Background: Mycosis fungoides (MF) is a cutaneous T-cell lymphoma. Previous reports have suggeste... more Background: Mycosis fungoides (MF) is a cutaneous T-cell lymphoma. Previous reports have suggested MF is associated with inflammatory conditions such as psoriasis, increased cardiovascular risk factors as well as secondary neoplasms. Methods: A cross-sectional study of MF patients seen from 2013 to 2019 was performed. Comorbidities were selected based on the 2015 Medicare report highlighting the most common chronic medical illnesses in the United States. Lifetime comorbidity occurrence in patients with MF were compared with that in patients with atopic dermatitis, psoriasis and patients without MF. Additional analyses were performed with patients sub-stratified by race. Results: Compared to control groups, MF was strongly associated with lymphomatoid papulosis and Hodgkin’s disease, but not significantly associated with lung, breast or colon cancer. Interestingly, the association with lymphomatoid papulosis was observed in Caucasians (CI 1062-4338; p < 0.001) and not African Amer...
How to cite this article: Patra S, Nimitha P, Kaul S, Valakkada J, Verma KK, Ramam M, Bhari N. Pr... more How to cite this article: Patra S, Nimitha P, Kaul S, Valakkada J, Verma KK, Ramam M, Bhari N. Primary cutaneous histoplasmosis in an immunocompetent patient presenting with severe pruritus.Indian J Dermatol Venereol Leprol 2018;84:465468 How to cite this URL: Patra S, Nimitha P, Kaul S, Valakkada J, Verma KK, Ramam M, Bhari N. Primary cutaneous histoplasmosis in an immunocompetent patient presenting with severe pruritus. Indian J Dermatol Venereol Leprol [serial online] A 60yearold man presented with severe generalized pruritus of 1year duration. In the initial 6 months, the pruritus was not associated with any skin lesions. The pruritus was severe enough to disturb his sleep and daily activities. It was not relieved by overthecounter oral antihistamines and topical steroids. Over the next 6 months, he developed multiple erythematous papules on the trunk, followed by face and extremities. There was no history of fever, malaise, weight loss or other systemic symptoms. He did not report any comorbidities other than a single episode of angina 3 years back. At presentation, he had multiple monomorphic, shiny, erythematoustoskin colored, 0.2 cm × 0.3 cm papules and small nodules on the face, upper trunk and upper limbs [Figure 1]a,[Figure 1]b,[Figure 1]c. The papules coalesced to form plaques on the eyelids and nape of the neck. There was also diffuse infiltration of the face and ears. The scalp, flexures and mucosae were spared. Systemic examination revealed mild splenomegaly. Clinical diagnoses of lepromatous leprosy, post kalaazar dermal leishmaniasis and sarcoidosis were considered.{Figure 1} Skin biopsy revealed a dense dermal inflammatory infiltrate of histiocytes, epithelioid cells and multinucleated giant cells with numerous ovoidshaped yeasts with a peripheral halo which stained positively with Periodic AcidSchiff stain, suggestive of Histoplasma capsulatum [Figure 2]a. Potassium hydroxide preparation of a tissue sample also revealed yeasts. However, the fungus could not be isolated on culture. On further questioning, the patient reported living near a poultry farm, though he did not have any direct exposure to birds. Based on the presence of yeasts resembling Histoplasma in the biopsy, a clinical diagnosis of cutaneous histoplasmosis was considered and the patient was evaluated for systemic involvement.{Figure 2}
Hyperuricemia and gout have been linked to an increased risk for cardiovascular (CV) disease, str... more Hyperuricemia and gout have been linked to an increased risk for cardiovascular (CV) disease, stroke, hypertension, heart failure, and chronic kidney disease, possibly through a proinflammatory milieu. However, not all the drugs used in gout treatment improve CV outcomes; colchicine has shown improved CV outcomes in patients with recent myocardial infarction and stable coronary artery disease independent of lipid-lowering effects. There is resurging interest in colchicine following publication of the COLCOT, LoDoCo, LoDoCo2, LoDoCo-MI trials, and COLCORONA trial which will shed light on its utility in COVID-19. Our aim is to review the CV use of colchicine beyond pericardial diseases, as well as CV outcomes of the available gout therapies, including allopurinol and febuxostat. The CARES trial and its surrounding controversies, which lead to the US FDA 'black box' warning on febuxostat, in addition to the recent FAST trial which contradicts this and finds febuxostat to be non-inferior, are discussed in this paper. Subuhi Kaul and Manasvi Gupta contributed equally to this work and are considered as first co-authors. Several anti-inflammatory and urate-lowering drugs used in gout have been found to have a favorable effect on cardiovascular (CV) outcomes. Colchicine is first-line therapy in both gout and pericar-ditis. It has also demonstrated benefit in the prevention of ischemic events in patients with stable coronary artery disease (CAD) and recent myocardial infarction (MI), postpericardiotomy syndrome and postoperative atrial fibrillation. Allopurinol may have a potential cardioprotective effect, particularly in the reduction of blood pressure and prevention of MI. CV outcomes with febuxostat are non-inferior to allopu-rinol and the long-term use of febuxostat is not associated with increased death or CV mortality. The CV effects of newer gout drugs such as arhalofenate, verinurad, and rilonacept need to be evaluated.
Obtaining high-quality sections of the nail plate poses a significant challenge to histopathology... more Obtaining high-quality sections of the nail plate poses a significant challenge to histopathology technicians world over. Nail is a heavily keratotic hard tissue that tends to split or tear while sectioning when processed and embedded in a routine manner. Many agents such as phenol, alcohol, and thioglycolate have been tried for the purpose of softening a variety of experimental materials. However, there is no clear consensus on any single agent. The study was conducted with the aim of evaluating and comparing the role of various compounds as softening agents for nail biopsies with inflammatory disease. Thirty paraffin-embedded nail biopsies were subjected to four softening agents: distilled water (DIH 2 0), 30% potassium hydroxide (KOH), hair removal cream, and fabric conditioner. The ease of sectioning, the incidence of juddering (i.e. 'venetian blind' effect), and the shattering of tissue were recorded. Hematoxylin and eosin-stained sections were examined microscopically. Sectioning was very easy after using fabric conditioner, with good quality sections, and hair removal cream produced comparable results. The incidence of juddered, shattered sections after using hair removal cream was considerably higher (63.33%) compared to fabric conditioner-treated nails (16.67%). Microtomy of nail biopsies was found to be easiest after using 30% KOH with moderate section quality. DIH 2 O could neither allow easier sectioning nor obtain good sections for interpretation. Fabric conditioner and hair removal cream proved to be the effective keratin softeners, while 30% KOH worked effectively when the nail plate alone was submitted for histological examination.
Dapsone induced agranulocytosis -symptoms may alert more reliably than the current blood monitori... more Dapsone induced agranulocytosis -symptoms may alert more reliably than the current blood monitoring protocol
BACKGROUND: Nail psoriasis can pose diagnostic difficulties as there are several close clinical m... more BACKGROUND: Nail psoriasis can pose diagnostic difficulties as there are several close clinical mimickers, including onychomycosis, lichen planus, and even squamous cell carcinoma. In view of differing treatment and prognostic implications, it is important to make an accurate diagnosis, especially in cases with isolated nail involvement. METHODS: Sixty consecutive patients with nail changes suggestive of psoriasis were included. A nail punch biopsy was performed and histopathological features were recorded for each case and percentage positivity of each individual feature was calculated. Periodic acid-Schiff (PAS) stain was performed to detect any fungal colonization or invasion. RESULTS: The most common clinical nail change was distal onycholysis (93.3% patients), followed by subungual hyperkeratosis (80%). On histological examination, the feature found most frequently was hyperkeratosis with parakeratosis (78% of biopsies), followed by neutrophilic infiltration of nail bed epithelium (63%), and hypergranulosis (58%). Unlike psoriasis elsewhere, nail bed and matrix histopathology revealed hypergranulosis in more than half of the cases. PAS stain was positive for fungal elements in 16 of 60 (26%) cases. CONCLUSION: This study provides a careful, detailed histopathological description of nail unit psoriasis in a large number of cases. The histopathologic features described, which are somewhat different from psoriasis elsewhere on the body, are of utility to pathologists who may receive nail biopsy specimens of hyperkeratotic lesions.
Dermatophytic infection of the skin and its appendages is a common occurrence. Though usually str... more Dermatophytic infection of the skin and its appendages is a common occurrence. Though usually straightforward, treatment of dermatophytosis becomes notably challenging in certain population groups - pregnant women, children, and elderly. Treatment with topical azoles/allylamines alone is effective in limited cutaneous disease in all three groups. Terbinafine is the preferred oral agent in elderly population for treatment of extensive cutaneous disease and onychomycosis due to its lack of cardiac complications and lower propensity for drug interactions. If required, additional physical/mechanical modalities can be employed for symptomatic onychomycosis. Data for systemic therapy in children mainly pertains to the treatment of tinea capitis. At present, very little data exists regarding the safety of systemic antifungals in pregnancy and there is an effort to restrict treatment to topical therapies because of their negligible systemic absorption.
Delusion of parasitosis is a rare condition characterised by an individual harbouring the delusio... more Delusion of parasitosis is a rare condition characterised by an individual harbouring the delusion of being infested with insects or parasites. We report a rare and interesting case of delusion of parasitosis presenting as folie a deux, that is, the delusion is shared by both the parents of an 18-month-old child, with proxy projection of parental delusion on the child. The case highlights the rare concomitant occurrence of two psychocutaneous disorders and emphasizes the importance of early recognition and appropriate intervention to safeguard the well-being of the child.
Background: Mycosis fungoides (MF) is a cutaneous T-cell lymphoma. Previous reports have suggeste... more Background: Mycosis fungoides (MF) is a cutaneous T-cell lymphoma. Previous reports have suggested MF is associated with inflammatory conditions such as psoriasis, increased cardiovascular risk factors as well as secondary neoplasms. Methods: A cross-sectional study of MF patients seen from 2013 to 2019 was performed. Comorbidities were selected based on the 2015 Medicare report highlighting the most common chronic medical illnesses in the United States. Lifetime comorbidity occurrence in patients with MF were compared with that in patients with atopic dermatitis, psoriasis and patients without MF. Additional analyses were performed with patients sub-stratified by race. Results: Compared to control groups, MF was strongly associated with lymphomatoid papulosis and Hodgkin’s disease, but not significantly associated with lung, breast or colon cancer. Interestingly, the association with lymphomatoid papulosis was observed in Caucasians (CI 1062-4338; p < 0.001) and not African Amer...
How to cite this article: Patra S, Nimitha P, Kaul S, Valakkada J, Verma KK, Ramam M, Bhari N. Pr... more How to cite this article: Patra S, Nimitha P, Kaul S, Valakkada J, Verma KK, Ramam M, Bhari N. Primary cutaneous histoplasmosis in an immunocompetent patient presenting with severe pruritus.Indian J Dermatol Venereol Leprol 2018;84:465468 How to cite this URL: Patra S, Nimitha P, Kaul S, Valakkada J, Verma KK, Ramam M, Bhari N. Primary cutaneous histoplasmosis in an immunocompetent patient presenting with severe pruritus. Indian J Dermatol Venereol Leprol [serial online] A 60yearold man presented with severe generalized pruritus of 1year duration. In the initial 6 months, the pruritus was not associated with any skin lesions. The pruritus was severe enough to disturb his sleep and daily activities. It was not relieved by overthecounter oral antihistamines and topical steroids. Over the next 6 months, he developed multiple erythematous papules on the trunk, followed by face and extremities. There was no history of fever, malaise, weight loss or other systemic symptoms. He did not report any comorbidities other than a single episode of angina 3 years back. At presentation, he had multiple monomorphic, shiny, erythematoustoskin colored, 0.2 cm × 0.3 cm papules and small nodules on the face, upper trunk and upper limbs [Figure 1]a,[Figure 1]b,[Figure 1]c. The papules coalesced to form plaques on the eyelids and nape of the neck. There was also diffuse infiltration of the face and ears. The scalp, flexures and mucosae were spared. Systemic examination revealed mild splenomegaly. Clinical diagnoses of lepromatous leprosy, post kalaazar dermal leishmaniasis and sarcoidosis were considered.{Figure 1} Skin biopsy revealed a dense dermal inflammatory infiltrate of histiocytes, epithelioid cells and multinucleated giant cells with numerous ovoidshaped yeasts with a peripheral halo which stained positively with Periodic AcidSchiff stain, suggestive of Histoplasma capsulatum [Figure 2]a. Potassium hydroxide preparation of a tissue sample also revealed yeasts. However, the fungus could not be isolated on culture. On further questioning, the patient reported living near a poultry farm, though he did not have any direct exposure to birds. Based on the presence of yeasts resembling Histoplasma in the biopsy, a clinical diagnosis of cutaneous histoplasmosis was considered and the patient was evaluated for systemic involvement.{Figure 2}
Hyperuricemia and gout have been linked to an increased risk for cardiovascular (CV) disease, str... more Hyperuricemia and gout have been linked to an increased risk for cardiovascular (CV) disease, stroke, hypertension, heart failure, and chronic kidney disease, possibly through a proinflammatory milieu. However, not all the drugs used in gout treatment improve CV outcomes; colchicine has shown improved CV outcomes in patients with recent myocardial infarction and stable coronary artery disease independent of lipid-lowering effects. There is resurging interest in colchicine following publication of the COLCOT, LoDoCo, LoDoCo2, LoDoCo-MI trials, and COLCORONA trial which will shed light on its utility in COVID-19. Our aim is to review the CV use of colchicine beyond pericardial diseases, as well as CV outcomes of the available gout therapies, including allopurinol and febuxostat. The CARES trial and its surrounding controversies, which lead to the US FDA 'black box' warning on febuxostat, in addition to the recent FAST trial which contradicts this and finds febuxostat to be non-inferior, are discussed in this paper. Subuhi Kaul and Manasvi Gupta contributed equally to this work and are considered as first co-authors. Several anti-inflammatory and urate-lowering drugs used in gout have been found to have a favorable effect on cardiovascular (CV) outcomes. Colchicine is first-line therapy in both gout and pericar-ditis. It has also demonstrated benefit in the prevention of ischemic events in patients with stable coronary artery disease (CAD) and recent myocardial infarction (MI), postpericardiotomy syndrome and postoperative atrial fibrillation. Allopurinol may have a potential cardioprotective effect, particularly in the reduction of blood pressure and prevention of MI. CV outcomes with febuxostat are non-inferior to allopu-rinol and the long-term use of febuxostat is not associated with increased death or CV mortality. The CV effects of newer gout drugs such as arhalofenate, verinurad, and rilonacept need to be evaluated.
Obtaining high-quality sections of the nail plate poses a significant challenge to histopathology... more Obtaining high-quality sections of the nail plate poses a significant challenge to histopathology technicians world over. Nail is a heavily keratotic hard tissue that tends to split or tear while sectioning when processed and embedded in a routine manner. Many agents such as phenol, alcohol, and thioglycolate have been tried for the purpose of softening a variety of experimental materials. However, there is no clear consensus on any single agent. The study was conducted with the aim of evaluating and comparing the role of various compounds as softening agents for nail biopsies with inflammatory disease. Thirty paraffin-embedded nail biopsies were subjected to four softening agents: distilled water (DIH 2 0), 30% potassium hydroxide (KOH), hair removal cream, and fabric conditioner. The ease of sectioning, the incidence of juddering (i.e. 'venetian blind' effect), and the shattering of tissue were recorded. Hematoxylin and eosin-stained sections were examined microscopically. Sectioning was very easy after using fabric conditioner, with good quality sections, and hair removal cream produced comparable results. The incidence of juddered, shattered sections after using hair removal cream was considerably higher (63.33%) compared to fabric conditioner-treated nails (16.67%). Microtomy of nail biopsies was found to be easiest after using 30% KOH with moderate section quality. DIH 2 O could neither allow easier sectioning nor obtain good sections for interpretation. Fabric conditioner and hair removal cream proved to be the effective keratin softeners, while 30% KOH worked effectively when the nail plate alone was submitted for histological examination.
Dapsone induced agranulocytosis -symptoms may alert more reliably than the current blood monitori... more Dapsone induced agranulocytosis -symptoms may alert more reliably than the current blood monitoring protocol
BACKGROUND: Nail psoriasis can pose diagnostic difficulties as there are several close clinical m... more BACKGROUND: Nail psoriasis can pose diagnostic difficulties as there are several close clinical mimickers, including onychomycosis, lichen planus, and even squamous cell carcinoma. In view of differing treatment and prognostic implications, it is important to make an accurate diagnosis, especially in cases with isolated nail involvement. METHODS: Sixty consecutive patients with nail changes suggestive of psoriasis were included. A nail punch biopsy was performed and histopathological features were recorded for each case and percentage positivity of each individual feature was calculated. Periodic acid-Schiff (PAS) stain was performed to detect any fungal colonization or invasion. RESULTS: The most common clinical nail change was distal onycholysis (93.3% patients), followed by subungual hyperkeratosis (80%). On histological examination, the feature found most frequently was hyperkeratosis with parakeratosis (78% of biopsies), followed by neutrophilic infiltration of nail bed epithelium (63%), and hypergranulosis (58%). Unlike psoriasis elsewhere, nail bed and matrix histopathology revealed hypergranulosis in more than half of the cases. PAS stain was positive for fungal elements in 16 of 60 (26%) cases. CONCLUSION: This study provides a careful, detailed histopathological description of nail unit psoriasis in a large number of cases. The histopathologic features described, which are somewhat different from psoriasis elsewhere on the body, are of utility to pathologists who may receive nail biopsy specimens of hyperkeratotic lesions.
Dermatophytic infection of the skin and its appendages is a common occurrence. Though usually str... more Dermatophytic infection of the skin and its appendages is a common occurrence. Though usually straightforward, treatment of dermatophytosis becomes notably challenging in certain population groups - pregnant women, children, and elderly. Treatment with topical azoles/allylamines alone is effective in limited cutaneous disease in all three groups. Terbinafine is the preferred oral agent in elderly population for treatment of extensive cutaneous disease and onychomycosis due to its lack of cardiac complications and lower propensity for drug interactions. If required, additional physical/mechanical modalities can be employed for symptomatic onychomycosis. Data for systemic therapy in children mainly pertains to the treatment of tinea capitis. At present, very little data exists regarding the safety of systemic antifungals in pregnancy and there is an effort to restrict treatment to topical therapies because of their negligible systemic absorption.
Delusion of parasitosis is a rare condition characterised by an individual harbouring the delusio... more Delusion of parasitosis is a rare condition characterised by an individual harbouring the delusion of being infested with insects or parasites. We report a rare and interesting case of delusion of parasitosis presenting as folie a deux, that is, the delusion is shared by both the parents of an 18-month-old child, with proxy projection of parental delusion on the child. The case highlights the rare concomitant occurrence of two psychocutaneous disorders and emphasizes the importance of early recognition and appropriate intervention to safeguard the well-being of the child.
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Papers by Subuhi Kaul
METHODS:
Sixty consecutive patients with nail changes suggestive of psoriasis were included. A nail punch biopsy was performed and histopathological features were recorded for each case and percentage positivity of each individual feature was calculated. Periodic acid-Schiff (PAS) stain was performed to detect any fungal colonization or invasion.
RESULTS:
The most common clinical nail change was distal onycholysis (93.3% patients), followed by subungual hyperkeratosis (80%). On histological examination, the feature found most frequently was hyperkeratosis with parakeratosis (78% of biopsies), followed by neutrophilic infiltration of nail bed epithelium (63%), and hypergranulosis (58%). Unlike psoriasis elsewhere, nail bed and matrix histopathology revealed hypergranulosis in more than half of the cases. PAS stain was positive for fungal elements in 16 of 60 (26%) cases.
CONCLUSION:
This study provides a careful, detailed histopathological description of nail unit psoriasis in a large number of cases. The histopathologic features described, which are somewhat different from psoriasis elsewhere on the body, are of utility to pathologists who may receive nail biopsy specimens of hyperkeratotic lesions.
METHODS:
Sixty consecutive patients with nail changes suggestive of psoriasis were included. A nail punch biopsy was performed and histopathological features were recorded for each case and percentage positivity of each individual feature was calculated. Periodic acid-Schiff (PAS) stain was performed to detect any fungal colonization or invasion.
RESULTS:
The most common clinical nail change was distal onycholysis (93.3% patients), followed by subungual hyperkeratosis (80%). On histological examination, the feature found most frequently was hyperkeratosis with parakeratosis (78% of biopsies), followed by neutrophilic infiltration of nail bed epithelium (63%), and hypergranulosis (58%). Unlike psoriasis elsewhere, nail bed and matrix histopathology revealed hypergranulosis in more than half of the cases. PAS stain was positive for fungal elements in 16 of 60 (26%) cases.
CONCLUSION:
This study provides a careful, detailed histopathological description of nail unit psoriasis in a large number of cases. The histopathologic features described, which are somewhat different from psoriasis elsewhere on the body, are of utility to pathologists who may receive nail biopsy specimens of hyperkeratotic lesions.