Antiphospholipid syndrome in dermatology: An update

Antiphospholipid syndrome (APS) is characterized by the presence of antiphospholipid antibodies, recurrent thrombosis, and fetal loss. Antiphospholipid antibodies are a family of autoantibodies that recognize various combinations of phospholipids, phospholipid-binding proteins, or both. APS can occur in the absence of underlying or associated disease (primary APS) or in combination with other diseases (secondary APS). The exact pathogenic mechanism by which these antibodies cause thrombosis is not known; however, several hypotheses, such as activation of platelet and endothelial cells and interference with the coagulation system, have been proposed. Diagnosis is based on the presence of at least one clinical and laboratory criterion each, according to International Consensus Statement on preliminary classification criteria. However, APS can be diagnosed in individuals even in the absence of some of the classification criteria. Clinical manifestations involve different organs and systems such as the blood vessels, central nervous system, skin, kidneys, gastrointestinal tract, heart, and placenta. The unifying mechanism of all these manifestations is thrombosis, either arterial or venous. Skin manifestations are varied and although not included in the diagnostic criteria, may be the presenting feature of this syndrome. Therefore all dermatologists should investigate the possibility of APS when cutaneous findings are related to venous or arterial thrombosis. The risk of thrombosis cannot be predicted, and therefore treatment is not initiated until a thrombotic event occurs. Indefinite anticoagulation is prescribed once a thrombotic event occurs. Prognosis depends on the severity of the clinical manifestations and so, knowledge of the presentation of this disease is important for early detection and prompt treatment to prevent life-threatening consequences of this catastrophic disease process

Update on photoprotection

Photoprotection by sunscreens, clothing and glasses are important to protect the skin against the detrimental effects of sun exposure. In order to achieve complete protection, topical strategies must shield against the range of solar wavelengths ultraviolet A, ultraviolet B, infrared radiation that can damage the skin. To provide the necessary broad spectrum coverage, combinations of chemical and physical UV filters along with molecules that are capable of interfering with and/or preventing the deleterious effects of sunlight are discussed in this review

SCLE-LP OVERLAP SYNDROME

A 35-year-old female presented with scaly annular and pigmented lesions all over the body of 2 years duration. Her clinical features, histopathology, immunofluorescence findings and positive ANA and anti-Ro antibodies were suggestive of subacute cutaneous lupus erythematosus-lichen planus. We report this case because of its clinical rarity

Erythema elevatum diutinum in association with dermatitis herpetiformis

Erythema elevatum diutinum (EED) is a rare skin disease that initially presents as leucocytoclastic vasculitis and later resolves with fibrosis. Dermatitis herpetiformis is an autoimmune blistering disease characterized by granular deposits of immunoglobulin A (IgA) in dermal papillae. We report a rare association of these two disorders

Evaluation of the Xpert MTB Host Response assay for the triage of patients with presumed pulmonary tuberculosis: a prospective diagnostic accuracy study in Viet Nam, India, the Philippines, Uganda, and South Africa

Background: Non-sputum-based triage tests for tuberculosis are a priority for ending tuberculosis. We aimed to evaluate the diagnostic accuracy of the late-prototype Xpert MTB Host Response (Xpert HR) blood-based assay. Methods: We conducted a prospective diagnostic accuracy study among outpatients with presumed tuberculosis in outpatient clinics in Viet Nam, India, the Philippines, Uganda, and South Africa. Eligible participants were aged 18 years or older and reported cough lasting at least 2 weeks. We excluded those receiving tuberculosis treatment in the preceding 12 months and those who were unwilling to consent. Xpert HR was performed on capillary or venous blood. Reference standard testing included sputum Xpert MTB/RIF Ultra and mycobacterial culture. We performed receiver operating characteristic (ROC) analysis to identify the optimal cutoff value for the Xpert HR to achieve the target sensitivity of 90% or more while maximising specificity, then calculated diagnostic accuracy using this cutoff value. This study was prospectively registered with ClinicalTrials.gov, NCT04923958. Findings: Between July 13, 2021, and Aug 15, 2022, 2046 adults with at least 2 weeks of cough were identified, of whom 1499 adults (686 [45·8%] females and 813 [54·2%] males) had valid Xpert HR and reference standard results. 329 (21·9%) had microbiologically confirmed tuberculosis. Xpert HR had an area under the ROC curve of 0·89 (95% CI 0·86–0·91). The optimal cutoff value was less than or equal to –1·25, giving a sensitivity of 90·3% (95% CI 86·5–93·3; 297 of 329) and a specificity of 62·6% (95% CI 59·7–65·3; 732 of 1170). Sensitivity was similar across countries, by sex, and by subgroups, although specificity was lower in people living with HIV (45·1%, 95% CI 37·8–52·6) than in those not living with HIV (65·9%, 62·8–68·8; difference of 20·8%, 95% CI 13·0–28·6; p\u3c0·0001). Xpert HR had high negative predictive value (95·8%, 95% CI 94·1–97·1), but positive predictive value was only 40·1% (95% CI 36·8–44·1). Using the Xpert HR as a triage test would have reduced confirmatory sputum testing by 57·3% (95% CI 54·2–60·4). Interpretation: Xpert HR did not meet WHO minimum specificity targets for a non-sputum-based triage test for pulmonary tuberculosis. Despite promise as a rule-out test that could reduce confirmatory sputum testing, further cost-effectiveness modelling and data on acceptability and usability are needed to inform policy recommendations. Funding: National Institute of Allergy and Infectious Diseases of the US National Institutes of Health. Translations: For the Vietnamese and Tagalog translations of the abstract see Supplementary Materials section

Evaluation of the Xpert MTB Host Response assay for the triage of patients with presumed pulmonary tuberculosis: a prospective diagnostic accuracy study in Viet Nam, India, the Philippines, Uganda, and South Africa

BackgroundNon-sputum-based triage tests for tuberculosis are a priority for ending tuberculosis. We aimed to evaluate the diagnostic accuracy of the late-prototype Xpert MTB Host Response (Xpert HR) blood-based assay.MethodsWe conducted a prospective diagnostic accuracy study among outpatients with presumed tuberculosis in outpatient clinics in Viet Nam, India, the Philippines, Uganda, and South Africa. Eligible participants were aged 18 years or older and reported cough lasting at least 2 weeks. We excluded those receiving tuberculosis treatment in the preceding 12 months and those who were unwilling to consent. Xpert HR was performed on capillary or venous blood. Reference standard testing included sputum Xpert MTB/RIF Ultra and mycobacterial culture. We performed receiver operating characteristic (ROC) analysis to identify the optimal cutoff value for the Xpert HR to achieve the target sensitivity of 90% or more while maximising specificity, then calculated diagnostic accuracy using this cutoff value. This study was prospectively registered with ClinicalTrials.gov, NCT04923958.FindingsBetween July 13, 2021, and Aug 15, 2022, 2046 adults with at least 2 weeks of cough were identified, of whom 1499 adults (686 [45·8%] females and 813 [54·2%] males) had valid Xpert HR and reference standard results. 329 (21·9%) had microbiologically confirmed tuberculosis. Xpert HR had an area under the ROC curve of 0·89 (95% CI 0·86-0·91). The optimal cutoff value was less than or equal to -1·25, giving a sensitivity of 90·3% (95% CI 86·5-93·3; 297 of 329) and a specificity of 62·6% (95% CI 59·7-65·3; 732 of 1170). Sensitivity was similar across countries, by sex, and by subgroups, although specificity was lower in people living with HIV (45·1%, 95% CI 37·8-52·6) than in those not living with HIV (65·9%, 62·8-68·8; difference of 20·8%, 95% CI 13·0-28·6; p<0·0001). Xpert HR had high negative predictive value (95·8%, 95% CI 94·1-97·1), but positive predictive value was only 40·1% (95% CI 36·8-44·1). Using the Xpert HR as a triage test would have reduced confirmatory sputum testing by 57·3% (95% CI 54·2-60·4).InterpretationXpert HR did not meet WHO minimum specificity targets for a non-sputum-based triage test for pulmonary tuberculosis. Despite promise as a rule-out test that could reduce confirmatory sputum testing, further cost-effectiveness modelling and data on acceptability and usability are needed to inform policy recommendations.FundingNational Institute of Allergy and Infectious Diseases of the US National Institutes of Health.TranslationsFor the Vietnamese and Tagalog translations of the abstract see Supplementary Materials section