Scabies presenting with bullous pemphigoid-like lesions

A wide range of clinical manifestations may be seen in scabies, from classic pruritic papules and burrows to secondary features such as impetigo. Bullus lesions are a less frequent. Twenty cases of scabies presenting with bullae have been reported so far in the medical literature. Differentiating this subtype of scabies from the immunobullous disease bullus pemphigoid is a diagnostic challenge. A 42-year-old man was referred to our dermatology outpatient clinic with 3-month history of severe pruritus and tense blisters affecting mainly the lower trunk, arms and legs. An initial biopsy was suggestive for bullous pemphigoid. Close physical examination revealed small excoriated papules and a few burrows on borders of the hands and wrists. Skin scraping of the lesions on wrists was positive for Sarcoptes scabiei. Another biopsy specimen from a recent blister revealed subepidermal bullae with fibrin and inflammatory cells, particularly eosinophils. Direct immunofluorescence exam was negative. The patient was treated with lindane lotion followed by crotamiton cream with near complete resolution of the lesions. Scabies must be considered in patients presenting with recent onset of unexplained pruritic bullous lesions. Biopsy and immunofluorescence studies together with skin scrapings for Sarcoptes scabiei could help to differentiate these cases from bullous pemphigoid. Antiscabietic treatment results in resolution of bullous lesions in the affected patients. © 2006 Dermatology Online Journal

Skin tag as a cutaneous marker for impaired carbohydrate metabolism: A case-control study

Background: Skin tags are common benign skin tumors usually occurring on the neck and major flexors of older people. A possible association with impaired carbohydrate metabolism has been suggested in previous studies, but the results are not conclusive. Objective: To investigate and compare the prevalence of diabetes and impaired glucose tolerance (IGT) in patients with skin tag and a control group. Patients and methods: A case-control study was conducted in individuals over 15 years old, comparing cases (n=104) with at least three skin tags and age-, sex-, and body mass index (BMI)-matched controls (n=94) without skin tag. Cases and controls were recruited from patients consecutively seen at an academic outpatient dermatology clinic. All patients underwent a standard 2-h oral glucose tolerance test with 75 g glucose. Results: Patients with skin tag had higher frequency of diabetes than the control group (23.07 vs. 8.51, �2 -test, P=0.005). The difference in the frequency of IGT was not significant (13.46 vs. 10.63, �2 -test, P=0.543). There was a positive correlation between the total number of skin tags and the mean fasting plasma glucose (Pearson correlation, r=0.260, P=0.031); patients with more than 30 skin tags were particularly at an increased risk of diabetes (52.0). No correlation was found between the number of skin tags and BMI. We did not find any correlation between the anatomical localization of skin tags and impaired carbohydrate metabolism, except for skin tags under the breast in women. Conclusion: These results showan increased risk of diabetes mellitus in patients with multiple skin tags. With regard to the importance of early diagnosis of diabetes, we recommend a high level of suspicion for impaired carbohydrate metabolism in patients with skin tag. © 2007 The International Society of Dermatology

Clinical presentation and etiologic factors of hirsutism in premenopausal Iranian women

Background: Hirsutism is a common clinical condition with different etiologies. Many of these patients have frank or subclinical abnormalities in the adrenal and ovarian steroidogenesis. The disease may be associated with other clinical signs of hyperandrogenism. The objective of this study was to investigate the clinical features of hirsutism and its etiologic factors in premenopausal Iranian women. Methods: In a cross-sectional study, 790 consecutive premenopausal women referred to the dermatology Clinics of Hazrat-e Rasool and Firoozgar University Hospitals and three private dermatology clinics during 2001-2003 with the clinical diagnosis of hirsutism were studied. All patients underwent detailed clinical assessment and transabdominal ultrasonography of the ovaries. Endocrinologic work-up was performed for 285 patients. Results: Hirsutism was mild in 65, moderate in 32.5, and severe in 2.5 of the patients. Positive family history was found in 56.2. Hormonal studies revealed some abnormalities in 35.2 of the patients. Coexisting medical conditions included acne in 70 of the patients, menstrual irregularity in 38.6, androgenic alopecia in 21.3, obesity in 6.5, acanthosis nigricans in 4.9, and diabetes in 0.6 of the patients. Etiology of hirsutism was identified as polycystic ovary syndrome (62.53), idiopathic (35.19), congenital adrenal hyperplasia (0.38), prolactinoma (0.13), and undetermined (1.77). Polycystic ovary syndrome was diagnosed more frequently in women with menstrual irregularity than eumenorrheic patients (97.70 vs. 40.41, P < 0.001). Conclusion: Hirsute patients frequently have either elevated androgen levels or clinical conditions associated with hyperandrogenemia. Eumenorrhea does not rule out endocrine abnormality and particularly polycystic ovary syndrome which is a common cause of hirsutism. We recommend performing endocrinologic work up, investigation of coexisting hyperandrogenic. states, and evaluation of polycystic ovary syndrome in all patients with hirsutism

Challenging script concordance test reference standard by evidence : Do judgments by emergency medicine consultants agree with likelihood ratios?

Acknowledgements We would like to acknowledge Dr. Amir Nejati for his contributions in collecting data for this study. Sources of funding This study was the M.D. thesis of SK and was funded by Iran University of Medical Sciences. The authors have not received fund from any other source.Peer reviewedPublisher PD

Molecular characterization of the Iranian isolates of Giardia lamblia: Application of the glutamate dehydrogenase gene

Background: This study was conducted to determine of molecular epidemiology of the Giardia lamblia by PCR-RFLP method in Tehran, capital of Iran. Methods: Thirty eight stool samples were randomly selected from 125 patients diagnosed with giardiasis using microscopy in Tehran. DNA extraction of some samples were performed by phenol/chloroform/isoamyl alcohol method and to raise the sensitivity of the PCR assay, the genomic DNA of the others were extracted using glass beads and the QIAamp Stool Mini Kit in order to effectively remove the PCR inhibitors. A single step PCR-RFLP assay, targeting the glutamate dehydrogenase (gdh) locus, was used to differentiate within and between assemblages A and B that have been found in humans. Results: Of the 38 isolates, 33 samples (87) were found as G. lamblia (genotype AII), 3 (7.8) belonged to assemblage B, genotype BIII, the mixed of genotype AII and B were detected only in two samples (5.2). Conclusions: PCR-RFLP is a sensitive and powerful analytical tool that allows effective genotype discrimination within and between assemblages at targeting gdh gene, and makes it possible to identify the presence of mixed genotypes. Our data suggest that there is an anthroponotic origin of the infection route, assemblage A group II, in Tehran so it seems that the main reservoir of Giardia infection is humans in the area studies

Multiple Loci within the Major Histocompatibility Complex Confer Risk of Psoriasis

Psoriasis is a common inflammatory skin disease characterized by thickened scaly red plaques. Previously we have performed a genome-wide association study (GWAS) on psoriasis with 1,359 cases and 1,400 controls, which were genotyped for 447,249 SNPs. The most significant finding was for SNP rs12191877, which is in tight linkage disequilibrium with HLA-Cw*0602, the consensus risk allele for psoriasis. However, it is not known whether there are other psoriasis loci within the MHC in addition to HLA-C. In the present study, we searched for additional susceptibility loci within the human leukocyte antigen (HLA) region through in-depth analyses of the GWAS data; then, we followed up our findings in an independent Han Chinese 1,139 psoriasis cases and 1,132 controls. Using the phased CEPH dataset as a reference, we imputed the HLA-Cw*0602 in all samples with high accuracy. The association of the imputed HLA-Cw*0602 dosage with disease was much stronger than that of the most significantly associated SNP, rs12191877. Adjusting for HLA-Cw*0602, there were two remaining association signals: one demonstrated by rs2073048 (p = 2×10−6, OR = 0.66), located within c6orf10, a potential downstream effecter of TNF-alpha, and one indicated by rs13437088 (p = 9×10−6, OR = 1.3), located 30 kb centromeric of HLA-B and 16 kb telomeric of MICA. When HLA-Cw*0602, rs2073048, and rs13437088 were all included in a logistic regression model, each of them was significantly associated with disease (p = 3×10−47, 6×10−8, and 3×10−7, respectively). Both putative loci were also significantly associated in the Han Chinese samples after controlling for the imputed HLA-Cw*0602. A detailed analysis of HLA-B in both populations demonstrated that HLA-B*57 was associated with an increased risk of psoriasis and HLA-B*40 a decreased risk, independently of HLA-Cw*0602 and the C6orf10 locus, suggesting the potential pathogenic involvement of HLA-B. These results demonstrate that there are at least two additional loci within the MHC conferring risk of psoriasis

Expression of p53 in aggressive and non-aggressive histologic variants of basal cell carcinoma

Basal cell carcinoma (BCC) generally has an indolent course but a subgroup of BCCs tends to grow aggressively into deep tissues and even metastasize. Although studies have shown a positive correlation between mutations in the tumor suppressor gene p53 and aggressive behavior in epithelial tumors, the results for BCC are conflicting. We aimed to determine whether there is any relationship between p53 expression in BCC and histopathologic subtype of the tumor.Thirty-three formalin-fixed BCC tissue samples were examined at Hazrat-e Rasool University Hospital, Tehran, Iran, from March 2003 to April 2004. Tumors were categorized as aggressive (infiltrative or morpheic) and non-aggressive (nodular or superficial) based on histopathological examination of hematoxylin and eosin sections. p53 expression was demonstrated by immunohistochemical staining using the monoclonal anti-p53 antibody (PAb240) and results were reported using a semiquantitative score. Expression of p53 was compared between aggressive and non-aggressive tumors. All of the 11 aggressive tumors exhibited nuclear staining in more than 50 of the tumor cells. In the 22 non-aggressive tumors, less than 50 of cells showed positive staining. p53 immunoreactivity was significantly higher in aggressive BCCs than non-aggressive ones (x 2 test; p &lt; 0.01). No correlation was found between p53 expression and the age of the patient or site of the tumor. History of childhood radiotherapy correlated positively with higher levels of p53 expression. We conclude that expression of p53 might be used as a marker to predict the aggressiveness of BCCs

Oral isotretinoin for acne, adjusting treatment according to patient's response.

BACKGROUND: Oral isotretinoin is an established effective therapy for acne. No published data is available on the efficacy and side effects of this drug in Iranian patients. PATIENTS AND METHODS: A total of 132 acne patients with a mean age of 22.9 +/- 6.2 years were treated with oral isotretinoin (Roaccutane) and followed-up from 1999 through 2005. Each patient was started with a dose of 0.75 mg/kg per day until all active lesions healed, followed by a maintenance dose of 20 mg/kg per day for one more month. Laboratory tests were done at monthly intervals. Evaluation of clinical response was based on Leeds technique. Patients were followed-up for a mean period of 4.4 years. RESULTS: Most of the patients had severe nodulocystic acne involving both trunk and face. Treatment was continued for 6.6 +/- 2.5 months with a cumulative dose of 111.5 mg/kg +/- 33.9. The mean final improvement rate was 96.7 (95 CI, 84.9 to 108.5). There was no correlation between improvement rate and age, sex, duration of acne, length of treatment, or cumulative dose. Side effects were generally mild and treated conservatively. In the follow-up, period 18.35 experienced relapse after a mean interval of 1.28 years, 9.17 required a second course of isotretinoin, and only one case needed 3 courses of treatment. CONCLUSION: Isotretinoin is an effective and safe treatment for acne in Iranian patients. Starting treatment with a high dose and modifying the length of treatment based on the therapeutic response in each patient, might lead to a rapid and good response rate with minimal side effects