Rituximab Treatment for Paraneoplastic Pemphigus Associated with Follicular B-Cell Lymphoma: A Case Report and Review of Treatment Outcome

Objective: To report a case of paraneoplastic pemphigus (PNP), a rare disease, associated with follicular B-cell lymphoma. Treatment outcomes of PNP associated with follicular B-cell lymphoma following rituximab treatment were also reviewed in this article. Case presentation: We reported a PNP patient presenting with intractable stomatitis and erythema multiforme-like lesions. Skin biopsy from erythema multiforme-liked lesion revealed interface dermatitis and necrotic keratinocytes. Direct immunofluorescence demonstrated immunoglobulin G deposition at intercellular space, as well as complement deposition at dermo-epidermal junction. Indirect immunofluorescence using rat bladder substrate was helpful in confirming the diagnosis of PNP. Further investigations revealed an underlying disease of follicular B-cell lymphoma. He was treated with rituximab and systemic corticosteroids. Improvement of mucocutaneous lesions and lymphoma were noted. Nevertheless, he developed hospital-acquired pneumonia and died from septic shock shortly after receiving conventional chemotherapy. His survival duration was approximately 8 months after diagnosis of PNP. Conclusion: It seemed that rituximab might provide promising benefits for mucocutaneous lesions in PNP patients associated with follicular B-cell lymphoma

Organomegalies as a predictive indicator of leukemia cutis in patients with acute myeloid leukemia.

BackgroundLeukemia cutis (LC) is an extramedullary acute myeloid leukemia (AML) infiltrate. No previous study has described the clinical characteristics and outcomes of Thai patients diagnosed with AML with LC.Materials and methodsWe conducted a 7-year retrospective case-control study on Thai AML patients at Siriraj Hospital from November 2013 to July 2020. Patients were divided into LC and non-LC groups. Initial clinical presentations and laboratory findings were examined to identify LC-associated factors. Overall survival (OS) and relapse-free survival (RFS) were assessed. Pathological tissues underwent re-evaluation to validate the LC diagnoses.ResultsThe study included 159 patients in a 2:1 ratio (106 non-LC and 53 LC). The LC group had a mean ± SD age of 54.3 ± 15.5 years; females were predominant. Three-fifths of the LC patients had intermediate-risk cytogenetics; 20.4% had an adverse risk, and 10.2% had a favorable risk. Most were classified as AML-M4 and AML-M5. Leukemic nodules were the primary finding in 58.5% of the cases, mainly on the legs. In the multivariate analysis of predictive factors associated with LC, organomegalies, specifically hepatomegaly, and lymphadenopathy, remained significant factors associated with LC [OR 4.45 (95%CI 1.20, 16.50); p = 0.026 and OR 5.48 (95%CI 1.65, 18.20); p = 0.005], respectively. The LC group demonstrated a significantly reduced OS (log-rank test p = 0.002) (median OS of 8.6 months vs. 32.4 months). RFS was considerably lower in the LC group (log-rank test p = 0.001) (median duration of 10.3 months vs. 24.4 months in the non-LC).ConclusionsAML patients who developed LC tended to experience notably poorer prognoses. Therefore, it is imperative to consider aggressive treatment options for such individuals. The presence of organomegalies in AML patients serves as a strong predictor of the possible occurrence of LC when accompanied by skin lesions

Wood’s Lamp Examination: Evaluation of Basic Knowledge in General Physicians

Background: Wood’s lamp examination is a useful diagnostic test in many dermatological disorders. However, there was limited data on knowledge of physicians about this tool. Objective: To evaluate basic knowledge of physicians on Wood’s lamp and its applications. Methods: The study used questionnaires in Thai general physicians who attended the 2013 Dermatology Annual Meeting. The questionnaire composed of a picture of a Wood’s lamp instrument and two open-end questions including 1) What is the name of this device? 2) Which diseases can this device help to make the diagnosis? Results: Eighty-two physicians enrolled in this study. Only 55 physicians (67.1%) answered the name of a Wood’s lamp correctly. There were 29 out of 55 physicians (52.7%) knew at least one application of Wood’s lamp. About half did not know any applications. Tinea versicolor, followed by melasma, tinea captitis, erythrasma, acne, porphyria, and vitiligo, respectively were the common applications that most physicians answered. Conclusion: This study showed around two-third of physicians know Wood’s lamp, but only half of them were knowledgeable about its’ application in dermatoses. Education regarding Wood’s lamp and application should be emphasized more in physicians to assist in dermatologic diagnoses

Histopathological Diagnosis of Alopecia Clinically Relevant to Alopecia Areata

Objective: To study the histopathological diagnosis of alopecia clinically relevant to AA and to compare the histopathology between acute and chronic AA divided by time to onset at three and six months. Materials & Methods: We conducted a cross-sectional study of 113 patients with typical manifestation of AA. Two scalp biopsies were done horizontally and vertically to confirm diagnosis. Histological findings of AA in the acute group were subsequently compared with the chronic group.  Results: Of the 113 eligible patients, 109 (96.5%) were pathologically diagnosed with AA. Other diagnoses included lichen planopilaris, lupus panniculitis, and unspecified scarring alopecia. The percentage of terminal telogen hairs in the acute group was significantly higher than the chronic group (mean % anagen: % telogen ratio = 21.2%:78.8% vs. 36.0%:64.0%; p = 0.016), while the chronic group had a significantly higher number of follicular streamers (mean ± SD; 2.5 ± 2.2 vs. 3.7 ± 2.6; p = 0.023). The number of vellus hairs significantly increased in the acute group at the six-month onset (p = 0.006). The number of nanogen hairs also increased significantly in the chronic group at both the three- and six-month onset (p = 0.020 and p = 0.007). Conclusion: Typical manifestations of AA are not always diagnosed as AA. Acute AA has more terminal telogens and vellus hairs, while chronic AA has more follicular streamers and nanogen hairs

Thermal Response of In Vivo Human Skin to Fractional Radiofrequency Microneedle Device

Background. Fractional radiofrequency microneedle system (FRMS) is a novel fractional skin resurfacing system. Data on thermal response to this fractional resurfacing technique is limited. Objectives. To investigate histologic response of in vivo human skin to varying energy settings and pulse stacking of a FRMS in dark-skinned subjects. Methods. Two female volunteers who were scheduled for abdominoplasty received treatment with a FRMS with varying energy settings at 6 time periods including 3 months, 1 month, 1 week, 3 days, 1 day, and the time immediately before abdominoplasty. Biopsy specimens were analyzed using hematoxylin and eosin (H&E), Verhoeff-Van Gieson (VVG), colloidal iron, and Fontana-Masson stain. Immunohistochemical study was performed by using Heat Shock Protein 70 (HSP70) antibody and collagen III monoclonal antibody. Results. The average depth of radiofrequency thermal zone (RFTZ) ranged from 100 to 300 μm, correlating with energy levels. Columns of cell necrosis and collagen denaturation followed by inflammatory response were initially demonstrated, with subsequent increasing of mucin at 1 and 3 months after treatment. Immunohistochemical study showed positive stain with HSP70. Conclusion. A single treatment with a FRMS using appropriate energy setting induces neocollagenesis. This wound healing response may serve as a mean to improve the appearance of photodamaged skin and atrophic scars

Evaluation of Hair Follicle Counts of Occipital Scalp Biopsies from Male Hair Transplant Patients in Thailand

Objective: To evaluate the average hair follicle count from the occipital scalp of Thai males with AGA who were candidates for hair transplantation. Materials & Methods: A cross-sectional study of 47 male with AGA undergoing hair transplantation surgery was conducted.  The 4-mm punch biopsies from the occipital scalp were evaluated for hair count parameters. The results were compared to prior studies. Results: The average counts of total hair follicles and the density of hair follicle per square millimeter were 18.6±1.2, and 1.5±0.1, respectively. The terminal-to-vellus ratio was 11.1, and the percent ratio of anagen-to-telogen ratio was 91.9:8.1. The hair count number is significantly lower than other ethnicities including Thais in general population (P < 0.001), but greater than the Thai males with AGA in the previous study. (P < 0.001). Conclusion: Our study showed a lower average hair density as compared to the other normal Asian population.  The total hair count in the occipital area from this study is less when compared to the previous studies conducted in Thai normal controls but higher than those with more advanced AGA. This result supported the evidence of hormonal effect involving the occipital scalp of male AGA.