The Confusion between Pustular Psoriasis and Acute Generalized Exanthematous Pustulosis as a Cause of Exfoliative Dermatitis: A Case Report

Background: Pustular psoriasis and Acute Generalized Exanthematous Pustulosis (AGEP) are grouped under pustular diseases, in which their clinical manifestations are similar. Those diseases can lead to exfoliative dermatitis. Purpose:To evaluate a specific histopathological examination in differentiating Pustular Psoriasis and AGEP. Case: A 55-year-old woman presented with sudden redness and diffused scaly skin with multiple pustules and also fever. She had taken Cefadroxil 2 days before the scales and pustules appeared. Leukocytosis and histopathological examination results from biopsy supported the diagnosis of AGEP. The patient was then hospitalized and received steroid therapy. Within the first week of tapering off, the scales disappeared but the pustules increased. After such clinical findings, the histopathological examination results were revisited and reassessed. Thus, we considered changing the diagnosis to Pustular Psoriasis, and the therapy was switched to Methotrexate. The patient had a better outcome, and the pustules slowly disappeared entirely. Discussion: It is often difficult to differentiate between the pustules in pustular psoriasis and AGEP unless by thorough history-taking and physical examinations. AGEP is characterized by a widespread of pustules with an acute febrile onset; while pustular psoriasis is an acute variant of psoriasis where pustules are spread over erythematous skin and accompanied by high fever and leukocytosis. Conclusion: Histopathological examination is the gold standard for the establishment of pustular psoriasis diagnosis. The histopathological characteristics of pustular psoriasis and AGEP are difficult to differentiate. Therefore, we need detailed history-taking and physical examination to establish the diagnosis.

Generalized dermatophytosis caused by Trichophyton equinum in 8 juvenile black bears in California

From 2014–2019, 8 juvenile black bears ( Ursus americanus) from different geographic regions were presented to the California Department of Fish and Wildlife because of emaciation, alopecia, and exfoliative dermatitis that resulted in death or euthanasia. Autopsy and histopathology revealed that all 8 bears had generalized hyperkeratotic dermatitis, folliculitis, and furunculosis. Skin structures were heavily colonized by fungal hyphae and arthrospores; fungal cultures of skin from 7 bears yielded Trichophyton equinum, a zoophilic dermatophyte reported only rarely in non-equid species. Additional skin conditions included mites (5), ticks (2), and coagulase-negative Staphylococcus sp. infections (2). No other causes of morbidity or mortality were identified. Molecular comparisons performed at the University of Texas Fungal Reference Laboratory determined that all isolates produced identical banding patterns, potentially representing a clonal population. Dermatophytosis is commonly localized and limited to the stratum corneum of the epidermis and hair follicles. Generalized disease with dermal involvement is rare in immunocompetent individuals; illness, malnutrition, age, or immunosuppression may increase susceptibility. Underlying causes for the severe disease impact in these bears were not evident after physical or postmortem examination. The mechanism by which bears from different geographic locations had severe, T. equinum–associated dermatophytosis from a potentially clonal dermatophyte could not be explained and warrants further investigation.

The treatment of Covid tongue in an isolation unit

Background: In 2019, a viral disease spread from Wuhan, Hubei Province in China. The disease was caused by severe acute respiratory syndrome related to coronavirus 2 (SARS-CoV-2 virus), which was named by the Coronavirus Study Group of the International Committee on Taxonomy of Viruses. Purpose: This article reports the multi-discipline treatment of Covid tongue and exfoliative cheilitis with a main diagnosis of bilateral pneumonia caused by SARS-CoV-2 infection. Case: A female patient, 70 years old was referred with a diagnosis of bilateral pneumonia by a pulmonologist. She complained of painful wounds all over her mouth. An intraoral clinical examination revealed white-thick lesion and multiple ulcerations, whilst an extraoral exam for exfoliative dermatitis has not been described. The working diagnosis was Covid tongue mixed with exfoliative cheilitis. Case management: The procedure was performed by teledentistry and direct visits to implement oral health care by asepsis, debridement and the application of Oxygene gel. Conclusion: The lesion was treated successfully due to the multidisciplinary approaches by an internist and pulmonologist by implementing integrated knowledge and was supported hugely by patient cooperation.

Exfoliative dermatitis as a complication of drug eruption associated with COVID-19

We report a clinical case of exfoliative dermatitis associated with a novel coronavirus disease. A patient with moderate COVID-19 and decompensation of insulin-dependent diabetes mellitus, hypertension and obesity developed a generalized drug eruption. Treatment of coronavirus infection included drugs associated with the frequent development of skin allergic reactions: third-generation cephalosporin and hydroxychloroquine. In this clinical case, the patient had a generalized form of exfoliative dermatitis with moderate COVID-19. Thus, the generalization of drug eruption occurred with a decrease in the viral pneumonia foci area and was accompanied by repeated deterioration of general condition of the patient. Skin rashes resolved in the correction of concomitant pathology. Erythroderma has a benign course in hemostatic disorders and the use of systemic glucocorticosteroids, hyperglycemia therapy. For managing such patients, it is important to use an integrated approach, providing both the treatment of the underlying disease and the correction of comorbidity and complications. This is relevant for both dermatologist-venereologist and specialists involved in the treatment of COVID-19.

Systematic analysis of safety profile for darunavir and its boosted agents using data mining in the FDA Adverse Event Reporting System database

This current investigation was aimed to generate signals for adverse events (AEs) of darunavir-containing agents by data mining using the US Food and Drug Administration Adverse Event Reporting System (FAERS). All AE reports for darunavir, darunavir/ritonavir, or darunavir/cobicistat between July 2006 and December 2019 were identified. The reporting Odds Ratio (ROR), proportional reporting ratio (PRR), and Bayesian confidence propagation neural network (BCPNN) were used to detect the risk signals. A suspicious signal was generated only if the results of the three algorithms were all positive. A total of 10,756 reports were identified commonly observed in hepatobiliary, endocrine, cardiovascular, musculoskeletal, gastrointestinal, metabolic, and nutrition system. 40 suspicious signals were generated, and therein 20 signals were not included in the label. Severe high signals (i.e. progressive extraocular muscle paralysis, acute pancreatitis, exfoliative dermatitis, acquired lipodystrophy and mitochondrial toxicity) were identified. In pregnant women, umbilical cord abnormality, fetal growth restriction, low birth weight, stillbirth, premature rupture of membranes, premature birth and spontaneous abortion showed positive signals. Darunavir and its boosted agents induced AEs in various organs/tissues, and were shown to be possibly associated with multiple adverse pregnant conditions. This study highlighted some novel and severe AEs of darunavir which need to be monitored prospectively.

A common disease masked by complex clinical manifestations: A case report of hypothyroidism

Background: Hypothyroidism is a common disease in elderly people. Although hypothyroidism can theoretically have clinical implications related to nearly all major organs, it is often excluded from diagnostic algorithms for elderly patients with multi-system disease because its symptoms are non-specific. Case summary: A 61-year-old woman presented with dizziness, fatigue, facial swelling, dry cracked skin, and myalgia. She had a 2-year history of impairment of multiple organs and multiple adverse drug events. Blood tests showed abnormal liver and kidney function, an elevated creatine kinase concentration, and hyperlipidaemia. During the last 2 years, she had experienced multiple severe adverse drug events, including eosinophilia and systemic symptoms caused by carbamazepine, acute kidney impairment related to ceftriaxone and cefdinir, exfoliative dermatitis caused by ceftazidime, and intolerance to statins. After visiting several large hospitals, she was finally diagnosed in our clinic with hypothyroidism. At the time of diagnosis, she was extremely ill and unable to walk independently. After taking levothyroxine, all of her symptoms and signs completely resolved. Conclusion: Hypothyroidism might be overlooked in elderly patients, especially those with complex and severe clinical conditions. Keywords: Aged; adverse drug events; multiple organ dysfunction; hypothyroidism.

A CASE STUDY ON MANAGEMENT OF ERYTHRODERMA

Erythroderma also known as generalized Exfoliative dermatitis which refers to a scaling involving 90% or more of the cutaneous surface. Clinicians are challenged to find the cause of exfoliative dermatitis by eliciting history of illness prior to erythema. Patients presenting acutely with exfoliative dermatitis often require admission because their total body functions can require monitoring. In western medicine, the principle management is to maintain skin moisture, avoid scratching, apply topical steroids; prolonged glucocorticoids therapy often is needed. From Ayurvedic perspective it could be correlated to Eka Kusta. Eka Kusta is the Vata Kapha Pradhana Vikara. Where skin lesions are Mahavastu, Masthyashaklopamam, Krisha Aruna in Varna. Here presenting a case of 48 years old female with erythroderma who was on long- term steroidal therapy. Treatment was planned with Shamana line of management based on her Bala. The treatment is carried out for one and half month in OPD and IPD section, all the western medicine was stopped and there was total remission of symptoms with Shamana Aushadhis. Keywords: Erythroderma, Eka Kusta, Shamana Aushadhis