Factors Related to ICU Admissions of Childhood Cancer Patients in Tertiary Preferred Hospital in the Private Sector of India

This study was performed to assess the predictive factors of Intensive Care Units (ICU) admission in newly diagnosed pediatric oncologic patients and in patients under ongoing oncologic treatment. Methods used to explore the research question included a retrospective analysis of children admitted to the ICU of the MAX Saket Superspecialty Hospital between March 1, 2013 and May 2018 in order to identify those patients with an oncologic condition who were admitted to an ICU. This subgroup was further evaluated for factors associated to ICU admissions, including: diagnosis, risk factors, complications leading to Pediatric ICU (PICU) admission, PICU therapy, and mortality outcome. Of the 258 total pediatric oncology patients in the 5 years analyzed, 149 patients (58%) were admitted to the ICU. The ICU with the highest number of admissions was the Neurosurgery-ICU (NSICU) with 54 episodes. Out of the 149 patients with ICU admissions, 66% were male and 44% were female. There were 27 (18%) ICU deaths reported. While demographic factors may not be entirely predictive of risk for ICU admission, the patterns identified through this analysis, particularly diagnostic indicators, can be used to guide planning and precautions for future patients. Other variables, including sex and country of origin, showed no significant predilection for ICU admission. Further exploration on factors associated with ICU mortality are of interest for future research

28353 Hemorrhagic cellulitis secondary to vibrio fluvialis infection

A 75-year-old male with a medical history of heart failure, interstitial lung disease, end stage renal disease on hemodialysis, and carcinoid tumor presented to the ER due to diarrhea and abdominal rash. His abdominal rash started as asymptomatic bruising along the left abdomen which spread to the right. He developed myalgias, lethargy, and altered mental status; he later developed fever, tachycardia, and hypovolemia and was found to be in septic shock. Labwork revealed a leukocytosis with neutrophilic predominance, elevated lactate, and negative Clostridium difficile. Blood cultures grew Gram-negative bacilli which later speciated as Vibrio fluvialis. Biopsy revealed neutrophilic dermatitis and panniculitis with hemorrhage consistent with hemorrhagic cellulitis. The patient was treated with IV piperacillin/tazobactam and oral doxycycline with which he had improvement of his abdominal rash, mental status, and systemic symptoms. V fluvialis is a Gram-negative bacterium which occurs widely in aquatic environments. V fluvialis has been detected in mollusks, oysters, mussels, among other marine creatures commonly consumed as seafood. Upon questioning, this patient did admit to eating uncooked clams three days prior to presentation. This organism is known to cause gastroenteritis with diarrheal illness as in this patient. Cases of peritonitis, suppurative cholangitis, and bacteremia have been noted with V fluvialis. There is one reported case of hemorrhagic cellulitis and cerebritis in a patient who swam in brackish water following multiple fire ant stings. We report a novel case of hemorrhagic cellulitis and bacteremia leading to septic shock secondary to V fluvialis infection following raw clam ingestion

A man with diffuse hyperkeratotic papules and plaques

HISTORY: A 47-year-old African American man with no relevant past medical history presented to Dermatology with a rash that began 2-3 years prior with a sudden onset on the arms and knees and has since spread diffusely. He endorses oral involvement. Denies any history of hepatitis C, syphilis, or HIV. No family history of similar condition. EXAMINATION: Diffusely on the body were many hyperkeratotic scaly papules coalescing into plaques with underlying violaceous macules and patches on the arms, legs, buttocks, and hips. Many papules and plaques were in a linear distribution, suggesting possibility of koebnerization. The mouth had hyperkeratotic papules along the oral commissures, cobblestoning of the palate, and reticulated white streaks on the upper and lower mucosal lip and the left buccal mucosa. HISTOPATHOLOGY: Pathology revealed marked verrucous epidermal hyperplasia with overlying parakeratosis and neutrophils in the stratum corneum. A lichenoid infiltrate at dermal-epidermal junction and necrotic keratinocytes were also seen. Negative HPV staining. DIFFERENTIAL DIAGNOSIS: Hypertrophic lichen planus (HLP) vs keratosis lichenoides chronica (KLC) vs less likely extensive verruca. LABORATORY: CBC and CMP within normal limits. Hepatitis C, syphilis, and HIV negative. DIAGNOSIS: The KLC and HLP present similarly histologically with hyperkeratosis and lichenoid infiltrate with interface change. Given clinical similarity, both are high in the differential in this case. KLC was favored due chronicity of individual lesions and due to the confluent parakeratosis and corneal neutrophils seen on pathology which are uncharacteristic of HLP. COURSE AND THERAPY: At time of presentation, he was on a regimen of acitretin 50 mg daily, betamethasone dipropionate ointment to the body, and tacrolimus 0.1% ointment to the face without significant improvement. Patient was continued on topical steroids and acitretin, and was also started on CellCept 500mg BID, later increased to 1000mg BID. DISCUSSION: HLP and KLC can present similarly with erythematous to violaceous hyperkeratotic papules and plaques. These are usually present on the lower extremities but may present more diffusely, including on the trunk and face. KLC is a rarer condition with a chronic course. Lesions can be pruritic and are typically in a reticular or linear pattern as seen in our patient. Oral and nail involvement, as in our patient, have been reported in about 20-30% of patients. KLC also may present with facial eruption similar to seborrheic dermatitis or rosacea. KLC may present at any age and has a slight male predominance. The etiology of this condition is unknown and given its similarity to other keratotic skin diseases as well as its rarity, it has not been well-studied. Although difficult to treat, oral retinoids such as acitretin and phototherapy have had some documented efficacy in treating KLC.HLP is a variant of lichen planus (LP) with a similar presentation of hyperkeratotic papules and plaques and usually a more chronic course. Lesions often are pruritic and koebnerization may play a role, causing more linear formations. Oral involvement, particularly Wickham striae, or nail changes may also be observed. Given longstanding inflammation, hypertrophic LP may develop malignant transformation to squamous cell carcinomas or keratoacanthomas. Treatments for HLP include topical or intralesional corticosteroids, methotrexate, metronidazole, cyclosporine, dapsone, azathioprine, and phototherapy. Acitretin and mycophenolate mofetil (CellCept) have shown efficacy in resistant HLP.https://scholarlycommons.henryford.com/merf2020caserpt/1002/thumbnail.jp

Acquired Acrodermatitis Enteropathica Secondary to Nutritional Deficiency from Alcoholism

History A 30-year-old white male with history of alcoholism complicated by cirrhosis who presented to an outside hospital with loss of consciousness after being found down in excrement and urine for an unknown amount of time. Patient’s course was complicated by pancreatitis, urosepsis, spontaneous bacterial peritonitis, and hepatic encephalopathy. Patient was transferred to Henry Ford Hospital for further management, and dermatology was consulted for a one-year history of pruritic rash on the arms and legs with concern for scabies. Examination: Patient appeared thin and malnourished. He was intubated with 2+ pitting edema to his mid-thighs. On his scalp, lateral neck, right abdomen, bilateral dorsal hands extending onto the dorsal forearms, dorsal feet, bilateral inner thighs and the entirety of his scrotum, the patient had well-demarcated pink plaques with cracked riverbed-appearing scale. There was no involvement of the axillae, interdigital finger or toe web spaces, mons pubis, or umbilicus. Course and therapy: Zinc level was found to be markedly decreased at 35 mcg/dL [normal: 70-150 mcg/dL], confirming a diagnosis of acrodermatitis enteropathica (AE). HIV 4th generation Ag/Ab was found to be nonreactive. Alkaline phosphatase was found to be elevated at 735 IU/L [normal: 44-147 IU/L]. Patient was treated with oral zinc replacement at 1.5 mg/kg/day as well as topical petrolatum as needed. Patient had improvement of his zinc level from 35 mcg/dL to within normal limits at 80 mcg/dL within three weeks. Discussion: Acrodermatitis enteropathica is a condition resulting from zinc deficiency characterized by sharply demarcated, symmetric erythematous patches and plaques with erosions and scale-crust in a peri-oral, genital, and acral distribution. Severe deficiency may be accompanied by alopecia, diarrhea, depression, hypogonadism, and immunosuppression. AE may be inherited as an autosomal recessive gene mutation in SLC39A4 leading to deficiency in an intestinal zinc transporter protein. This process often presents in neonates when weaning from breast milk to formula or in cases of low maternal breast milk zinc concentrations. AE, however, may also be acquired secondary to decreased nutritional intake or increased excretion/malabsorption leading to zinc deficiency. Risk factors for decreased nutritional zinc intake include limited resources, alcoholism, anorexia nervosa, vegan diets, and diets high in mineral-binding phytates. Risk factors for increased excretion include intestinal malabsorption, liver disease, renal disease, Crohn’s disease, cystic fibrosis, and sickle cell disease. Diagnosis is made based on clinical features and serum zinc level \u3c 60 mcg/dL. In our patient, his zinc level was found to be significantly lower at 35 mcg/dL. Typically in AE, given that serum alkaline phosphatase (ALP) is a zinc-dependent enzyme, a decreased ALP is expected. Our patient’s ALP was found to be elevated, likely secondary to concomitant pancreatitis. Appropriate treatment is with oral zinc replacement at 1-2 mg/kg/day of elemental zinc with cutaneous improvement expected in weeks to months. Extracutaneous improvement often shows within 24 hours of beginning treatment. Our patient was treated with 1.5 mg/kg/day of oral elemental zinc, with improvement in his cutaneous lesions seen within 3 weeks.https://scholarlycommons.henryford.com/merf2019caserpt/1086/thumbnail.jp

In-Depth Molecular Characterization of Mycobacterium tuberculosis from New Delhi – Predominance of Drug Resistant Isolates of the ‘Modern’ (TbD1−) Type

BACKGROUND: India has the highest estimated burden of tuberculosis in the world, accounting for 21% of all tuberculosis cases world-wide. However, due to lack of systematic analysis using multiple markers the available information on the genomic diversity of Mycobacterium tuberculosis in India is limited. METHODOLOGY/PRINCIPAL FINDINGS: Thus, 65 M. tuberculosis isolates from New Delhi, India were analyzed by spoligotyping, MIRU-VNTR, large deletion PCR typing and single nucleotide polymorphism analysis (SNP). The Central Asian (CAS) 1 _DELHI sub-lineage was the most prevalent sub-lineage comprising 46.2% (n = 30) of all isolates, with shared-type (ST) 26 being the most dominant genotype comprising 24.6% (n = 16) of all isolates. Other sub-lineages observed were: East-African Indian (EAI)-5 (9.2%, n = 6), EAI6_BGD1 (6.2%, n = 4), EAI3_IND, CAS and T1 with 6.2% each (n = 4 each), Beijing (4.6%, n = 3), CAS2 (3.1%, n = 2), and X1 and X2 with 1 isolate each. Genotyping results from five isolates (7.7%) did not match any existing spoligopatterns, and one isolate, ST124, belonged to an undefined lineage. Twenty-six percent of the isolates belonged to the TbD1+ PGG1 genogroup. SNP analysis of the pncA gene revealed a CAS-lineage specific silent mutation, S65S, which was observed for all CAS-lineage isolates (except two ST26 isolates) and in 1 orphan. Mutations in the pncA gene, conferring resistance to pyrazinamide, were observed in 15.4% of all isolates. Collectively, mutations in the rpoB gene, the katG gene and in both rpoB and katG genes, conferring resistance to rifampicin and isoniazid, respectively, were more frequent in CAS1_DELHI isolates compared to non-CAS_DELHI isolates (OR: 3.1, CI95% [1.11, 8.70], P = 0.045). The increased frequency of drug-resistance could not be linked to the patients' history of previous anti-tuberculosis treatment (OR: 1.156, CI95% [0.40, 3.36], P = 0.79). Fifty-six percent of all new tuberculosis patients had mutations in either the katG gene or the rpoB gene, or in both katG and rpoB genes. CONCLUSION: CAS1_DELHI isolates circulating in New Delhi, India have a high frequency of mutations in the rpoB and katG genes. A silent mutation (S65S) in the pncA gene can be used as a putative genetic marker for CAS-lineage isolates

Safety and Efficacy of Nail Products

Over the past several decades, the commercialization of nail cosmetics has increased. From nail polishes to artificial nails, different methods of nail beautification have become popularized. However, the impact of these products remains largely unknown. Governments have passed legislation in attempts to regulate nail cosmetics, but these regulations may not be adequate and are difficult to enforce. Knowledge of the safety and efficacy of nail products remains limited due to the relative dearth of literature published on the topic. This review serves to summarize and interpret the data available regarding common nail products and their safety and efficacy. Nail products such as nail polish, nail polish removers, and artificial nails have shown to have some adverse effects through case reports and studies. Harmful substances such as toluenesulfonamide-formaldehyde resin and methacrylates have been identified in commercial nail products, leading to several adverse effects, but in particular, allergic contact dermatitis. Exposure to substances such as acetonitrile found in removers may have more toxic and caustic effects, especially if ingested. In addition, for nail technicians there are negative effects linked with occupational exposure. Compounds used in nail products may become aerosolized and lead to asthma, eye and throat irritation, and even neurocognitive changes

Safety and Efficacy of Nail Products

Over the past several decades, the commercialization of nail cosmetics has increased. From nail polishes to artificial nails, different methods of nail beautification have become popularized. However, the impact of these products remains largely unknown. Governments have passed legislation in attempts to regulate nail cosmetics, but these regulations may not be adequate and are difficult to enforce. Knowledge of the safety and efficacy of nail products remains limited due to the relative dearth of literature published on the topic. This review serves to summarize and interpret the data available regarding common nail products and their safety and efficacy. Nail products such as nail polish, nail polish removers, and artificial nails have shown to have some adverse effects through case reports and studies. Harmful substances such as toluenesulfonamide-formaldehyde resin and methacrylates have been identified in commercial nail products, leading to several adverse effects, but in particular, allergic contact dermatitis. Exposure to substances such as acetonitrile found in removers may have more toxic and caustic effects, especially if ingested. In addition, for nail technicians there are negative effects linked with occupational exposure. Compounds used in nail products may become aerosolized and lead to asthma, eye and throat irritation, and even neurocognitive changes