Erythema multiforme major with ocular involvement following COVID-19 infection

ABSTRACT We report a case of membranous conjunctivitis and erythema multiforme major (EMM) after a coronavirus disease 2019 (COVID-19) diagnosis. A previously well 18-year-old man presented with increasingly erythematous eyes and oral and genital ulceration 2 weeks after confirmation of COVID-19 infection. Clinical examination showed sloughy membranous conjunctivitis with normal visual acuity. He was reviewed by dermatology and diagnosed with EMM secondary to severe acute respiratory syndrome coronavirus 2 infection. The symptoms resolved with oral and topical steroids, lubricants and chloramphenicol eye drops. Erythema multiforme has been reported in association with COVID-19, although the major form is rare. Ophthalmologists should consider current or previous COVID-19 infection in patients presenting with conjunctivitis or pseudomembrane formation. Prompt initiation of steroids aids resolution.

AB0767 SEVERE BREAST ULCERATION IN BEHÇET’S DISEASE TREATED WITH CYCLOPHOSPHAMIDE: A CASE REPORT

Background:Behcet’s disease is a systemic autoimmune vasculitis that typically involves mucocutaneous surfaces, the eyes and the skin with varying manifestations. Skin ulceration often secondary to pathergy is a common feature.Objectives:To raise awareness of breast ulceration as a clinical manifestation in Behcet’s disease.Methods:We report a case of complex Bechet’s disease associated with severe refractory breast ulceration successfully treated with cyclophosphamide.Results:A 27 year old female patient presented to the rheumatology department with a non-healing lesion on her face secondary to a cat scratch. She reported previous episodes of ulceration usually as a result of minor trauma such as IV cannulation, as well as a two year history of severe oral and genital ulceration. She had also been diagnosed with ‘colitis’ requiring iliocaecal resection two years prior to presentation. Previous treatments for her bowel included azathioprine, infliximab, adalimumab and vedolizumab. Over the next three years she developed recurrent eye involvement in the form of scleritis with ongoing oral and genital ulceration. Further treatment under our care included ustekinumab, entanercept, benepali, certolizumab and tacrolimus with background prednisolone. She then developed a small area of broken skin on her left breast which continued to extend and ulcerate despite treatment with IV steroids. Tissue biopsy showed deep focal vasculitis with intravascular thrombi. Anticoagulation was commenced and she was treated with tocilizumab IV for 3 months with no clinical improvement. Involvement extended to include 80 percent of the breast surface and the nipple self-amputated. Due to the severity and extent of the ulceration which was extremely painful and distressing, she was given 3 months of IV cyclophosphamide at a dose of 15mg/kg every 2-3 weeks. The ulceration showed rapid clinical improvement (see Figure 1).Figure 1.Breast ulceration before and after 3 months of cyclophosphamide treatmentConclusion:Involvement of the breast in systemic vasculitides (such as GPA or PAN) has been reported, although usually manifesting as a palpable mass with diagnosis on biopsy 1. Similar presentations in Behcet’s disease have been recognised 2, although much less commonly. Our case demonstrates that severe breast ulceration can be a clinical manifestation of this condition and can be refractory to usual therapies.References:[1]Ren J, Liu J, Su J, Zhang J, Zhao J. Systemic vasculitis involving the breast: a case report and literature review. Rheumatol Int. 2019 Aug;39(8):1447-1455[2]Soleto MJ, Marcos L. Behçet’s disease involving the breast. Eur Radiol. 2002 Dec;12 Suppl 3:S98-S100. doi: 10.1007/s00330-002-1420-4.Disclosure of Interests:None declared

Lipschütz Ulcer: An Unusual Diagnosis that Should Not be Neglected

The diagnosis of genital ulcers remains a challenge in clinical practice. Lipschütz ulcer is a non-sexually transmitted rare and, probably, underdiagnosed condition, characterized by the sudden onset of vulvar edema along with painful necrotic ulcerations. Despite its unknown incidence, this seems to be an uncommon entity, with sparse cases reported in the literature. We report the case of an 11-year-old girl who presented at the emergency department with vulvar ulcers. She denied any sexual intercourse. The investigation excluded sexually transmitted infections, so, knowledge of different etiologies of non-venereal ulcers became essential. The differential diagnoses are extensive and include inflammatory processes, drug reactions, trauma, and malignant tumors. Lipschütz ulcer is a diagnosis of exclusion. With the presentation of this case report, the authors aim to describe the etiology, clinical course, and outcomes of this rare disease, to allow differential diagnosis of genital ulceration.

Genital abnormalities, hormonal contraception, and HIV transmission risk in Rwandan serodifferent couples

Background We explored the role of genital abnormalities and hormonal contraception in HIV transmission among heterosexual serodifferent couples in Rwanda. Methods From 2002-2011, non-antiretroviral treatment using HIV serodifferent couples were followed and sociodemographic and clinical data were collected, family planning provided, and HIV-negative partners retested. Couples were assessed for genital ulcers; non-ulcerative genital sexually transmitted infection (STI) including gonorrhea, chlamydia, and trichomoniasis; and non-STI vaginal infections including bacterial vaginosis and candida. Multivariable models evaluated associations between covariates and HIV transmission genetically linked to the index partner. Results Among 877 couples where the man was HIV-positive, 37 linked transmissions occurred. Factors associated with women’s HIV acquisition included female partner genital ulceration (adjusted hazard ratio [aHR]=14.1) and male partner non-ulcerative STI (aHR=8.6). Among 955 couples where the woman was HIV-positive, 46 linked transmissions occurred. Factors associated with men’s HIV acquisition included female partner non-ulcerative STI (aHR=4.4), non-STI vaginal dysbiosis (aHR=7.1), and male partner genital ulceration (aHR=2.6). Hormonal contraception use was not associated with HIV transmission or acquisition. Conclusions Our findings underscore the need for integrating HIV services with care for genital abnormalities. Barriers (e.g., cost for training, demand creation, advocacy, client education; provider time; clinic space) to joint HIV/STI testing need to be considered and addressed.

Seroprevalence of human immunodeficiency virus among reproductive age group females presenting with genital ulcer: study from a tertiary care centre in India

Background: The co-existence genital ulcers either in the recipient or donor could potentially increase the risk of transmission of human immunodeficiency virus (HIV). Hence the meticulous clinical and serologic evaluation of females presenting with genital ulceration is important to curb the future spread of HIV.Methods: A total 80 female patients within the age group 15-45 years presenting with genital ulceration were enrolled in the study done at tertiary care centre in Amritsar for a period of one year. Various investigations such as Tzanck smear, VDRL, gram staining, genital mucosal biopsy, HSV serology and HIV testing - ELISA and Tri dot were done on study participants.Results: Out of 80 females, 8 patients with genital ulceration tested positive for HIV. Most common cause of genital ulceration in HIV positive female patients was herpes progenitalis (50%). Only 25% of HIV seropositive females were married rest were widowed or unmarried. History of condom use was absent in 62.5% of HIV positive females.Conclusions: Pre-existing genital ulcers due to sexually transmitted diseases (STD) or due to non-STDs, inconsistent condom use, urbanization and pre/extra marital affairs are risk factors for the acquisition of HIV.

Ulceration of the skin

This is a short chapter covering the causes of ulcers. The conditions are grouped into sections covering different aetiologies. Congenital conditions covered are epidermolysis bullosa, aplasia cutis, and Goltz syndrome. Infectious conditions are considered including bacterial, viral, and tropical ulcers. Traumatic ulcers including neuropathic and non-accidental causes are listed. There are further categories covering inflammation, including pyoderma gangrenosum, drug reactions, toxicity, and other causes. Oral and genital ulceration is sign-posted to the relevant chapters.