How scabies crusts: Dermatoscopy aspects of Norwegian scabies

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P6865 Greater psychiatric morbidity in patients with bacterial infections of the skin versus cutaneous neoplasms: Analysis of an epidemiologic sample of 74,753 patient visits for dermatologic disorders Madhulika A. Gupta, MD, Department of Psychiatry, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada; Aditya K. Gupta, MD, PhD, Division of Dermatology, Department of Medicine, University of Toronto, London, Ontario, Canada; Branka Vujcic, Department of Psychiatry, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada Background: Bacterial infections of the skin are common dermatologic conditions that can be related to several factors, including compromise of personal hygiene and self-care by the patient and the patient’s overall immune status. Many psychiatric disorders are associated with some degree of compromise of self-care, in conjunc- tion with poor physical health and nutritional state which in turn can affect immune status, and a relatively high incidence of diabetes mellitus, which can all contribute to bacterial infections of the skin. We examined the frequency of psychiatric disorders in patients with bacterial infections of the skin versus cutaneous neoplasms. Methods: We examined an estimated 1,016,864,533 (6 SE 40,274,557) patient visits (unweighted count ¼ 74, 753) from 1995-2009, with a dermatologic diagnosis (ICD9 CM codes 680-709), from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. There were estimated 164,389,493 6 7,343,047 (unweighted count ¼ 18,587) patient visits with Infections of the Skin and Subcutaneous Tissue (ICD9 CM codes 680-686) (including ‘‘carbuncle and furuncle,’’ ‘‘cellulitis and abscess of finger and toe,’’ ‘‘othercellulitis and abscess,’’ ‘‘acute lymphadenitis,’’ ‘‘impetigo,’’ ‘‘pilonidal cyst,’’ and ‘‘other local infections of skin and subcutaneous tissue’’) and an estimated 179,374,288 6 9,534,026 (unweighted count ¼ 9376) visits with cutaneous neoplasms (including melanoma, primary malignant skin neoplasms, carcinoma in situ, neoplasms of uncertain behavior, neoplasms of unspecified nature, and benign neoplasms). Variables were created for Mental Disorders (ICD9 CM codes 290-319), and diabetes mellitus (ICD9 CM code 250). Results: Logistic regression analysis revealed a significantly higher odds ratio (OR ¼ 2.92, 95% CI 1.67-5.13) of psychiatric disorders among patients with bacterial infections of the skin and subcutaneous tissue vs cutaneous neoplasms, even after controlling for diabetes (OR ¼ 14.3, 95% CI 9.50-21.54) and age. Frequencies (6SE) of some psychiatric diagnoses in the group with infections of the skin were as follows: substance abuse (19.2% 6 2.2%); ADHD (14.5% 6 3.6%); anxiety disorders (11.6% 6 3.0%); depressive disorders (19.2% 6 3.2%); and schizophrenia (3.9% 6 2.0%). Conclusion: In contrast to cutaneous neoplasms, bacterial infections of the skin and subcutaneous tissue are associated with a higher frequency of major psychiatric disorders or substance abuse, which can affect the onset and course of the skin infections. Commercial support: None identified. P6823 Hansen disease after etanercept treatment Cl audia Oliveira, Universidade Federal do Amazonas, Manaus - AM, Brazil; Ana Carre~ no, Universidade Federal do Amazonas, Manaus - AM, Brazil; F abio Francesconi, MD, Universidade Federal do Amazonas, Manaus - AM, Brazil; Isy Peixoto, Universidade Federal do Amazonas, Manaus - AM, Brazil; Jullyene Campos, Universidade Federal do Amazonas, Manaus - AM, Brazil; Maria de F atima Maroja, MD, Fundac ¸~ ao Alfredo da Matta, Manaus - AM, Brazil; Patr ıcia Akel, MD, Universidade Federal do Amazonas, Manaus - AM, Brazil Background: Tumor necrosis factorealfa antagonists have changed the management of diseases such as rheumatoid arthritis. Nevertheless, the risk of granulomatous infection reactivation requires caution in eligibility for its use. We present a rare case of association between borderline tuberculoid leprosy with type 1 reaction and etanercept. Case report: A 22-years-old woman from the Amazon region, diagnosed with juvenile rheumatoid arthritis, complained about spots on the right forearm and the left leg 4 months after starting etanercept. Skin examination revealed erythematous plaque with poorly defined borders and occasional central clearing on the right upper limb (Fig 1) and another one with the same characteristics on the left lower limb, surrounded by multiple small plaques (Fig 2). Loss of sensitivity was detected and lymph smears were negative. Biopsy of the plaque on the right forearm revealed nodular dermal inflammatory infiltrate with centered histiocytes and Lanerghans giant cells and peripheral lymphocytes (Fig 3), consistent with tuberculoid leprosy. One month later, swelling and redness were noticed on the plaques. Therefore, the findings were compatible with borderline tuberculoid leprosy with type 1 reaction. Discussion: Since the beginning of the use of tumor necrosis factorealfa inhibitors, a few cases were reported relating them to leprosy. The lepromatous presentations are more often described and it seems to be related to the interference of granuloma formation performed by tumor necrosis factorealfa. This case highlights the unexpected evolution for good immune response leprosy in a patient submitted to immunosuppressive treatment. Commercial support: None identified. P6916 How scabies crusts: Dermatoscopy aspects of Norwegian scabies Loan Towersey, PhD, MD, Hospital Municipal Carlos Tortelly (HMCT), Niteroi, Brazil; Alice Buc ¸ard, MD, Instituto de Dermatologia Professor Rubem David Azulay da Santa Casa da Miseric ordia do Rio de Janeiro (SCMRJ), Rio de Janeiro, Brazil; Marina Cunha, MD, Hospital Municipal Carlos Tortelly (HMCT), Niteroi, Brazil; Tha ıs Genn, MD, Policl ınica Geral do Rio de Janeiro, Rio de Janeiro, Brazil; Timothy Berger, MD, Universidade da Calif ornia (UCSF), San Francisco, CA, United States We report a case of Norwegian scabies in a 20-year-old woman with AIDS by vertical transmission and irregular antiretroviral treatment (ART) with tenofovir, lamivudine, atazanavir e ritonavir. She was admitted at Hospital Municipal Carlos Tortely, Niteroi, RJ, Brazil presenting severe wasting, chronic diarrhea, oroesophageal candidiasis, productive cough and crusted, pruritic lesions disseminated over her body and scalp, including the palms and the soles. The crusts blurred a star shaped tattoo on her neck. Immunologic parameters showed a reduction in CD4 lymphocytes (27cells/mm 3 )and a viral load of 11,983 copies/mL. Dermatoscopy was performed (Dermlite Pro II)at a magnification of 103 and revealed brown triangular delta glider-shaped structures that represent mites, linear lesions (burrows) and milli- pede-like images (wide and winding tunnels). These coalesced to form crusts. These dermatoscopic aspects are particularly relevant and explain the forming of crusts in Norwegian scabies, caused by intraepidermal digging of tunnels by thousands to millions of mites which converge to form crusts. Diagnosis of scabies was confirmed by direct microscopic examination of 10% potassium hydroxide (KOH) preparation of skin burrow and skin crust scraping which revealed numerous mites and eggs. The patient was placed in isolation and oral ivermectine (9 mg/single dose), amoxicillin + clavulan acid (1.5 g/day), 10% sulphur oinment, and 1% selenium sulphide shampoo were prescribed, but the patient died because of acute respira- tory failure by Pneumocystis jiroveci pneumonia before this treatment could be started. Commercial support: None identified. P6974 Late reversal reaction 6 months after completion of WHO standard treatment for multibacillary leprosy Raquel Iglesias Conde, MD, University Hospital of ACoru~ na, Coru~ na, Spain; Eduardo Fonseca Capdevila, MD, PhD, University Hospital of ACoru~ na, Coru~ na, Spain; Felipe Sacrist an Lista, MD, University Hospital of ACoru~ na, Coru~ na, Spain; Marta Gonz alez Sab ın, MD, University Hospital of ACoru~ na, Coru~ na, Spain; Marta Mazaira, MD, University Hospital of ACoru~ na, Coru~ na, Spain; Rosa Mar ıa Fern andez Torres, MD, University Hospital of ACoru~ na, Coru~ na, Spain; Sabela Paradela De la Morena, MD, PhD, University Hospital of ACoru~ na, Coru~ na, Spain Background: Leprosy is a chronic granulomatous disease caused by the bacillus Mycobacterium leprae. It primarily affects the skin and peripheral nerves and is still endemic in various regions of the world. Reactional states are acute episodes that interrupt the usual chronic course and clinical stability of leprosy. Case report: A 28-year-old Brazilian woman living in Spain for 3 months and with a history of contact with leprosy patients, presented by thermal anesthetic skin lesions since age 12. Some of these lesions become raised during last 3 months. A skin biopsy showed a dermal inflammatory infiltrate with granulomas and stimu- lated macrophages preferably arranged around neurovascular complex, without epithelioidactivation or giant cell transformation. Fite stain revealed abundant acid- fast bacilli without globi formation. He was diagnosed with borderline lepromatous leprosy (BL), starting WHO standard treatment for multibacillary leprosy. At 6 months of completing treatment, our patient developed new hypopigmented skin lesions on her back and lumbar region, with reduced thermal and tactile sensitivity. The skin biopsy showed discrete granulomatous infiltrates around the neurovascu- lar bundles, with disappearance of foam cells, and some histiocytes with epithelioid activation. Oral prednisone, 30 mg/day for 15 days, was prescribed showing a gradual improvement, although with persistence of slight hypochromia. Discussion: Leprosy (type I) reactions occur in borderline leprosy, and are usual- lyassociated with a shift toward the tuberculoid pole (upgrading) as aresult of an increase in delayed hypersensitivity. They are often seen in the first 6 months of treatment, but they may occur in untreated patients or be associated with pregnancy, stress, or intercurrent infections.Reversal reactions observed within 2 years ofcompletion of multidrug therapy have been labeled as late reversal reactions, exceptional and poorly reported in the literature being. These result from an enhanced immune reactivity directed against the remnants of M leprae antigens or the host’s own antigenic determinantswith structures similar to those of M leprae. Differentiation between a relapseanda late reversal reaction following completion of regular drug therapy in patients with leprosy is often difficult. Conclusion: The present case documents a late reversal reaction occurring an unusually long time after the completion of multidrug therapy. Commercial support: None identified. APRIL 2013 JAM ACAD DERMATOL AB119

Transcript of How scabies crusts: Dermatoscopy aspects of Norwegian scabies

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P6865Greater psychiatric morbidity in patients with bacterial infections of theskin versus cutaneous neoplasms: Analysis of an epidemiologic sample of74,753 patient visits for dermatologic disorders

Madhulika A. Gupta, MD, Department of Psychiatry, Schulich School of Medicineand Dentistry, University of Western Ontario, London, Ontario, Canada; Aditya K.Gupta, MD, PhD, Division of Dermatology, Department of Medicine, Universityof Toronto, London, Ontario, Canada; Branka Vujcic, Department of Psychiatry,Schulich School of Medicine and Dentistry, University of Western Ontario,London, Canada

Background: Bacterial infections of the skin are common dermatologic conditionsthat can be related to several factors, including compromise of personal hygiene andself-care by the patient and the patient’s overall immune status. Many psychiatricdisorders are associated with some degree of compromise of self-care, in conjunc-tion with poor physical health and nutritional state which in turn can affect immunestatus, and a relatively high incidence of diabetes mellitus, which can all contributeto bacterial infections of the skin. We examined the frequency of psychiatricdisorders in patients with bacterial infections of the skin versus cutaneousneoplasms.

Methods: We examined an estimated 1,016,864,533 (6 SE 40,274,557) patient visits(unweighted count ¼ 74, 753) from 1995-2009, with a dermatologic diagnosis(ICD9 CM codes 680-709), from the National Ambulatory Medical Care Survey andNational Hospital Ambulatory Medical Care Survey. There were estimated164,389,493 6 7,343,047 (unweighted count ¼ 18,587) patient visits withInfections of the Skin and Subcutaneous Tissue (ICD9 CM codes 680-686) (including‘‘carbuncle and furuncle,’’ ‘‘cellulitis and abscess of finger and toe,’’ ‘‘other cellulitisand abscess,’’ ‘‘acute lymphadenitis,’’ ‘‘impetigo,’’ ‘‘pilonidal cyst,’’ and ‘‘other localinfections of skin and subcutaneous tissue’’) and an estimated 179,374,288 69,534,026 (unweighted count ¼ 9376) visits with cutaneous neoplasms (includingmelanoma, primary malignant skin neoplasms, carcinoma in situ, neoplasms ofuncertain behavior, neoplasms of unspecified nature, and benign neoplasms).Variables were created for Mental Disorders (ICD9 CM codes 290-319), and diabetesmellitus (ICD9 CM code 250).

Results: Logistic regression analysis revealed a significantly higher odds ratio (OR ¼2.92, 95% CI 1.67-5.13) of psychiatric disorders among patients with bacterialinfections of the skin and subcutaneous tissue vs cutaneous neoplasms, even aftercontrolling for diabetes (OR ¼ 14.3, 95% CI 9.50-21.54) and age. Frequencies (6SE)of some psychiatric diagnoses in the group with infections of the skin were asfollows: substance abuse (19.2%6 2.2%); ADHD (14.5% 6 3.6%); anxiety disorders(11.6% 6 3.0%); depressive disorders (19.2% 6 3.2%); and schizophrenia (3.9% 62.0%).

Conclusion: In contrast to cutaneous neoplasms, bacterial infections of the skin andsubcutaneous tissue are associated with a higher frequency of major psychiatricdisorders or substance abuse, which can affect the onset and course of the skininfections.

APRIL 20

cial support: None identified.

Commer

P6823Hansen disease after etanercept treatment

Cl�audia Oliveira, Universidade Federal do Amazonas, Manaus - AM, Brazil; AnaCarre~no, Universidade Federal do Amazonas, Manaus - AM, Brazil; F�abioFrancesconi, MD, Universidade Federal do Amazonas, Manaus - AM, Brazil; IsyPeixoto, Universidade Federal do Amazonas, Manaus - AM, Brazil; JullyeneCampos, Universidade Federal do Amazonas, Manaus - AM, Brazil; Maria deF�atima Maroja, MD, Fundac~ao Alfredo da Matta, Manaus - AM, Brazil; Patr�ıcia Akel,MD, Universidade Federal do Amazonas, Manaus - AM, Brazil

Background: Tumor necrosis factorealfa antagonists have changed the managementof diseases such as rheumatoid arthritis. Nevertheless, the risk of granulomatousinfection reactivation requires caution in eligibility for its use. We present a rare caseof association between borderline tuberculoid leprosy with type 1 reaction andetanercept.

Case report: A 22-years-oldwoman from the Amazon region, diagnosedwith juvenilerheumatoid arthritis, complained about spots on the right forearm and the left leg 4months after starting etanercept. Skin examination revealed erythematous plaquewith poorly defined borders and occasional central clearing on the right upper limb(Fig 1) and another one with the same characteristics on the left lower limb,surrounded by multiple small plaques (Fig 2). Loss of sensitivity was detected andlymph smears were negative. Biopsy of the plaque on the right forearm revealednodular dermal inflammatory infiltrate with centered histiocytes and Lanerghansgiant cells and peripheral lymphocytes (Fig 3), consistent with tuberculoid leprosy.One month later, swelling and redness were noticed on the plaques. Therefore, thefindings were compatible with borderline tuberculoid leprosy with type 1 reaction.

Discussion: Since the beginning of the use of tumor necrosis factorealfa inhibitors, afew cases were reported relating them to leprosy. The lepromatous presentationsare more often described and it seems to be related to the interference of granulomaformation performed by tumor necrosis factorealfa. This case highlights theunexpected evolution for good immune response leprosy in a patient submittedto immunosuppressive treatment.

cial support: None identified.

Commer

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P6916How scabies crusts: Dermatoscopy aspects of Norwegian scabies

Loan Towersey, PhD, MD, Hospital Municipal Carlos Tortelly (HMCT), Niteroi,Brazil; Alice Bucard, MD, Instituto de Dermatologia Professor Rubem DavidAzulay da Santa Casa da Miseric�ordia do Rio de Janeiro (SCMRJ), Rio de Janeiro,Brazil; Marina Cunha, MD, Hospital Municipal Carlos Tortelly (HMCT), Niteroi,Brazil; Tha�ıs Genn, MD, Policl�ınica Geral do Rio de Janeiro, Rio de Janeiro, Brazil;Timothy Berger, MD, Universidade da Calif�ornia (UCSF), San Francisco, CA,United States

We report a case of Norwegian scabies in a 20-year-old woman with AIDS by verticaltransmission and irregular antiretroviral treatment (ART) with tenofovir, lamivudine,atazanavir e ritonavir. She was admitted at Hospital Municipal Carlos Tortely, Niteroi,RJ, Brazil presenting severe wasting, chronic diarrhea, oroesophageal candidiasis,productive cough and crusted, pruritic lesions disseminated over her body andscalp, including the palms and the soles. The crusts blurred a star shaped tattoo onher neck. Immunologic parameters showed a reduction in CD4 lymphocytes(27cells/mm3)and a viral load of 11,983 copies/mL. Dermatoscopy was performed(Dermlite Pro II)at a magnification of 103 and revealed brown triangular deltaglider-shaped structures that represent mites, linear lesions (burrows) and milli-pede-like images (wide and winding tunnels). These coalesced to form crusts. Thesedermatoscopic aspects are particularly relevant and explain the forming of crusts inNorwegian scabies, caused by intraepidermal digging of tunnels by thousands tomillions of mites which converge to form crusts. Diagnosis of scabies was confirmedby direct microscopic examination of 10% potassium hydroxide (KOH) preparationof skin burrow and skin crust scraping which revealed numerous mites and eggs.The patient was placed in isolation and oral ivermectine (9 mg/single dose),amoxicillin + clavulan acid (1.5 g/day), 10% sulphur oinment, and 1% seleniumsulphide shampoo were prescribed, but the patient died because of acute respira-tory failure by Pneumocystis jiroveci pneumonia before this treatment could bestarted.

cial support: None identified.

Commer

P6974Late reversal reaction 6 months after completion of WHO standardtreatment for multibacillary leprosy

Raquel Iglesias Conde, MD, University Hospital of ACoru~na, Coru~na, Spain;Eduardo Fonseca Capdevila, MD, PhD, University Hospital of ACoru~na, Coru~na,Spain; Felipe Sacrist�an Lista, MD, University Hospital of ACoru~na, Coru~na, Spain;Marta Gonz�alez Sab�ın, MD, University Hospital of ACoru~na, Coru~na, Spain; MartaMazaira, MD, University Hospital of ACoru~na, Coru~na, Spain; Rosa Mar�ıaFern�andez Torres, MD, University Hospital of ACoru~na, Coru~na, Spain; SabelaParadela De la Morena, MD, PhD, University Hospital of ACoru~na, Coru~na, Spain

Background: Leprosy is a chronic granulomatous disease caused by the bacillusMycobacterium leprae. It primarily affects the skin and peripheral nerves and is stillendemic in various regions of the world. Reactional states are acute episodes thatinterrupt the usual chronic course and clinical stability of leprosy.

Case report: A 28-year-old Brazilian woman living in Spain for 3 months and with ahistory of contact with leprosy patients, presented by thermal anesthetic skinlesions since age 12. Some of these lesions become raised during last 3 months. Askin biopsy showed a dermal inflammatory infiltrate with granulomas and stimu-lated macrophages preferably arranged around neurovascular complex, withoutepithelioidactivation or giant cell transformation. Fite stain revealed abundant acid-fast bacilli without globi formation. He was diagnosed with borderline lepromatousleprosy (BL), starting WHO standard treatment for multibacillary leprosy. At 6months of completing treatment, our patient developed new hypopigmented skinlesions on her back and lumbar region, with reduced thermal and tactile sensitivity.The skin biopsy showed discrete granulomatous infiltrates around the neurovascu-lar bundles, with disappearance of foam cells, and some histiocytes with epithelioidactivation. Oral prednisone, 30 mg/day for 15 days, was prescribed showing agradual improvement, although with persistence of slight hypochromia.

Discussion: Leprosy (type I) reactions occur in borderline leprosy, and are usual-lyassociated with a shift toward the tuberculoid pole (upgrading) as aresult of anincrease in delayed hypersensitivity. They are often seen in the first 6 months oftreatment, but they may occur in untreated patients or be associated withpregnancy, stress, or intercurrent infections.Reversal reactions observed within 2years ofcompletion ofmultidrug therapy have been labeled as late reversal reactions,exceptional and poorly reported in the literature being. These result from anenhanced immune reactivity directed against the remnants of M leprae antigens orthe host’s own antigenic determinantswith structures similar to those of M leprae.Differentiation between a relapseanda late reversal reaction following completion ofregular drug therapy in patients with leprosy is often difficult.

Conclusion: The present case documents a late reversal reaction occurring anunusually long time after the completion of multidrug therapy.

cial support: None identified.

Commer

J AM ACAD DERMATOL AB119