conclude that routine skin smear in all new leprosy cases is mandatory to differentiate localized multibacillary cases from paucibacillary cases for the purpose of accurate categorization and treatment.