Prescribing practices of tranexamic acid for melasma: Delphi consensus from the Pigmentary Disorders Society

Introduction There is ambiguity regarding usage of tranexamic acid for melasma in India, be it in its pre-administration evaluation, administration route, dosing or monitoring. Hence, we conducted this study to understand various tranexamic-acid prescribing patterns and provide practical guidelines. Materials and methods A Google-form-based questionnaire (25-questions) was prepared based on the key areas identified by experts from the Pigmentary Disorders Society, India and circulated to practicing dermatologists across the country. In rounds 2 and 3, the questionnaire was re-presented to the same group of experts and their opinions were sought. The results of the practitioners' survey were denoted graphically alongside, to guide them. Consensus was deemed when at least 80% of respondents chose an option. Results The members agreed that history pertaining to risk factors for thromboembolism, cardiovascular and menstrual disorders should be sought in patients being started on oral tranexamic-acid. Baseline coagulation profile should be ordered in all patients prior to tranexamic-acid and more exhaustive investigations such as complete blood count, liver function test, protein C and S in patients with high risk of thromboembolism. The preferred oral dose was 250 mg orally twice daily, which can be used alone or in combination with topical hydroquinone, kojic acid and sunscreen. Repeated dosing of tranexamic-acid may be required for those relapsing with melasma following initial tranexamic-acid discontinuation. Coagulation profile should ideally be repeated at three monthly intervals during follow-up, especially in patients with clinically higher risk of thromboembolism. Treatment can be stopped abruptly post improvement and no tapering is required. Limitation This study is limited by the fact that open-ended questions were limited to the first general survey round. Conclusion Oral tranexamic-acid provides a valuable treatment option for melasma. Frequent courses of therapy may be required to sustain results and a vigilant watch is recommended for hypercoagulable states during the course of therapy.

Clinical Profile and Diagnostic Accuracy of Patient-submitted Photographs in Teledermatology

Background

The COVID-19 pandemic has shifted healthcare from physical in-person patient visits to teleconsultations in order to curtail the spread of this virus. Dermatology, being a visual science, lends itself amenably to teleconsultation.

Objective

This study was performed to assess the basic dermatological diseases which are more easily diagnosable and managed through teleconsultation, distinguishing them from diseases for which a face-to-face consultation may be a better option and to delineate the factors affecting the image quality which is the cornerstone of a teledermatology consultation.

Methods

A retrospective observational study was conducted over a three-month period during the pandemic. Store and forward, video conferencing, and hybrid consultations were included. Two dermatologists of different clinical experience independently assessed the clinical photographs of the patients and gave each photograph an objective score (Physician Quality Rating Scale) and a diagnosis. The diagnostic concordance between the two dermatologists as well as the correlation of this score with the certainty of diagnosis was calculated.

Results

A total of 651 patients completed the study. Mean PQRS score of Dermatologist 1 was 6.22 while the mean score of Dermatologist 2 was 6.24. Patients in whom both the dermatologists were absolutely certain about their diagnosis had a higher PQRS score and interestingly had a higher education level than the rest. There was 97.7 percent diagnostic concordance between the two dermatologists. Infections, acne, follicular disorders, pigmentary disorders, tumors, and STDs had the largest proportion of cases wherein both the dermatologists were in total agreement with each other.

Conclusion

Teledermatology might be best for the care of patients with characteristic clinical presentation or for follow-up of already diagnosed patients. It can be used in the post-COVID era to triage patients requiring emergency care and reduce patient wait times.

Brachial artery flow-mediated dilation in patients with systemic sclerosis: an experience from tertiary care center from North India

Role of flow-mediated dilatation (FMD) testing in the assessment of the macrovascular dysfunction in systemic sclerosis (SS) and correlation of FMD values with disease severity. Twenty-five patients of SS and 25 healthy age-matched controls were recruited. Modified Rodnan skin thickness score (MRSS) was used for skin thickness assessment. FMD values were measured in the brachial artery. FMD values done at baseline before the initiation of treatment were lower in SSc patients (4.044 ± 2.742) compared to the healthy controls (11.076 ± 5.896) (P < 0.05). Comparison of FMD values between patients with limited cutaneous systemic sclerosis (LSSc) and diffuse cutaneous systemic sclerosis (DSSc) showed a trend toward lower in LSSc (3.182 ± 2.482) as compared to DSSc patients (5.111 ± 2.711); however, the difference was not statistically significant. Patients with lung manifestations on high-resolution CT chest showed lower FMD values (2.66 ± 2.23) compared to those without HRCT changes (6.45 ± 2.56) (P < 0.05). We demonstrate that FMD values in SSc patients were lower when compared to healthy controls. Patients with SS having pulmonary manifestations showed a lower value of FMD. Key Points • FMD is a simple non-invasive tool to assess the endothelial function in patients with systemic sclerosis. • Lower values of FMD in systemic sclerosis suggest that the endothelial dysfunction and values can also be correlated with other organ involvement such as lung and skin involvement. So, lower FMD values might be a useful marker for disease severity.

Species Distribution and Antifungal Susceptibility Profile of Dermatophytes from a Tertiary Care Centre in North India

Objective Dermatophytoses, one of the most ancient diseases, is becoming a menace in recent times. This has made the knowledge of antifungal susceptibility a priority in today's times.

Material and Methods This is a prospective study conducted over 18 months including all dermatophytes isolated during the period. Dermatophytes were identified by routine phenotypic methods. Antifungal susceptibility testing was performed for griseofulvin, terbinafine, and itraconazole as per the Clinical Laboratory Standard Institute M38 A2, and minimum inhibitory concentrations (MICs) were read after 5 days.

Results Patient details and associated risk factors were recorded. Fixed dose combinations with steroids were associated with 79.3% (46 out of 58) of patients with dermatophytosis of skin. Among the 72 dermatophytes isolated during the study period, 58 (80.5%) were isolated from skin scrapings and 14 (19.4%) from nail samples. Tinea corporis with cruris was the most common presentation. The most common dermatophyte isolated from skin scrapings was Trichophyton mentagrophytes complex (70.6%, 41 out of 58), while from nail samples it was Trichophyton rubrum complex (78.57%, 11 out of 14). Based on the MIC50 and MIC90 results, itraconazole showed the lowest MICs, followed by terbinafine and then griseofulvin.

Conclusion With the changing epidemiology of species distribution and antifungal resistance, there is a need for continuous surveillance of these parameters of dermatophytes.

Platelet-rich plasma is a promising therapy for melasma

INTRODUCTION

Platelet-rich plasma (PRP) is an autologous blood product which has recently been used in multiple spheres of dermatology including facial rejuvenation, androgenetic alopecia, acne scars, and wound healing. Its use in melasma is comparatively an understudied topic.

MATERIAL AND METHODS

An extensive systematic literature search of the PubMed electronic database and Cochrane central register of controlled trials was done using the keywords "platelet rich plasma" and "melasma" in the title. Relevant studies were selected and data were analyzed by two different authors. Four articles were excluded as they did not adhere to the inclusion criteria of this review and a total of 6 articles were reviewed.The relevant references of the included articles were also traced and included.

DISCUSSION

These studies showed that PRP has been used effectively not only as an adjuvant therapy but also as a standalone treatment for melasma. PRP contains about 30 growth factors, transforming growth factor beta (TGF-β) being one of the growth factors having a predominant role in treatment of melasma. TGF-β decreases signal transduction of microphthalmia-induced transcription factor and thus decreases tyrosinase and tyrosinase-related proteins. In addition to this, PRP also has an additional benefit of inducing collagen synthesis thus improving the quality and texture of the skin. But there is a scarcity of data and large randomized controlled trials. This review is an effort to highlight and upscale the use of this excellent blood product for melasma which is quite a treatment refractory disorder.

A Rare Case of Congenital Vitiligo in a Neonate

BACKGROUND

Vitiligo affects one percent of general population and usually manifests in the second and third decades of life. Vitiligo is believed to be an acquired condition, though a positive family history is seen in 30 to 40 percent of cases. Few cases of vitiligo at birth have been reported. We report a case of congenital vitiligo in a neonate and discuss disease course and pathogenesis.

CASE REPORT

A 27- days-old female neonate patient presented with multiple, rapidly progressing, depigmented patches over the body that had been present since birth. The lesions showed chalky white accentuation under Wood's lamp. There was positive history of vitiligo in the mother. The child was started on topical fluticasone propionate 0.05% cream in the morning and tacrolimus 0.03% ointment at night. At the one-year of follow-up period, there were no new lesions, and partial repigmentation was noticed in the existing lesions.

CONCLUSION

Manifestation of vitiligo at birth is a very rare occurrence. The presentation at birth in this case suggests a genetic link, as opposed to acquired factors, and supports the in-utero hypothesis, adding to the scant literature available on congenital vitiligo.

Aspergillus candidus eumycetoma with review of literature

OBJECTIVE

Mycetoma is a slowly progressive, chronic granulomatous infection of skin and subcutaneous tissues with involvement of underlying fasciae and bones, usually affecting extremities. In India, among mycetoma, the eumycetoma constitutes about 35% of cases. Hereby, we report the first case of eumycetoma caused by uncommon fungus, Aspergillus candidus.

CASE REPORT

A 61 year old female presented to the Department of Dermatology with history of swelling of right foot associated with multiple firm nodules of approx. 1.5 × 1.5 cm each over dorsum of foot with discharging sinus containing white color granules. Biopsy of lesion on right foot on direct KOH examination revealed septate hyphae. Histopathology examination showed a histiocytic granuloma with fungal elements. Culture on Sabouraud Dextrose Agar grew white mycelial colonies which were identified to be Aspergillus species phenotypically. Genetic sequencing using Internal transcribed spacer gene, beta tubulin gene and Calmodulin gene was done and the isolate was identified to be Aspergillus candidus. Lesion was excised and patient was started on itraconazole.

CONCLUSION

Timely identification and starting of antifungal treatment can help in reducing morbidity due to eumycetoma to a large extent. As newer and newer species of fungi are emerging as significant causative agents of human infections, it is pertinent to report such findings from epidemiological point of view.

Autologous intralesional platelet rich plasma improves melasma

Platelet rich plasma (PRP) is an upcoming interventional therapy for the treatment of melasma. Its efficacy is due to the multiple growth factors present in it which decrease melanogenesis by various signal transduction pathways. The present study evaluated the efficacy of PRP as a standalone agent in treatment of melasma. This is an open labeled prospective trial. Forty patients were given intralesional PRP at once monthly interval. Three such PRP sessions were carried out and the patients were followed up for 3 months. Assessment was done by calculating the modified melasma area severity index score (mMASI) for each patient. Patients were also asked to self-evaluate their improvement based on a scale. There was an average 54.5% reduction in the mMASI score at the end of the study. There was no relapse in any patient. This reduction was irrespective of the skin type, gender, and type of melasma. Patients self-evaluation showed that more than 90% of the patients were pleased or very pleased with the results. There were no significant side effects. PRP appears to be a potential new therapy with significant efficacy in improving pigmentation of melasma, standalone as monotherapy.

Efficacy of tuberculin immunotherapy in verruca vulgaris: Our experience from single center from North-West India and review of literature

Verruca vulgaris (VV) acquired through direct contact or autoinoculation of human papilloma virus (HPV). Treatment of VV are challenging as destructive modalities have variable efficacy and recurrence rates. Various immunotherapies attempt to stimulate the cell-mediated host immune response against HPV. We have assessed efficacy of intralesional tuberculin in patients with verruca vulgaris and to see the long term follow-up at 12 months. Forty patients were enrolled in the study. All patients received intralesional tuberculin injections (5 Tuberculin U/mL) in a dose of 0.1 mL/lesion every fortnightly. Patients were followed up for 12 months duration, and response to treatment assessed. Thirty patients (75%) showed complete resolution, 5 (12.5%) patients showed partial response, 3 (7.5%) showed minimal response and 2 (5%) were non-responders. Irrespective of tuberculin sensitivity test response the majority of patients showed grade 3 response. Five (12.5%) patients had a recurrence of lesions. Two had a recurrence on the same site, and three had recurrences over distant sites. Intralesional tuberculin immunotherapy is an effective modality for VV. Immunotherapy of warts is a potential area of research, and exact method and agents are still under investigation.

Blindness associated with platelet-rich plasma temporomandibular joint injections

This case report highlights an ocular complication associated with platelet-rich plasma temporomandibular joint injections. This pioneering treatment can risk irreversible visual loss. This case highlights the importance of an experienced technique, in depth understanding of facial anatomy, and promptly recognising and referring the patient to a specialist to manage the complication should it arise.

Increased Notching of the Corpus Callosum in Fetal Alcohol Spectrum Disorder: A Callosal Misunderstanding?

BACKGROUND AND PURPOSE

In the medicolegal literature, notching of the corpus callosum has been reported to be associated with fetal alcohol spectrum disorders. Our purpose was to analyze the prevalence of notching of the corpus callosum in a fetal alcohol spectrum disorders group and a healthy population to determine whether notching occurs with increased frequency in the fetal alcohol spectrum disorders population.

MATERIALS AND METHODS

We performed a multicenter search for cases of fetal alcohol spectrum disorders and included all patients who had a sagittal T1-weighted brain MR imaging. Patients with concomitant intracranial pathology were excluded. The corpus callosum was examined for notches using previously published methods. A χ² test was used to compare the fetal alcohol spectrum disorders and healthy groups.

RESULTS

Thirty-three of 59 patients with fetal alcohol spectrum disorders (0-44 years of age) identified across all centers had corpus callosum notching. Of these, 8 had an anterior corpus callosum notch (prevalence, 13.6%), 23 had a posterior corpus callosum notch (prevalence, 39%), and 2 patients demonstrated undulated morphology (prevalence, 3.4%). In the healthy population, the anterior notch prevalence was 139/875 (15.8%), posterior notch prevalence was 378/875 (43.2%), and undulating prevalence was 37/875 (4.2%). There was no significant difference among the anterior (P = .635), posterior (P = .526), and undulating (P = .755) notch prevalence in the fetal alcohol spectrum disorders and healthy groups.

CONCLUSIONS

There was no significant difference in notching of the corpus callosum between patients with fetal alcohol spectrum disorders and the healthy population. Although reported to be a marker of fetal alcohol spectrum disorders, notching of the corpus callosum should not be viewed as a specific finding associated with fetal alcohol spectrum disorders.

Familial Dermatophytosis in India: A Study of the Possible Contributing Risk Factors

Background: Dermatophytes are keratinophilic fungi responsible for skin, nail, and scalp infections. Chronic dermatophytosis, defined as persistent infection for six months or more, was very rare in the 1980s and mostly limited to patients with nail involvement, but this is no longer true. Currently, patients with chronic dermatophytosis are increasing, and about 50 percent of patients with dermatophytosis have at least one other member of their family infected at the same time, sometimes with entire families being affected at once. Objective: We sought to study the possible risk factors associated with familial dermatophytosis. Methods: The present questionnaire-based study was conducted from May 2017 to July 2017. Patients with a clinical diagnosis of dermatophytosis and at least one other family member affected were included. A proforma was filled and history was taken, including number of family members affected, site of infection in the index case, site(s) of infection of all other subsequent family members affected, and use of over-the-counter drugs. Results: Out of the 113 families surveyed, which included 673 subjects, a little over half (55.4%) were affected by dermatophytosis. In 103 families, the initial site of infection in the subsequent family member affected was the same site as that affected in the first member. All families reported a history of using an irritant soap and over-the-counter drugs. Washing all the family's clothing together was a common factor. All families had a single bathroom and used the same soap and stool for bathing. Conclusion: Through our survey, we identified possible risk factors that might be responsible for the increasing epidemic of familial dermatophytosis in India, including sharing of soaps and towels, washing clothes in the same vessel, sharing of lavatories, abuse of topical steroids and over the counter topicals, and use of antiseptic soaps that kill normal flora.

Evaluation of efficacy and safety of oral terbinafine and itraconazole combination therapy in the management of dermatophytosis

Background: There has been an alarming increase in recalcitrant dermatophytosis in recent years. The standard treatment guidelines no longer seem effective in achieving clearance and results in high failure rates.Objective: To evaluate the efficacy and safety of oral terbinafine and itraconazole combination therapy in the management of dermatophytosis.Methods: Clinically diagnosed and KOH positive patients of tinea corporis/cruris/faciei were randomly divided into three groups and given terbinafine 250 mg, itraconazole 200 mg and a combination of both once daily taken on the same day respectively for 3 weeks. Partial responders at the end of the therapy were given same treatment for additional 3 weeks. Clinical parameters namely itching, erythema, and scaling were evaluated at baseline, 3, 6, and 9 weeks. Adverse effects were noted at the end of therapy.Results: Maximum clinical and mycological cure was achieved in group III (receiving combination therapy) (90%) followed by group II (receiving itraconazole) (50%) and group I (receiving terbinafine) (35%). The combination therapy of oral terbinafine and itraconazole was found to be as safe as monotherapy without any significant adverse effects.Conclusions: The combination of systemic terbinafine and itraconazole therapy may be an effective and safe therapeutic strategy in the management of dermatophytosis.

Lithium-induced Linear Psoriasis: A Rare Presentation

Atypical forms of psoriasis are frequently seen. However, linear psoriasis precipitated by drugs is extremely rare. We report a case of an adult woman who presented with lithium-induced unilateral psoriasis arranged in Blaschko lines on the left leg. A brief discussion on etiology and differential diagnosis is included, as well as treatment methods.

Evaluating the Unusual Histological Aspects of Granuloma Annulare: A Study of 30 Cases

BACKGROUND

Granuloma annulare (GA) is an uncommon dermatologic disorder that presents as annular, skin-colored to erythematous plaques. Histopathologically, it is characterized by palisaded histiocytic granulomas. A definitive diagnosis of GA is based on clinicopathologic correlation.

OBJECTIVE

The aim of this study was to study the histomorphologic spectrum of GA.

MATERIALS AND METHODS

A total of 30 cases reported as GA over 6 years (2012-2017) were retrieved. The detailed clinical profile and histomorphologic findings on the skin biospies were reviewed.

RESULTS

Majority of the cases (40%) presented in the 6th decade of life with a mean age of 48.3 ± 16.5 years and with a female predominance (77%). The lesions were localized in 22 cases (73%). Asymptomatic to erythematous, annular plaques was the most frequent presentation (60%). GA was not suspected clinically in two cases. Histopathologically, interstitial pattern of infiltrate was most common (44%), whereas granuloma formation and palisaded histiocytes were seen in 4 (13%) and 3 cases (10%), respectively. A mixed pattern was observed in 10 (33%) cases. Collagen degeneration was universal finding (100%) and presence of dermal mucin was noted in 24 cases (80%), both of which were important clues to the diagnosis of GA. Additional features such as presence of plasma cells, eosinophils, and vasculitis were noted in 10 (33%), 6 (20%), and 6 (20%) cases, respectively.

CONCLUSION

The diagnosis of GA may be challenging owing to its diverse morphology. Acquaintance with the varied histomorphology of GA is of utmost importance to render a correct diagnosis and understand the pathogenesis.

Localized Hypertrichosis at Vaccination Site

Hypertrichosis is described as an increased hair growth on any part or over whole body in comparison to persons of the same age, sex, and race which is independent of androgen excess. It may be localized and generalized or alternatively acquired and congenital forms. The acquired localized hypertrichosis has been associated with various causes including local trauma, chronic irritation, inflammation, occlusion by cast, and drugs. Here, we report a case of 2½-month-old healthy infant presenting with localized area of hypertrichosis over anterolateral aspect of the left thigh which was confined to the site of vaccination.

Annular alopecia areata: A morphologically rare variant

Alopecia areata (AA) is the most common form of nonscarring alopecia involving the scalp and/or body. The most common pattern of hair loss is oval or round, but newer morphological variants are increasingly being described. We hereby report two cases of annular pattern of AA due to its unusual morphology.

Trichothiodystrophy without Associated Neuroectodermal Features in Two Siblings

Trichothiodystrophy (TTD) is characterized by the common feature of sulfur-deficient brittle hair associated with a constellation of neuroectodermal symptoms. There is a wide phenotypic variation in the severity; ranging from isolated hair defect to multiple neuroectodermal symptoms such as photosensitivity, ichthyosis, intellectual impairment, decreased fertility, and short stature. This case report describes TTD in two sisters with only hair fragility and no other associated feature. This case highlights the variable clinical presentation of TTD and the need for regular follow-up in such patients for an early detection of any neurological, physical, and sexual impairment.

Multidrug-resistant tuberculosis and leprosy: An unsolved mystery

Tuberculosis (TB) and leprosy are two age-old infections, which we are facing even today. With drug-resistant TB on the rise, we report a case of multidrug-resistant TB with leprosy, which has never been reported previously. The peculiar course of this case forces us to rethink about the upcoming challenges due to their cooccurrence.

Early detection of multi-drug resistance and common mutations in Mycobacterium tuberculosis isolates from Delhi using GenoType MTBDRplus assay

PURPOSE

There is scarcity of prevalence data of multi-drug-resistant tuberculosis (MDR-TB) data and common mutations responsible in North India. This study aimed to detect MDR-TB among MDR-TB suspects from Delhi and mutation patterns using GenoType MTBDRplus assay.

MATERIALS AND METHODS

All MDR suspects in five districts of New Delhi were referred to the laboratory from 1 st October 2011 to 31 st December 2012 as per criterion defined by Programmatic Management of Drug Resistant Tuberculosis (PMDT). GenoType MTBDRplus assay was performed on 2182 samples or cultures and mutations in the rpoB gene for rifampicin (RIF) and katG and inhA genes for isoniazid (INH) were analyzed.

RESULTS

A total of 366 (16.8%) MDR-TB cases were diagnosed. MDR rate was found to be 32%, 16.6% and 10.2% during criterion A, B and C respectively. The most common mutation detected for RIF was S531L (59.0%) and for INH was S315T1 (88.3%). Mutations S531L and S315T1 occurred significantly higher in MDR strains as compared to RIF mono-resistant and INH mono-resistant strains, respectively. Average laboratory turn-around time (TAT) for dispatch of result to districts for test conducted on samples was 4.4 days.

CONCLUSION

GenoType MTBDRplus is a useful assay for rapid detection of MDR-TB. The common mutations for RIF and INH were similar to those seen in other regions. However, mutations determining MDR strains and mono-resistant strains differed significantly for both RIF and INH.

Changing Epidemiology of Mucoralean Fungi: Chronic Cutaneous Infection Caused by Mucor irregularis

INTRODUCTION

The fungi pertaining to order Mucorales usually cause an acute form of clinical disease called mucormycosis. A primary chronic presentation in an immunocompetent patient is a rare form of mucormycosis. Mucor irregularis is known for causing chronic cutaneous infections geographically confined to Asia, mainly in China. We describe a case of primary chronic cutaneous mucormycosis caused by M. irregularis from a new geographical niche in India, highlighting changing aspects of its epidemiology.

CASE PRESENTATION

The patient was a farmer with a history of skin lesions over the lower limb for the past 6 years. The biopsy taken from the lesions showed pauci-septate hyphae with right-angle branching on KOH wet mount as well as special fungal stains. On fungal culture, greyish-white cottony mycelial growth of Mucormycetes was obtained. The strain was finally identified as M. irregularis on macro- and microscopic features on 2 % MEA and DNA sequencing. The antifungal susceptibility was done using EUCAST broth microdilution method and was found to be susceptible to commonly used antifungal agents. The patient was started on oral itraconazole and saturated solution of potassium iodide (SSKI). While undergoing treatment for 2 months, he was lost to follow-up, however, after a year when he recently visited the hospital; the disease got completely healed with no new crops of skin lesions.

CONCLUSION

Mucoralean fungi should also be suspected in cases with chronic presentation, in immunocompetent host, as there is emergence of such fungi in new endemic areas, particularly located in Asia. The role of other antifungal agents apart from amphotericin B for the treatment of chronic mucormycosis needs to be explored.

Phylogenetic associations with drug-resistant Mycobacterium tuberculosis isolates in a paediatric population

SETTING

Department of Microbiology, National Institute of Tuberculosis and Respiratory Diseases, New Delhi, India.

OBJECTIVES

As paediatric tuberculosis (TB) is a surrogate marker for actively transmitted disease in a community, we investigated drug resistance patterns of 97 Mycobacterium tuberculosis complex strains isolated from children and explored their phylogenetic associations.

DESIGN

A total of 111 paediatric patients who attended the out-patient department during the study period 2009-2011 and whose sputum samples were sent to the Microbiology Department for liquid culture and drug susceptibility testing (DST) were included in this study. DST and spoligotyping were performed on cultures positive for M. tuberculosis complex.

RESULTS

DST against four first-line drugs showed that 31 of 97 (32%) strains were pan-susceptible, while 66/97 (68%) were resistant to at least one drug, including 55/97 (56.7%) that were resistant to at least isoniazid and rifampicin (i.e., multidrug-resistant). The majority of the isolates (n = 81/90, 90%) belonged to the principal genetic group 1 strains, the most predominant spoligotyping clusters being spoligotyping international type (SIT)1/Beijing (n = 28), SIT26/CAS1-Delhi (n = 27) and SIT53/T1 (n = 6).

CONCLUSION

The involvement of Beijing and CAS1-Delhi clades in paediatric TB patients suggests that these two lineages play a major role in ongoing active transmission.

Photoletter to the editor: Bullous dermatitis artefacta induced with a hot spoon

A 22-year-old female presented to the dermatology department with a 8-month history of blistering lesions over the left forearm and face. Most of the bullae and erosions were perfectly round and of nearly the same size. In absence of any obvious etiological, precipitating or aggravating factor, a provisional diagnosis of dermatitis artefacta (self-inflicted dermatological lesions) was made. A detailed anamnesis revealed that stress caused by her ex-boyfriend's threats and apprehension of consequences prompted her to create the lesions using a hot spoon. The patients of dermatitis artefacta usually present to dermatologists as their pathology manifests as unexplained and variable cutaneous lesions which may go undiagnosed for a long time. It is important for the dermatologist to have a high index of suspicion to recognise the underlying psychopathology.

Recurrent erythema nodosum: a red flag sign of hidden systemic vasculitis

Takayasu's arteritis is a rare, systemic vasculitis with varied presentations across multiple medical specialities. Here, we present a young woman who had recurrent episodes of erythema nodosum on the background of a low-grade fever and no vascular manifestations. The presence of a high erythrocyte sedimentation rate generated a high index of suspicion for underlying vasculitis, and radioimaging confirmed the suspicion of Takayasu's arteritis. The patient was found to have type III diseases in the vasculitic stage and was managed with systemic corticosteroids.

Serum potassium predicts time to blood pressure response among African Americans with hypertensive nephrosclerosis

It is not known whether serum potassium levels affect blood pressure response to anti-hypertensive medication. The African American trial of Kidney disease and Hypertension (AASK) Genomics Study (N=828) is a subset of the AASK trial that randomized 1,094 African American men and women with hypertensive nephrosclerosis to ramipril, amlodipine or metoprolol. Participants were also randomized to a usual (102–107 mmHg) or low (≤92 mmHg) mean arterial pressure (MAP) treatment goal. Time-to-event analyses were used to determine the relationship between serum potassium prior to randomization and time (days) to reach an MAP of 107 mmHg. Mean baseline serum potassium was 4.22 (standard deviation +/− 0.56 and range 2.8–6.0) mmol/L and the median days to reach target MAP was 32 (interquartile range 8–95) days. The adjusted hazard ratio (HR) for each 1mmol/L increase in serum potassium was 1.31 (95%CI: 1.08–1.59) in the usual MAP group, and 1.21 (95%CI: 1.02–1.44) in the low MAP group. Secondary findings suggested that women in the usual MAP group on amlodipine were more likely to reach target MAP compared to women randomized to ramipril (HR: 2.05, 95%CI: 1.30–3.21). Older subjects in the low MAP group (≥55 years) were also more likely to reach target MAP on amlodipine compared to ramipril (HR: 1.57, 95%CI: 1.03–2.38). Serum potassium appears to be a significant predictor of time to blood pressure response, independent of drug class. Results also suggest a benefit of using amlodipine when more rapid blood pressure control is clinically indicated among women and more aggressively managed older subjects.

Effect of light-emitting diode and halogen light curing on the micro-hardness of dental composite and resin-modified glass ionomer cement: an in vitro study

AIMS

This in vitro study was conducted to evaluate and compare the micro-hardness of composite resin and resin-modified glass ionomer cement using light-emitting diode (LED) and halogen curing and also to inter-compare the effect of LED and halogen curing.

MATERIALS AND METHODS

The study sample comprised of 4 stainless steel plates with a thickness of 2 mm. For these stainless steel plates, holes were made to a diameter of 3 mm. The samples were divided into 4 groups of 8 each and labeled as group I, group II, group III, group IV, thus making provision for the two different modes of light exposure. In each group, the hole was restored with its respective restorative material and cured with light-curing unit according to manufacturer instructions. The results were statistically analyzed using Mann-Whitney test.

RESULTS AND CONCLUSION

It was concluded that the curing efficacy of the LED lamp was comparable to that of conventional halogen lamp, even with a 50% reduction in cure time, and resin composite (Filtek Z-250) presented the highest hardness values, whereas complete hardening of resin-modified glass ionomer cement (RMGIC) (Vitremer) was observed because of its self-curing system even after the removal of light source.

Transient infantile patterned hyperpigmentation

Patterned transient pigmentation along lines of creases occurring in a newborn is rare. A case report of this entity is described, along with a review of all six cases described in the literature so far.

Chondroid syringoma: report of two cases in young patients

Chondroid syringoma (CS) is a relatively rare cutaneous tumor arising from sweat glands. It usually presents in the head and neck area as an asymptomatic nodule. Although usually it presents in middle aged or older patients, we here present two much younger patients with CS, located over the nose and cheek areas, respectively.

Prevalence of XDR TB cases--a retrospective study from a tertiary care TB hospital

BACKGROUND

The emergence of XDR -TB strains is a major roadblock in the successful implementation of TB control programmes. This further leads to high morbidity and mortality, especially in immuno-compromised patients. Identification and observation of resistance patterns of XDR-TB strains may help clinicians manage MDR-TB cases, the treatment line of which is expensive, time-taking and involves intake of toxic drugs with many side-effects. Our study is aimed to find out the prevalence of XDR-TB among the MDR-TB strains isolated in a tertiary care hospital.

MATERIAL & METHODS

The study population consisted of 223 patients of tuberculosis who were culture positive and Mycobacterium tuberculosis was resistant to Rifampicin and Isoniazid during January 2007 to December 2009. Each patient had submitted two sputum samples i.e. spot and morning. The identified Mycobacterium tuberculosis complex was subjected to drug sensitivity testing by first and second line drugs by proportion and absolute concentration methods as per standard procedure.

RESULTS

The results showed that 20.17% strains (45/223) were XDR-TB strains. Most of these strains showed resistance to four drug combination viz. KM, ETH, OFX & PAS (5.82%), KM & OFX (3.13%), OFX, KM and ETH (1.79%), 1.34% strains showed resistance to all the drugs i.e. pan resistance and other combinations in the remaining strains. Nearly 80% of the XDR-TB strains showed resistance to three or more drugs combination pattern.

CONCLUSION

The multidrug resistant TB cases need urgent and timely sensitivity report for second line ATT drugs to help clinicians start proper drug combinations to treat MDR-TB patients.