De bedwants: a bad bug?

The bed bug: a bad bug? The common bed bug, Cimex lectularius, is a bloodsucking ectoparasite which attacks mammals and is on the rise since the beginning of the early 21st century. They are brown and flat. Skin lesions appear after the painless bite, often during the predawn hours. Small, purpuric macules develop into erythematous, indurated papules on exposed areas of skin of the face, neck and extremities, and resolve over the course of 2 weeks. Often, a linear or cluster configuration of 3 to 4 lesions (‘breakfast, lunch and dinner’) appears. Pruritic wheal reactions represent a type 1 hypersensitivity reaction elicited by the parasite’s saliva antigens. The clinical differential diagnosis is broad and may include other insect and arthropod bites and stings, scabies infestation, dermatitis herpetiformis, ecthyma, etc. There is no evidence that bed bugs are vectors and transmit human pathogens. They are responsible for considerable physical irritation and significant psychological distress. Very rarely, the patient could develop anemia or anaphylaxis. Control involves treating both the patient’s symptoms and the cause by the eradication of the infestation, a challenge that may require a professional exterminator for an integrated pest management strategy. “Good night, sleep tight, don’t let the bed bugs bite!”

Primary umbilical endometriosis – A rare presentation of cutaneous endometriosis

Primary umbilical endometriosis is a rare condition with an overall incidence of around 0.5% to 1% among all the endometriosis cases, but at times it poses a diagnostic dilemma. In our institution we encountered a case of primary umbilical endometriosis presented to multiple surgical speciality departments. A prompt clinical examination with surgical biopsy was the key tool which lead to the diagnosis and providing a complete cure for the patient. Pelvic endometriosis affects 5-10% of women in the child bearing age group. The most pronounced symptoms are dyspareunia, pelvic pain, and infertility. Clinical presentations of umbilical endometriosis are as a nodule with or without associated umbilical pain and bleeding. This patient was given primary hormonal therapy and later underwent a biopsy which paved way for an accurate diagnosis of primary umbilical endometriosis. In this case of umbilical swelling, conditions like a benign nevus, lipoma, abscess, cyst, hernia, as well as metastatic deposit from a systemic malignancy were considered in the clinical differential diagnosis. However surgical excision helped us arrive at a definitive diagnosis and cure for the patient.

Non-Melanoma Facial Skin Tumors—The Correspondence between Clinical and Histological Diagnosis

This paper consists of a retrospective study that includes a total of 186 cases with facial skin tumors diagnosed and treated between January 2015 and December 2017. Our aim was to correlate the initial clinical diagnosis with the histological results, in order to observe the success rate of our clinical experience, but also to underline that certain clinical tumor aspects can be misleading as the histological findings can result in different final diagnostics. From the total number of cases, we counted a total of 226 tumors (both benign and malignant), from which 194 had the clinical diagnosis confirmed by the anatomopathological exam and 34 had a different laboratory result from the clinical presumption: 10 benign tumors and 22 malignant tumors (eight BCC and 14 SCC, 12 of the latter being confused with ulcerovegetant BCC). Detailed correlation data were presented, as well as different situations of incongruence between the clinical and the histological diagnosis. The long-term goal of the study was to use our experience of correlating the clinical and the histological diagnosis, in order to improve the existing knowledge on the clinical differential diagnosis of both malignant and benign facial skin tumors.

Isolated eosinophilic mastitis: a rare breast disease mimicking malignancy

Eosinophilic mastitis is a rare benign breast pathology which presents with lump breast and can mimic malignancy. So far eight reported cases have been found in literature review. All cases were associated with peripheral eosinophilia and systemic involvement except one. Isolated eosinophilic mastitis in the absence of peripheral eosinophilia or systemic involvement is a very rare presentation. Being one of the rare cases, prompted us to take up this case in our present study. A 40-year-old lady presented with progressively enlarging, slightly painful swelling in left breast of 15 days duration with no other relevant past and family history. The clinical differential diagnosis of mastitis and carcinoma was suggested. Aspiration cytology was reported as benign breast disease- fibroadenosis. Imaging studies undertaken were inconclusive. Case managed surgically with wide local excision. Post-surgical tissue specimen was subjected to histopathology examination and was diagnosed as eosinophilic mastitis. A prolonged follow-up revealed no recurrence.

Vulvar vestibular papillomatosis: All genital lesions are not sexually transmitted diseases

Vulvar vestibular papillomatosis (VVP) is considered as normal anatomical variant of the vulva. A 19-year-old female presented with asymptomatic pinkish filliform papules symmetrically distributed on vulva. She denied having any sexual exposure. Clinical differential diagnosis included genital wart and vestibular papillomatosis, however biopsy was consistent with Vestibular papillomatosis. PAS stain was negative. Application of 5% acetic acid did not show any change in color. We report this case to create awareness about normal variant of vulva and unnecessary exaggerated treatment and proper counseling of patient to decrease psychological trauma and associated venereophobia.

Genetic Architecture and Molecular, Imaging and Prodromic Markers in Dementia with Lewy Bodies: State of the Art, Opportunities and Challenges

Dementia with Lewy bodies (DLB) is one of the most common causes of dementia and belongs to the group of α-synucleinopathies. Due to its clinical overlap with other neurodegenerative disorders and its high clinical heterogeneity, the clinical differential diagnosis of DLB from other similar disorders is often difficult and it is frequently underdiagnosed. Moreover, its genetic etiology has been studied only recently due to the unavailability of large cohorts with a certain diagnosis and shows genetic heterogeneity with a rare contribution of pathogenic mutations and relatively common risk factors. The rapid increase in the reported cases of DLB highlights the need for an easy, efficient and accurate diagnosis of the disease in its initial stages in order to halt or delay the progression. The currently used diagnostic methods proposed by the International DLB consortium rely on a list of criteria that comprises both clinical observations and the use of biomarkers. Herein, we summarize the up-to-now reported knowledge on the genetic architecture of DLB and discuss the use of prodromal biomarkers as well as recent promising candidates from alternative body fluids and new imaging techniques.

Treatment of corneal ulcers and endophthalmitis caused by yeast fungi

Aim: To analyze the pathogenesis, clinical features, and treatment algorithm of fungal corneal ulcer with endophthalmitis to increase medical alertness and reduce the unjustified use of antibacterial and corticosteroid therapy in corneal diseases of various etiologies, leading to the development of secondary ophthalmomycosis. Results: The pathogenesis was analyzed, and the characteristic clinical symptoms of severe fungal corneal ulcer and endophthalmitis caused by Candida albicans were described. Intensive, long-term, unjustified antibacterial and corticosteroid therapy caused a prolonged course of herpetic corneal ulcer, as well as the addition of a secondary bacterial infection, and led to the development of severe corneal ulcer and fungal endophthalmitis in a 13-year-old child. Conclusion: The required maximum medical alertness and early, accurate clinical differential diagnosis between bacterial and fungal corneal ulcer, as well as the rapid flow of ophthalmomycosis and false-negative results of sowing content conjunctival sac entail expansion of the range and quantity of antibacterial drugs used in the absence of positive dynamics of antibiotic therapy and an increased frequency of secondary fungal infection. The clinical symptoms of a severe fungal corneal ulcer with endophthalmitis described in this report contribute to the early diagnosis of ophthalmomycosis before the type of pathogen is identified by laboratory methods, which makes it possible to start antifungal therapy earlier and avoid corneal perforation and eye loss. In most countries, due to the lack of an ocular form of antifungal drugs, for local treatment of corneal candidiasis, a 0.2% solution of fluconazole intended for intravenous administration is installed in the eyes.

Diffuse gingival enlargement with stromal calcifications occurring in a background of amelogenesis imperfecta - An oral medicine case book

A 12-year-old female patient presented with diffusely enlarged fibrous gingivae, enamel hypoplasia, an anterior open bite and impacted permanent maxillary canines (Figures 1-4). The patient's mother reported that the child had an unremarkable medical history and was currently not taking any medications. Radiographic examination showed features of amelogenesis imperfecta affecting all erupted teeth and the impacted permanent maxillary canines (Figure 4). The clinical differential diagnosis included hereditary gingival fibromatosis or diffuse peripheral odontogenic fibromas involving both the maxilla and mandible. Gin-givectomies from the anterior maxillary and mandibular regions were performed and submitted for histological assessment.

Children with COVID-19 like symptoms in Italian Pediatric Surgeries: the dark side of the coin

BACKGROUND: Symptoms of SARS-CoV-2 infection in children are nonspecific and shared with other common acute viral illnesses (fever, respiratory or gastrointestinal symptoms, and cutaneous signs), thus making clinical differential diagnosis tricky. In Italy, first line management of pediatric care is handed over to Primary Care Pediatricians (PCPs), who were not allowed to directly perform diagnostic tests during the recent COVID-19 outbreak. Without a confirmatory diagnosis, PCPs could only collect information on ″COVID-19 like symptoms″ rather than identify typical COVID-19 symptoms. AIM: To evaluate the prevalence of COVID-19 like symptoms in outpatient children, during Italian lockdown. To provide PCPs a risk score to be used in clinical practice during the differential diagnosis process. METHODS: A survey was submitted to 50 PCPs (assisting 47,500 children) from 7 different Italian regions between the 4th of March and the 23rd of May 2020 (total and partial lockdown period). COVID-19 like symptoms in the assisted children were recorded, as well as presence of confirmed/suspected cases in children′s families, which was taken as proxy of COVID-19. Multivariable logistic regression was accomplished to estimate the risk of having suspected/confirmed cases in families, considering symptoms as potential determinants. RESULTS: 2,300 children (4.8% of overall survey population) fell ill with COVID-19 like symptoms, 3.1% and 1.7% during total and partial lockdown period respectively. The concurrent presence of fatigue, cough, and diarrhea in children, in absence of sore throat/earache and abnormal skin signs, represents the maximum risk level of having a suspected/confirmed case of COVID-19 at home. CONCLUSIONS: The percentage of children presenting COVID-19 like symptoms at home has been remarkable also during the total lockdown period. The present study identified a pattern of symptoms which could help, in a cost-effective perspective, PCPs in daily clinical practice to define priorities in addressing children to the proper diagnostic procedure.

Fibrolamellar Carcinoma With Predominantly Pseudoglandular Architecture: A Potential Diagnostic Pitfall

Biopsies of liver mass lesions are encountered frequently in general surgical pathology practice. The clinical differential diagnosis is typically hepatocellular carcinoma (HCC) versus metastatic adenocarcinoma. There are a variety of HCC variants that show a range of morphological appearances. The presence of malignant glands in the liver prompts the pathologist to consider adenocarcinoma, either metastatic or primary intrahepatic cholangiocarcinoma. It is important to remember that some variant patterns of HCC can show pseudoglandular growth. In this article, we present a case of fibrolamellar carcinoma that showed predominantly pseudoglandular growth to highlight the importance of a systematic approach and the routine use of a panel of immunohistochemical stains (HepPar1, CK7, and CD68).