Oral manifestations of mpox (monkeypox)

The zoonotic infectious disease mpox (previously known as monkeypox) is caused by the monkeypox virus (MPXV) from the Poxviridae family. Presently, mpox is receiving worldwide attention because of its emergence in countries that have never previously documented the illness, resulting in a public health emergency. MPXV is transmitted via human-to-human contact, and sexual contact is especially implicated in spread of the disease. Affected individuals experience fever, headache, malaise, and early lymphadenopathy, followed by a secondary mucotaneous rash. Oral ulcers and perioral papules may be the first evidence of the disease. Although there are numerous articles in medical publications documenting the cutaneous presentations of mpox, there is limited information in the dental literature regarding oral lesions. The objective of this article is to review the oral manifestations of mpox and strategies for management of the disease.

Antibiotics for acute otitis media in children

BACKGROUND

Acute otitis media (AOM) is one of the most common diseases in childhood for which antibiotics are commonly prescribed; a systematic review reported a pooled prevalence of 85.6% in high-income countries. This is an update of a Cochrane Review first published in the Cochrane Library in 1997 and updated in 1999, 2005, 2009, 2013 and 2015.

OBJECTIVES

To assess the effects of antibiotics for children with AOM.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Current Contents, CINAHL, LILACS and two trial registers. The date of the search was 14 February 2023.

SELECTION CRITERIA

We included randomised controlled trials comparing 1) antimicrobial drugs with placebo, and 2) immediate antibiotic treatment with expectant observation (including delayed antibiotic prescribing) in children with AOM.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened trials for inclusion and extracted data using the standard methodological procedures recommended by Cochrane. Our primary outcomes were: 1) pain at various time points (24 hours, two to three days, four to seven days, 10 to 14 days), and 2) adverse effects likely to be related to the use of antibiotics. Secondary outcomes were: 1) abnormal tympanometry findings, 2) tympanic membrane perforation, 3) contralateral otitis (in unilateral cases), 4) AOM recurrences, 5) serious complications related to AOM and 6) long-term effects (including the number of parent-reported AOM symptom episodes, antibiotic prescriptions and health care utilisation as assessed at least one year after randomisation). We used the GRADE approach to rate the overall certainty of evidence for each outcome of interest.

MAIN RESULTS

Antibiotics versus placebo We included 13 trials (3401 children and 3938 AOM episodes) from high-income countries, which we assessed at generally low risk of bias. Antibiotics do not reduce pain at 24 hours (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.78 to 1.01; 5 trials, 1394 children; high-certainty evidence), or at four to seven days (RR 0.76, 95% CI 0.50 to 1.14; 7 trials, 1264 children), but result in almost a third fewer children having pain at two to three days (RR 0.71, 95% CI 0.58 to 0.88; number needed to treat for an additional beneficial outcome (NNTB) 20; 7 trials, 2320 children; high-certainty evidence), and likely result in two-thirds fewer having pain at 10 to 12 days (RR 0.33, 95% CI 0.17 to 0.66; NNTB 7; 1 trial, 278 children; moderate-certainty evidence). Antibiotics increase the risk of adverse events such as vomiting, diarrhoea or rash (RR 1.38, 95% CI 1.16 to 1.63; number needed to treat for an additional harmful outcome (NNTH) 14; 8 trials, 2107 children; high-certainty evidence). Antibiotics reduce the risk of children having abnormal tympanometry findings at two to four weeks (RR 0.83, 95% CI 0.72 to 0.96; NNTB 11; 7 trials, 2138 children), slightly reduce the risk of experiencing tympanic membrane perforations (RR 0.43, 95% CI 0.21 to 0.89; NNTB 33; 5 trials, 1075 children) and halve the risk of contralateral otitis episodes (RR 0.49, 95% CI 0.25 to 0.95; NNTB 11; 4 trials, 906 children). However, antibiotics do not reduce the risk of abnormal tympanometry findings at six to eight weeks (RR 0.89, 95% CI 0.70 to 1.13; 3 trials, 953 children) and at three months (RR 0.94, 95% CI 0.66 to 1.34; 3 trials, 809 children) or late AOM recurrences (RR 0.94, 95% CI 0.79 to 1.11; 6 trials, 2200 children). Severe complications were rare, and the evidence suggests that serious complications do not differ between children treated with either antibiotics or placebo. Immediate antibiotics versus expectant observation We included six trials (1556 children) from high-income countries. The evidence suggests that immediate antibiotics may result in a reduction of pain at two to three days (RR 0.53, 95% CI 0.35 to 0.79; NNTB 8; 1 trial, 396 children; low-certainty evidence), but probably do not reduce the risk of pain at three to seven days (RR 0.75, 95% CI 0.50 to 1.12; 4 trials, 959 children; moderate-certainty evidence), and may not reduce the risk of pain at 11 to 14 days (RR 0.91, 95% CI 0.75 to 1.10; 1 trial, 247 children; low-certainty evidence). Immediate antibiotics increase the risk of vomiting, diarrhoea or rash (RR 1.87, 95% CI 1.39 to 2.51; NNTH 10; 3 trials, 946 children; high-certainty evidence). Immediate antibiotics probably do not reduce the proportion of children with abnormal tympanometry findings at four weeks and evidence suggests that immediate antibiotics may not reduce the risk of tympanic membrane perforation and AOM recurrences. No serious complications occurred in either group.

AUTHORS' CONCLUSIONS

This review reveals that antibiotics probably have no effect on pain at 24 hours, a slight effect on pain in the days following and only a modest effect on the number of children with tympanic perforations, contralateral otitis episodes and abnormal tympanometry findings at two to four weeks compared with placebo in children with AOM. In high-income countries, most cases of AOM spontaneously remit without complications. The benefits of antibiotics must be weighed against the possible harms: for every 14 children treated with antibiotics, one child experienced an adverse event (such as vomiting, diarrhoea or rash) that would not have occurred if antibiotics were withheld. For most children with mild disease in high-income countries, an expectant observational approach seems justified. Therefore, clinical management should emphasise advice about adequate analgesia and the limited role for antibiotics.

Evaluation and monitoring of eye findings in children exposed to Zika virus during gestation: 3 years of follow-up

INTRODUCTION

Congenital Zika syndrome (CZS) is a recently described disease. Our main objective was to evaluate and monitor, over 3 years, the ophthalmoscopic findings in children exposed to zika virus (ZIKV) during gestation.

METHODS

This prospective observational study was conducted in Rio de Janeiro, Brazil, between April 2016 and May 2019. We evaluated two groups with exanthema serving as a proxy for viremia: (i) children whose mothers had exanthema during pregnancy and (ii) children who had microcephaly without maternal exanthema during pregnancy. We performed indirect ophthalmoscopy at recruitment and every 6 months thereafter. We also tested the association between ocular findings with maternal exanthema, microcephaly, CZS and maternal infection confirmed by reverse transcriptase quantitative polymerase chain reaction and gender.

RESULTS

Of the 72 children included, 16 (22.2%) had optic nerve and/or retinal lesions. All 16 had CZS and 15 (93.7%) had microcephaly (14 at birth and 1 postnatally). The child with postnatally acquired microcephaly was born to a mother without exanthema during pregnancy. Fifty-six (77.8%) of the 72 children were followed for a median time of 24 months and none exhibited differences between admission and follow-up examinations. After logistic regression, only microcephaly at birth was associated with eye abnormalities (odds ratio, 77.015; 95% confidence interval, 8.85-670.38; p < 0.001).

CONCLUSION

We observed that there was no progression of the lesions over the follow-up period. We also showed that the eye findings were associated only with microcephaly at birth. Attention should be paid to all children born during a ZIKV epidemic, regardless of maternal exanthema and/or microcephaly at birth.

Possibilities of Anxiolytic Therapy in the Elimination of Stress Skin Manifestations: A Case Report

The case of a 42-year-old female patient with pronounced itching and exanthema, mainly in the area of the trunk and lower limbs, is presented. Previously, the patient took antihistamines without effect, was treated for scabies, but the itching remained pronounced and led to rash and excoriations. From the anamnesis, it was found that the patient has a high level of stress. According to the Hospital Anxiety and Depression Scale, the anxiety of the patient reached 14 points, and depression 1 point. Functional (psychogenic) itching was suspected. Since the patient refused dermatologist consultation, therapy with the anxiolytic temgicoluril, topical antipruritic agents and nonpharmacological methods of treatment were recommended at the initial stage. The patient felt a significant relief of itching symptoms on the first day of anxiolytic usage, she withdrew topical antipruritic agents after 5 days of anxiolytic treatment, in 15 days she began to reduce the dose of temgicoluril, and at the end of the third week she stopped treatment with anxiolytic due to a significant positive effect. In three weeks, practically all elements of the rash, except for the largest wounds from scratching, disappeared. The peculiarity of the case is that functional itching was completely eliminated during anxiolytic therapy without other systemic medications, which emphasizes the importance of eliminating the component of stress and anxiety in the treatment of such patients.

JMM Profile: Sindbis virus, a cause of febrile illness and arthralgia

Sindbis virus (SINV) is the causative agent of a febrile infection commonly called Ockelbo disease, Pogosta disease or Karelian fever in northern Europe. Finland, Sweden, Russia and South Africa experience periodic SINV outbreaks. SINV is classified within the family Togaviridae and genus Alphavirus. Symptoms of SINV infection in humans include joint inflammation and pain, fever, rash and fatigue. In some cases, joint symptoms can persist for years after recovery from the initial infection. Clinical signs of SINV infection are rarely reported in animals, although infection in horses has been documented. There is no specific treatment or vaccination. The virus is transmitted by mosquitoes, particularly those belonging to the Culex genus, but Aedes, Culiseta or Mansonia species may also act as vectors. Wild birds act as amplifying hosts and are implicated in the long-distance spread of the virus.

Adult-onset still's disease and budd-chiari syndrome: A case report

Adult onset still's disease (AOSD) is a rare autoinflammatory disease displaying with a wide range of non-specific symptoms and budd-chiari syndrome (BCS) is an uncommon disorder characterized by obstruction of hepatic venous outflow. We present the case of a young patient who presented with persistent fever, sore throat, elbow, hand fingers and knees arthralgia with abdominal pain. The patient's symptoms had started 7 days before the referral. Imaging and laboratory data led to the diagnosis of BCS in the context of AOSD. The patient treated with corticosteroid in combination of warfarin with favorable outcome and complete improvement of signs and symptoms. We came to this conclusion AOSD complicated with BCS is a rare but potentially life-threatening entity. Clinicians should be aware of this complication.

Reactive infectious mucocutaneous eruption following COVID-19 in an adolescent boy: Case report and review of the literature

Reactive infectious mucocutaneous eruption (RIME) is a mucosal-predominant eruption that usually affects two or more mucosal sites. We present a case of RIME secondary to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and provide a brief review of the literature with a focus on the natural history and response to treatment. This entity may require inpatient management and systemic corticosteroids for symptom control in the pediatric population.

Eosinophilia in Amoxicillin-Induced Rash in Infectious Mononucleosis

A link between amoxicillin-induced rash in infectious mononucleosis and allergy has been previously reported. However, the pathophysiological cause and aspects are unclear. Additionally, the complex immunological interaction between the host and Epstein-Barr virus needs to be studied. This article reports a case of amoxicillin-induced rash in infectious mononucleosis resulting in an exuberant rash, facial edema, and marked eosinophilia, which prompted additional workup. Both the eosinophilia and the rash brought to light a possible association with a persistent delayed-type hypersensitivity. Further scientific discussion and investigation can identify predictive indicators that can portend clinical outcome.

COVID-associated non-vasculitic thrombotic retiform purpura of the face and extremities: A case report

SARS-CoV-2 infection can manifest many rashes. However, thrombotic retiform purpura rarely occurs during COVID-19 illness. Aggressive anti-COVID-19 therapy with a high-dose steroid regimen led to rapid recovery. This immunothrombotic phenomenon likely represents a poor type 1 interferon response and complement activation on the endothelial surface in response to acute infection.

Case Report of Multisystem Inflammatory Syndrome in Adults (MIS-A): A 31-Year-Old Man with Fever, Rash, and Cardiac Symptoms 6 Weeks Following SARS-CoV-2 Infection, Successfully Resuscitated Following Cardiac Arrest

BACKGROUND Multisystem inflammatory syndrome in adults (MIS-A) is an uncommon condition after a confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, manifesting as multiorgan failure despite apparent resolution of initial symptoms. While this syndrome shares similar characteristics with a syndrome found in children, fewer cases are reported in adults. This report details a 31-year-old man fulfilling the diagnostic criteria of MIS-A, who was successfully resuscitated following cardiac arrest. CASE REPORT A 31-year-old man was admitted to the intensive care unit for 3 days of progressively worsening fever, chills, diaphoresis, exanthematous rash, headache, and neck stiffness. The patient had a history of mild, resolved SARS-CoV-2 infection 6 weeks prior to his presentation, diagnosed by rapid antigen and reverse transcription polymerase chain reaction (RT-PCR) testing. Meningitis and autoimmune pathologies were initially suspected but were ruled out. Given the patient's symptoms, prior SARS-CoV-2 infection, and positive inflammatory markers, findings correlated with the Centers for Disease Control and Prevention's diagnostic criteria for multisystem inflammatory syndrome in adults. On hospital day 1, the patient decompensated into severe respiratory distress requiring intubation. Shortly after, the patient developed cardiac arrest and was successfully resuscitated. He was transferred from our rural hospital to an intensive care unit at a facility with additional resources. He remained critically ill for several weeks while receiving high-dose steroids, intravenous immunoglobulin (IVIG), and hemodialysis until his recovery. CONCLUSIONS Early diagnosis and treatment of MIS-A would significantly improve outcomes in this subset of patients, especially in clinical settings with limited resources.

Neonatal toxic shock syndrome-like exanthematous disease: A French case series

Neonatal toxic shock syndrome-like exanthematous disease (NTED) was first described in Japan in the 1990s. It results from the secretion of superantigenic toxins by Staphylococcus aureus. Diagnostic criteria include generalized macular erythema and at least one of the following three features: fever (>38°C), thrombocytopenia (<150,000/mm³ ), low positive C reactive protein (10-50 mg/L) in the absence of another known disease process. We herein describe four cases from France, involving both MSSA and "Geraldine" MRSA. This report aims to bring this underdiagnosed disease to the attention of pediatricians and infectious disease specialists, to improve the management of affected newborns.

Cutaneous adverse reactions of COVID-19 vaccines: a systematic review

OBJECTIVE

Numerous vaccines are under clinical development and implementation for the prevention of severe course and lethal outcomes of coronavirus disease 2019 (COVID-19). This systematic review aims to summarize and integrated the findings of studies regarding cutaneous side effects of COVID-19 vaccines.

METHODS

This systematic review conducted by searching the scientific databases of PubMed, Scopus, Science direct, and Web of knowledge from the beginning of the COVID-19 to10/5/2021. Articles were reviewed and analyzed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist.

RESULTS

17 studies on cutaneous side effects of COVID-19 vaccines were included after the screening of search results based on to the eligibility criteria. The results showed that the most common injection site reactions and delayed large local reactions, arising from all vaccine types, were redness/ erythema (39%), followed by: itchiness (28%), urticarial rash (17%) on the neck, upper limbs, and trunk, morbilliform eruptions (6.5%), Pityriasis rosea (3%), swelling, and burning, etc. Most cutaneous reactions occurred in women (84%), and middle aged people, after the first dose of vaccine, with the onset ranged from 1-21 days after vaccination. In addition, cutaneous reactions were generally self-limiting, and needed little or no therapeutic intervention, that were not regarded as a barrier to injecting a second dose.

CONCLUSION

In conclusion, severe cutaneous side effects are very rare and approved vaccines have satisfactory safety profiles. Therefore, mild or moderate cutaneous reactions should not discourage people from vaccination. In certain groups such as patients with allergies and a history of local injection reactions, pre-vaccination counseling and assurance, also use of appropriate medications may be helpful. However, more studies are needed to investigate the side effect profile of all COVID-19 vaccines.

Severe monkeypox with superimposed bacterial infection in an immunocompetent patient: A case report

Monkeypox, a member of the Orthopoxvirus genu, has been the center of global attention since it has been declared a public health emergency by the World Health Organization. Typically, it is a self-limiting disease; however, it can occasionally have severe presentations in patients with underlying conditions, such as HIV, malignancy, and transplantation. In this article, we will present a case of an immunocompetent patient with a severe presentation of monkeypox. The patient presented with facial pustules with superimposed bacterial infection; furthermore, he had painful vesicles in oral and nasal mucosa and the penis. Dermatologic conditions such as atopic dermatitis has been associated with severe monkeypox. While our patient does not have a history of atopic dermatitis, he does report contact dermatitis as well as a history of skin infections. Researchers have hypothesized that disruption of the skin barrier allows for proliferation of the monkeypox virus; therefore, it is important to take a thorough history of the patient’s skin conditions. Lastly, we described the use of Tecovirimat in our patient. Although it is impossible to demonstrate the efficacy of this medication without a randomized clinical trial, our patient seemed to have a faster improvement of the lesions after initiating this antiviral.

Hand-foot-mouth disease in puerperium

Our case report describes a case of an otherwise predominantly childhood disease in a young adult woman with a good socioeconomic background who developed pruritic exanthema on the 2nd day after spontaneous delivery. The aim of the paper is to characterize the disease and to describe the possible risks for mother and child according to the available literature, as well as complications not only in puerperium but also during pregnancy.

Cutaneous Adverse Reactions Associated with SARS-CoV-2 Vaccines

Many patients are receiving SARS-CoV-2 vaccinations, which have been associated with a variety of adverse effects. Cutaneous adverse reactions to SARS-CoV-2 vaccinations have been progressively reported, but they have not been reviewed according to their morphological clinical patterns. The objective of this review was to summarize the existing data concerning the cutaneous adverse reactions following SARS-CoV-2 vaccines and group them according to common morphological and pathogenetic patterns. We reviewed the English language literature up to 15 August 2021, using predefined keywords to identify the relevant studies evaluating cutaneous adverse reactions associated with SARS-CoV-2 vaccines. We search for recurrent morphological patterns sharing clinical signs and symptoms and physio-pathological mechanisms. Timing to onset following the first or booster dose of the vaccine, predisposing conditions, therapeutic management, and outcome were also collected. Among the dermatological manifestations associated with SARS-CoV-2 vaccinations, we distinguished: (1) new onset reactions and (2) flares of preexisting dermatoses. The most common were injection site reactions, affecting 30–70% and generally mild or moderate. Small case series or single case reports included filler reactions, exanthemas, vascular lesions, urticaria, eczematous dermatitis, autoimmune bullous reactions, and severe cutaneous adverse reactions. In addition, the exacerbation of chronic immuno-mediated dermatoses (mainly psoriasis and atopic dermatitis) and reactivations of herpes infection were reported. The cutaneous reactions were generally mild, self-limiting, and resembled common cutaneous drug eruptions and/or COVID-19 skin manifestations.

Fever, rash, and eosinophilia - early signs of angioimmunoblastic T-cell lymphoma

Angioimmunoblastic T-cell lymphoma (AITL) is an uncommon lymphoma of elderly adults with a poor prognosis. AITL patients show systemic symptoms, lymphadenopathy, and not infrequently, skin rash with various dysimmune phenomena rashes. The case is presented of a 68-year-old male with skin rash, lymphadenopathy and hypereosinophilia who, after investigations, was diagnosed with AITL. Despite the treatment used, the patient's condition gradually deteriorated and died due to heart and kidney failure. The diagnosis of AITL is often established only after several weeks or months because of transient physical findings, non-specific symptoms, and a broad range of serologic or radiologic abnormalities. Some patients with AITL experience non-specific dermatitis and eosinophilia. The presented case should raise awareness of the presentations of AITL which is important for physicians to reach an accurate diagnosis.

Cutaneous Adverse Reactions to COVID-19 Vaccines: Insights from an Immuno-Dermatological Perspective

(1) Background: Numerous vaccines are under preclinical and clinical development for prevention of severe course and lethal outcome of coronavirus disease 2019 (COVID-19). In light of high efficacy rates and satisfactory safety profiles, some agents have already reached approval and are now distributed worldwide, with varying availability. Real-world data on cutaneous adverse drug reactions (ADRs) remain limited. (2) Methods: We performed a literature research concerning cutaneous ADRs to different COVID-19 vaccines, and incorporated our own experiences. (3) Results: Injection site reactions are the most frequent side effects arising from all vaccine types. Moreover, delayed cutaneous ADRs may occur after several days, either as a primary manifestation or as a flare of a pre-existing inflammatory dermatosis. Cutaneous ADRs may be divided according to their cytokine profile, based on the preponderance of specific T-cell subsets (i.e., Th1, Th2, Th17/22, Tregs). Specific cutaneous ADRs mimic immunogenic reactions to the natural infection with SARS-CoV-2, which is associated with an abundance of type I interferons. (4) Conclusions: Further studies are required in order to determine the best suitable vaccine type for individual groups of patients, including patients suffering from chronic inflammatory dermatoses.

Skin eruptions in children: Drug hypersensitivity vs viral exanthema

Childhood rashes or exanthemas are common and are usually relatively benign. There are many causes of rash in children, including mainly viruses, and less often bacterial toxins, drugs, allergens and other diseases. Viral exanthema often appears while children are taking a medication in the course of a viral infection; it can mimic drug exanthema and is perceived as a drug allergy in 10% of cases. In the vast majority of cases, the distinction between virus-induced and drug-induced skin eruption during the acute phase is not possible. The drugs most commonly implicated are beta-lactams (BL) and non-steroidal anti-inflammatory drugs (NSAIDs). Viruses, commonly Epstein-Barr virus (EBV), human herpesvirus 6 (HHV6) and cytomegalovirus (CMV), and the bacterium, Mycoplasma pneumoniae, may cause exanthema either from the infection itself (active or latent) or because of interaction with drugs that are taken simultaneously. Determination of the exact diagnosis requires a careful clinical history and thorough physical examination. Haematological and biochemical investigations and histology are not always helpful in differentiating between the two types of exanthema. Serological and polymerase chain reaction (PCR) assays can be helpful, although a concomitant acute infection does not exclude drug hypersensitivity. A drug provocation test (DPT) is although considered the gold standard for the diagnosis and is not preferred by the patients. Skin tests are not well tolerated, and in vitro tests, such as the basophil activation test and lymphocyte transformation, are of low sensitivity and specificity and their relevance is debatable. Based on current evidence, we propose a systematic clinical approach for timely differential diagnosis and management of rashes in children who present a cutaneous eruption while receiving a drug.

Gianotti-crosti syndrome in the setting of recent coronavirus disease-19 infection

Since the onset of the COVID-19 pandemic, the growing body of literature has largely focused on the adult population. Reported symptoms among children appear to be consistent with those in adults, including fever, respiratory symptoms, and gastrointestinal symptoms, though children may experience an overall milder disease course. Viral exanthems with possible association to COVID-19 have been reported in pediatric patients. We describe a 10-month-old boy with Gianotti-Crosti syndrome in the setting of recent SARS-CoV-2 RT-PCR positive testing to increase physician awareness and add to the collection of cutaneous manifestations of COVID-19.

Surveillance for Enteroviruses Associated with Hand, Foot, and Mouth Disease, and Other Mucocutaneous Symptoms in Spain, 2006-2020

Hand, foot, and mouth disease (HFMD) is a mild illness caused by enteroviruses (EV), although in some Asian countries, large outbreaks have been reported in the last 25 years, with a considerable incidence of neurological complications. This study describes epidemiological and clinical characteristics of EV infections involved in HFMD and other mucocutaneous symptoms from 2006 to 2020 in Spain. EV-positive samples from 368 patients were included. EV species A were identified in 85.1% of those typed EV. Coxsackievirus (CV) A6 was the prevalent serotype (60.9%), followed by EV-A71 (9.9%) and CVA16 (7.7%). Infections affected children (1-6 years old) mainly, and show seasonality with peaks in spring-summer and autumn. Clinical data indicated few cases of atypical HFMD as well as those with neurological complications (associated with the 2016 EV-A71 outbreak). Phylogenetic analysis of CVA6 VP1 sequences showed different sub-clusters circulating from 2010 to present. In conclusion, HFMD or exanthemas case reporting has increased in Spain in recent years, probably associated with an increase in circulation of CVA6, although they did not seem to show greater severity. However, EV surveillance in mucocutaneous manifestations should be improved to identify the emergence of new types or variants causing outbreaks and more severe pathologies.

Pityriasis rubra pilaris post-infection due COVID-19: case report

Case description:

32-month-old boy, IgG positive for SARS-CoV-2, presented to the emergency department with dermatologic lesions.

Clinical findings:

Four days before admission, he presented skin eruptions with redness and pruritus on hands and feet. Generalized papular erythema was evidenced, upper extremities with diffuse erythematosquamous plaques, palmoplantar keratoderma, so he was evaluated by a dermatologist who diagnosed pityriasis rubra pilaris.

Treatment and outcome:

rehydrating cream, cetirizine 0.5 mg/kg/day every two days, and prednisolone 2 mg/kg/day in the morning. He was discharged after 14 days, the patient presented clinical improvement, but the erythematous lesion persisted on the trunk and extremities. In the evaluation, after three months, the patient did not show the described lesions, evidencing an improvement and clinical resolution of the dermatological problems.

Clinical relevance:

We report a patient with pityriasis rubra piloris associated with a post-infection by SARS-CoV-2 that had not been described before.

Suspected Ticagrelor-Induced Bullous Fixed Drug Eruption

We describe a case of a suspected cutaneous hypersensitivity reaction to ticagrelor. The patient displayed a localized bullous fixed drug eruption after being loaded with ticagrelor, which resolved with oral antihistamines and topical steroids after one week. Clopidogrel and rivaroxaban were successfully administered as alternative antithrombotic therapy without any apparent further hypersensitivity skin reaction.

[CME Dermatology 22/Answers: Measles - Empidemiology and Clinical Manifestations]

CME Dermatology 22/Answers: Measles - Empidemiology and Clinical Manifestations Abstract. Measles is a highly contagious, acute and febrile illness that results from infection with measles virus. The World Health Organization (WHO) estimates a worldwide prevalence of ten million patients per year, leading to approximately 142 000 deaths (case fatality rate 1.4 %). The illness begins with fever, malaise and typically with at least one of the following signs: cough, coryza and/or conjunctivitis. Three to four days later, the characteristical rash appears. The primary clinical diagnosis needs to be confirmed by detection of specific IgM antibodies in serum or viral RNA by a throat swap. The management mainly consists of supportive therapy, a specific antiviral treatment does not exist. Therefore, prevention by widespread measles vaccination has absolute priority.

Clinical Cutaneous Features of Patients Infected With SARS-CoV-2 Hospitalized for Pneumonia: A Cross-sectional Study

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a current pandemic worldwide. This virus can reach all organs and disturbs the immune system, leading to a cytokine storm in severe forms. We aimed to report cutaneous features among coronavirus disease 2019 (COVID-19) hospitalized patients.

Methods

We performed a cross-sectional study on 1 given day among all patients hospitalized in acute care for COVID-19 and included all patients with cutaneous features. Follow-up 48 hours later was obtained.

Results

Among 59 adult patients hospitalized on the day of the study in an infectious diseases ward for SARS-CoV-2 infection who were confirmed by molecular assay and/or radiological findings (computed tomography scan), 40 were included. Several cutaneous manifestations were found: macular exanthema (80%), face edema (32%), livedo (13%), urticarial rash (8%), purpura (5%), oral lichenoid lesions (33%), and conjunctivitis (18%). Cutaneous biopsy was performed in 17 patients. Histological findings showed mast cell hyperplasia (100%), superficial perivascular infiltrate of lymphocytes (94%), and superficial edema (47%) consistent with capillary leak.

Conclusions

Various dermatological signs can be encountered during COVID-19. A macular rash was the most frequent. All cutaneous features could be related to a vascular leak process.

Hypersensitivity Reactions to Multiple Iodinated Contrast Media

The incidence of hypersensitivity reactions (HSRs) to iodinated contrast media (ICM) has risen over last years, representing an important health problem. HSRs to ICMs are classified into immediate reactions (IRs) and non-immediate reactions (NIRs) according to if they occur within 1 h or longer after ICM administration. The diagnosis of HSRs to ICM is complex as skin test (ST) sensitivity ranges widely, and drug provocation test (DPT) protocols are heterogeneous. In this manuscript, we describe the clinical characteristics of a series of patients confirmed as HSR to ICM and the diagnosis procedure carried out, looking into those cases confirmed as HSRs to multiple ICMs. For this purpose, we prospectively evaluated patients suggestive of HSRs to ICMs and classified them as IRs or NIRs. STs were carried out using a wide panel of ICMs, and in those with a negative ST, a single-blind placebo controlled DPT was performed with the culprit. If ST or DPT were positive, then tolerance was assessed with an alternative negative ST ICM. We included 101 cases (12 IRs and 89 NIRs) confirmed as allergic. Among them, 36 (35.64%) cases were allergic to more than one ICM (8 IRs and 28 NIRs). The most common ICM involved were iomeprol and iodixanol. Although not statistically significant, the percentage of patients reporting anaphylaxis was higher in patients allergic to multiple ICMs compared with patients allergic to a single ICM (50 vs. 25%). Likewise, the percentage of positive results in STs was higher in patients allergic to multiple ICMs compared with those allergic to a single ICM (for IR 62.5 vs. 25%, p > 0.05; and for NIR, 85.71 vs. 24.59%, p < 0.000). In cases allergic to more than one ICM, DPT with negative-ST ICM was positive in more than 60% (24/36) of cases. Therefore, allergy to multiple ICMs is common, associated to severe reactions in IRs, and confirmed frequently by positive STs. The allergological work-up should include DPT not only to establish the diagnosis but also to identify safe alternative ICM, even if ICM is structurally unrelated and ST is negative. More studies are needed to clarify mechanisms underlying cross-reactivity among ICMs.

Viral exanthema as manifestation of SARS-CoV-2 infection: A case report

RATIONALE

The clinical manifestations of the SARS-CoV-2 infection are mainly respiratory but the virus can cause a variety of symptoms. Dermatological findings are less well-characterized. Data is scarce on their timing, type and correlation with the immune response.

PATIENT CONCERNS

We present the case of SARS-CoV-2 infection in a previously healthy woman who presented with respiratory symptoms and developed anosmia, diarrhea, and an erythematous maculo-papular rash on day 15 from symptom onset.

DIAGNOSIS

The nasopharyngeal swab tested by real time PCR for COVID-19 was positive. We interpreted this as a viral exanthema likely caused by an immune response to SARS-CoV-2 nucleotides.

INTERVENTIONS

She was treated with Hydroxychloroquine, Azithromycin and Lopinavir/Ritonavir, and the rash with topical corticosteroids.

OUTCOMES

All symptoms resolved except for anosmia which persisted for 6 weeks. At the 4- and 6-weeks follow-up the IgG titers for SARS-CoV-2 were high.

LESSONS

We must consider that SARS-CoV-2 has a multi-organ tropism. In our case, the SARS-CoV-2 infection had lung, nasopharyngeal, neurological, digestive, and skin manifestations. Identifying the different manifestations is useful for understanding the extent of SARS-CoV-2 infection. We not only present a rare manifestation but also suggest that cutaneous manifestations may correlate with immunity.

[CME Dermatology 22: Measles - Empidemiology and Clinical Manifestations]

CME Dermatology 22: Measles - Empidemiology and Clinical Manifestations Abstract. Measles is a highly contagious, acute and febrile illness that results from infection with measles virus. The World Health Organization (WHO) estimates a worldwide prevalence of ten million patients per year, leading to approximately 142 000 deaths (case fatality rate 1.4 %). The illness begins with fever, malaise and typically with at least one of the following signs: cough, coryza and/or conjunctivitis. Three to four days later, the characteristical rash appears. The primary clinical diagnosis needs to be confirmed by detection of specific IgM antibodies in serum or viral RNA by a throat swap. The management mainly consists of supportive therapy, a specific antiviral treatment does not exist. Therefore, prevention by widespread measles vaccination has absolute priority.

A Randomized Pilot Clinical Assessment Of Three Skincare Regimens On Skin Conditions In Infants

Introduction

Few data are available on the comparison between the effects on infant skin of skin care products and those of water alone.

Patients and methods

In this single-center, evaluator-blind, parallel-group pilot study, healthy infants were randomized to near-daily washing for 12 weeks (starting in the summer and finishing in the winter months) with a mild liquid baby wash followed by use of baby lotion (wash+lotion), water followed by baby lotion (water+lotion), or water alone. Clinical and instrumental assessments of skin moisturization and barrier function were made.

Results

As expected the skin condition in all groups was affected by the change of the season. The skin of infants in all groups was mildly deteriorated (clinical grading) and with reduced moisture levels and increased barrier function. Instrumental measurements indicated that skin moisture and barrier function were better maintained in the wash+lotion and water+lotion groups than in the water-only group at week 12. Clinical assessment scores increased slightly over 12 weeks in all groups (P<0.05). At week 12, the wash+lotion group (n = 44) had significantly less change from baseline in overall skin condition and softness (lower scores) than did the water+lotion (n = 43) or water-only (n = 43) groups. The wash+lotion regimen maintained stable erythema and rash scores with lower mean values over time than in the other groups.

Conclusion

A regimen of a liquid baby wash and a baby skin lotion for 12 weeks resulted in less detrimental changes in instrumental and clinical measures of skin than using water and lotion or water alone.

Impact of dermatologic adverse reactions on QOL in oncologic patients: results from a single-center prospective study

INTRODUCTION

Skin toxicity in patients receiving novel therapeutic cancer agents has become a very important marker in determining drug activity, but it can also severely impact their quality of life. About half of the patients receiving this type of oncologic treatment will develop cutaneous reactions, that is why adequate understanding and management of these side effects is very important for drug adherence and patients' quality of life.

MATERIALS AND METHODS

We conducted a prospective study of consecutive patients who received oncologic treatment in our institution and presented with dermatologic side effects. The severity of skin toxicity was assessed using the DLQI score and patients were prospectively followed to evaluate response to therapy. Univariate analysis of factors influencing the impact of skin toxicity on patient QOL was conducted.

RESULTS

52 patients were enrolled in the study. Patients who developed grade 3 and 4 skin toxicity had a higher DLQI score, with a greater impact on quality of life, but with better clinical outcome at 3 months follow-up, based on RECIST. Patients with moderate or severe cutaneous AE were more likely to achieve complete or partial response to therapy than those with mild AE (16/33 vs. 3/19, p = 0.035). Interestingly, female patients had a significantly poorer quality of life than male patients as assessed by the DLQI score (7.28 ± 7 vs. 3.7 ± 3.6, p = 0.038).

CONCLUSION

Cutaneous side effects are often encountered in cancer patients and their severity can be a surrogate marker for a positive clinical tumor response to therapy.

Erythema Nodosum Masking Kawasaki Disease with an Initial Manifestation of Skin Lesions

We report the first case demonstrating an association between Kawasaki disease (KD) and erythema nodosum (EN). A 3-year-old girl presented with EN as an initial manifestation of KD. At the initial visit, she showed high fever of 40°C, injection of the oropharynx, cervical lymphadenopathy, and red-purple cutaneous nodules, particularly on the lower limbs. She complained of severe pain in the neck and cutaneous lesions. Initially, the development of EN was attributed to Salmonella spp infection, which was detected in stool culture. However, the patient did not respond to high-dose ampicillin/sulbactam to which the Salmonella spp is sensitive. Echocardiography performed as screening for fever of unknown origin revealed medium-sized aneurysms of the left anterior descending artery. EN masked the diagnosis of KD, and the patient developed a coronary artery lesion. KD should be considered in the differential diagnosis of refractory EN in pediatric patients.

Mild cutaneous reactions to drugs

Adverse reactions to drugs are not frequent in childhood. Cutaneous reactions are the most frequent in this age group. Mild cutaneous reactions are immediate or delayed adverse reactions that do not seriously compromise the clinical condition of children. The patients usually early improve and recover the state of health. Although it is difficult to define the prevalence accurately, we could affirm that the rate adverse reaction to drugs are often over estimated by both the families and the physicians. Therefore, children may be prone to loss of school days and inappropriate or sub-optimal treatments. However, the identification of a true adverse reaction to drugs allows adequate treatment and alert to further exposure to harmful drugs.

An outbreak of schistosomiasis in a primary school in Omusati region, Namibia, March, 2016

Schistosomiasis is endemic in some parts of northern Namibia and there is a control program in the country with the use of mass drug administration to control and prevent the disease. On the 1st March, 2016, there was a report of bloody urine among primary school pupils in a school in Omusati region, Namibia. A team of health professionals was dispatched to investigate. This case study describes steps in conducting a schistosomiasis outbreak investigation and how to determine the risk factors. This describes how to calculate both the basic and analytical measures of association with 95% confidence intervals. This case study provides a step-by-step approach and can be used as a tool to teach the fundamental principles of outbreak investigation and response and how to measure the appropriate measures of association. This case study is targeted at intermediate- and advanced-level residents of the Field Epidemiology and Laboratory Training Program and other epidemiology trainees.

Symmetrical Drug-related Intertriginous and Flexural Exanthema Induced by Doxycycline

Symmetrical drug-related intertriginous and flexural exanthema (SDRIFE) is a cutaneous drug reaction characterized by erythema over the buttocks, thighs, groin, and flexural regions most commonly associated with the use of beta-lactam antibiotics. Although the exact pathophysiology of this disease remains unknown, it is theorized to be the result of a delayed hypersensitivity response presenting as a cutaneous eruption days to weeks after exposure to the drug. The treatment involves discontinuation of the suspected medication, symptomatic control of pruritus, and topical steroid therapy. A 51-year-old woman with homocystinuria and fibromyalgia was admitted with fevers, pancytopenia (later diagnosed to be acute myelogenous leukemia), and a targetoid cutaneous eruption in the setting of a recent tick bite. She was subsequently noted to have symmetric, pruritic, erythematous papules over the lateral neck, retroauricular regions, lateral aspects of the inframammary regions, medial upper arms, axillae, and the lower abdomen two weeks after starting doxycycline. Considering the morphology, distribution, and intense pruritis associated with the eruption, a diagnosis of SDRIFE was made. Doxycycline discontinuation along with topical steroid therapy resulted in the resolution of the eruption and pruritus. Given the widespread use of doxycycline, clinicians should be aware of this possible side effect.

Prognostic accuracy of clinical signs and diagnostic tests in cow's milk allergy in newborns

BACKGROUND

The aim of the study was to explore the correlation between clinical signs and confirmatory tests for cow's milk allergy (CMA) in the neonatal period and their relation to family history and the occurrence of food allergies in the postneonatal period.

METHODS

The medical documentation of 361 newborns with suspected CMA and exclusion of other comorbidities was analyzed. The correlations between clinical signs and methods to confirm CMA [elevated levels of total immunoglobulin E (IgE) and/or specific IgE for cow's milk, improvement after the introduction of a cow's milk-free diet and positive challenge procedure] were studied. In 90 children, the data were additionally analyzed in relation to outcome (at the age of 1-11 years), evaluated by questionnaires, which inquired about signs and symptoms of food allergy, methods of CMA confirmation, and the presence of other food allergies.

RESULTS

There was a positive correlation between exanthema and confirmed CMA in the neonatal period (R = 0.184; p = <0.001; n = 361), and hematochezia and confirmed CMA in the neonatal (R = 0.203; p < 0.001; n = 361) and postneonatal period (R = 0.215; p = 0.042; n = 90). Additional food allergies in the postneonatal period were positively correlated with neonatal CMA (R = 0.275; p = 0.009; n = 90). No correlation was found between a positive family history of food allergies and CMA in the neonatal (R = -0.66; p = 0.398; n = 165) and postneonatal periods (R = 0.00; p = 1.000; n = 116).

CONCLUSION

Neonatal exanthema and hematochezia were the predominant clinical signs in neonates with CMA. Allergies to other food allergens appeared more frequently in children with CMA in the neonatal period. Neonatal CMA did not occur more frequently in families with food allergies.

Different patterns of skin manifestations associated with parvovirus B19 primary infection in adults

BACKGROUND

Skin involvement is reported during primary parvovirus B19 infection in adults.

OBJECTIVES

We sought to describe the cutaneous presentations associated with parvovirus B19 primary infection in adults.

METHODS

We conducted a descriptive, retrospective, multicenter study. The patients included (>18 years old) had well-established primary infections with parvovirus B19.

RESULTS

Twenty-nine patients were identified between 1992 and 2013 (17 women, 12 men). The elementary dermatologic lesions were mostly erythematous (86%) and often purpuric (69%). Pruritus was reported in 48% of cases. The rash predominated on the legs (93%), trunk (55%), and arms (45%), with a lower frequency of facial involvement (20%). Four different but sometimes overlapping patterns were identified (45%): exanthema, which was reticulated and annular in some cases (80%); the gloves-and-socks pattern (24%); the periflexural pattern (28%); and palpable purpura (24%).

LIMITATIONS

The limitations of this study were its retrospective design and possible recruitment bias in tertiary care centers.

CONCLUSION

Our findings suggest that primary parvovirus B19 infection is associated with polymorphous skin manifestations with 4 predominant, sometimes overlapping, patterns. The acral or periflexural distribution of the rash and the presence of purpuric or annular/reticulate lesions are highly suggestive of parvovirus B19 infection.

Desensitization in delayed drug hypersensitivity reactions -- an EAACI position paper of the Drug Allergy Interest Group

Drug hypersensitivity may deprive patients of drug therapy, and occasionally no effective alternative treatment is available. Successful desensitization has been well documented in delayed drug hypersensitivity reactions. In certain situations, such as sulfonamide hypersensitivity in HIV-positive patients or hypersensitivity to antibiotics in patients with cystic fibrosis, published success rates reach 80%, and this procedure appears helpful for the patient management. A state of clinical tolerance may be achieved by the administration of increasing doses of the previously offending drug. However, in most cases, a pre-existent sensitization has not been proven by positive skin tests. Successful re-administration may have occurred in nonsensitized patients. A better understanding of the underlying mechanisms of desensitization is needed. Currently, desensitization in delayed hypersensitivity reactions is restricted to mild, uncomplicated exanthems and fixed drug eruptions. The published success rates vary depending on clinical manifestations, drugs, and applied protocols. Slower protocols tend to be more effective than rush protocols; however, underreporting of unsuccessful procedures is very probable. The decision to desensitize a patient must always be made on an individual basis, balancing risks and benefits. This paper reviews the literature and presents the expert experience of the Drug Hypersensitivity Interest Group of the European Academy of Allergy and Clinical Immunology.

Challenge Test Results in Patients With Suspected Penicillin Allergy, but No Specific IgE

Purpose

Patients with a history of allergic reaction to penicillin, but with no detectable specific IgE, are common and pose a dilemma. Challenge tests are considered to be the diagnostic gold standard. The aim of this study was to identify subgroups of patients with very low risk for reactions who could be safely tested using a more rapid and simple procedure.

Methods

A total of 580 consecutively referred adult patients with a history of non-serious cutaneous allergic reactions to penicillin, but with no IgE, were challenged with therapeutic doses of penicillin V (phenoxymethylpenicillin), penicillin G (benzylpenicillin), or both.

Results

Only 14 of 580 patients had a positive challenge test. In 11 of the 14, a reaction to challenge occurred within 2 hours, and none were anaphylactic. The year of the original reaction was known for 555 patients; a positive challenge was seen in only 0.4% of those with an original reaction >15 years before challenge, but in 4.6% of those with a more recent original reaction (P=0.001). Onset of a reaction within the first day of the original exposure was a predictive factor for a positive challenge (P=0.001) in patients challenged within 15 years of the original reaction.

Conclusions

Among suspected penicillin-allergic patients with non-severe skin reactions and no detectable specific IgE, the subgroup of patients who originally reacted more than 15 years previously had very low risk for reacting to a challenge. The risk was higher in patients with a more recent original reaction, especially if the symptoms had occurred within the first day of exposure.

[Human bocavirus infections in Spanish 0-14 year-old: clinical and epidemiological characteristics of an emerging respiratory virus]

INTRODUCTION

In 2005 a new respiratory virus, called human bocavirus (HBoV), was cloned from respiratory samples from Swedish infants and children with lower respiratory tract infections.

OBJECTIVES

To determine whether HBoV has circulated in Spain, estimate the frequency of HBoV infections in patients hospitalized for respiratory infection and describe the clinical and epidemiological characteristics of these patients.

PATIENTS AND METHODS

We performed a descriptive prospective study of confirmed HBoV infections in patients aged < 14 years old, hospitalized for respiratory infections between October 2004 and June 2005. Virologic diagnosis was based on multiple RT-PCR for respiratory syncytial virus (RSV) A and B, influenza A,B, and C, parainfluenza 1-4, adenovirus and rhinovirus; PCR was used for human metapneumovirus (hMPV) and PCR in nasopharyngeal aspirates was used for HBoV. The clinical and epidemiological characteristics of patients were analyzed.

RESULTS

Fifty-two cases of HBoV infection were detected, representing 17.1% (95% CI: 13% a 21%) of patients hospitalized for respiratory infections. HBoV was the third most frequent viral agent after RSV (30%) and rhinovirus (25%). In 39 patients (71.1%) coinfection with another respiratory virus was detected. Fifty percent of the patients were aged less than 13.6 months and 75% were aged less than 2 years. The most frequent diagnoses were recurrent wheezing (55.8%), bronchiolitis (21.2%) and pneumonia (15.4%). Clinical sepsis with petechial exanthema was found in two patients. Fever > 38 degrees C was found in 72.1% and radiological infiltrate in 44%. Hypoxia was present in 55.8 % of the patients. HBoV was isolated in distinct episodes in two patients. Coinfections were similar to simple infections except that hypoxia was more frequent in the former (p = 0.038).

CONCLUSIONS

HBoV is one of the most frequent viruses in severe respiratory infections in patients aged less than 14 years old. Only RSV and rhinovirus are more frequent. Coinfections are highly frequent. Most patients are infants with recurrent wheezing and bronchiolitis.