Easy question in principle, but with a bit of a catch. If you have the right intuition when you read it and go straight to what you think, you will probably get it right. The problem is option 4, which can confuse us. Let's see: we have a blow to the right eye area, with a hematoma on the eyelid. So far so normal. The problem is that retinal hemorrhages appear not only in that eye (which in itself is rare, because an external blow to the eye in a child rarely causes bleeding in the retina), but also in the other eye. Therefore, something other than the blow has caused hemorrhages in both retinas. Then we are told that the child seems drowsy and with little tone. Here we already have the two keys; we have to suspect what is not mentioned in the answers, but which is what the child has: the shaken baby syndrome (shaken baby syndrome). Characteristic of this syndrome are bilateral retinal hemorrhages, cerebral edema and subdural hematoma. There may also be fracture of long bones and other problems. Numbness and hypotonia allow us to suspect intracranial complications. The cause of shaken baby syndrome is almost always abuse, so the answer is 1. Options 2 and 3 are easy to rule out: nothing indicates perforating trauma, and it does not explain the hemorrhages in the other eye. And the berlin edema is an edema of the macula and appears as a whitish lesion, which is not described in the statement. The catch is option 4. Purstcher's retinopathy can also appear in the context of the child of the shaken child, and therefore occur in the case of child abuse. Seeing these two partly related questions, we may hesitate. However, if we read answer 4 carefully, it does not tell us that if there is child maltreatment Purstcher can occur. It states that the picture described above (intraretinal hemorrhages, without other findings) is characteristic of Purstcher's angiopathy. It is not. In Purstcher's there are hemorrhages, but also cottony exudates and edema. If there are only hemorrhages, it's not Purstcher's. Here's the messy bit, but it's really well worded. If he had a Purstcher it could also be for child abuse, but he doesn't.

Easy question in principle, but with a bit of a catch. If you have the right intuition when you read it and go straight to what you think, you will probably get it right. The problem is option 4, which can confuse us. Let's see: we have a blow to the right eye area, with a hematoma on the eyelid. So far so normal. The problem is that retinal hemorrhages appear not only in that eye (which in itself is rare, because an external blow to the eye in a child rarely causes bleeding in the retina), but also in the other eye. Therefore, something other than the blow has caused hemorrhages in both retinas. Then we are told that the child seems drowsy and with little tone. Here we already have the two keys; we have to suspect what is not mentioned in the answers, but which is what the child has: the shaken baby syndrome (shaken baby syndrome). Characteristic of this syndrome are bilateral retinal hemorrhages, cerebral edema and subdural hematoma. There may also be fracture of long bones and other problems. Numbness and hypotonia allow us to suspect intracranial complications. The cause of shaken baby syndrome is almost always abuse, so the answer is [HIDDEN]. Options 2 and 3 are easy to rule out: nothing indicates perforating trauma, and it does not explain the hemorrhages in the other eye. And the berlin edema is an edema of the macula and appears as a whitish lesion, which is not described in the statement. The catch is option 4. Purstcher's retinopathy can also appear in the context of the child of the shaken child, and therefore occur in the case of child abuse. Seeing these two partly related questions, we may hesitate. However, if we read answer 4 carefully, it does not tell us that if there is child maltreatment Purstcher can occur. It states that the picture described above (intraretinal hemorrhages, without other findings) is characteristic of Purstcher's angiopathy. It is not. In Purstcher's there are hemorrhages, but also cottony exudates and edema. If there are only hemorrhages, it's not Purstcher's. Here's the messy bit, but it's really well worded. If he had a Purstcher it could also be for child abuse, but he doesn't.

A parent comes to the emergency department with his 2-year-old son because he reports that he has hit his right eye while playing. Indeed, a hematoma is observed on the right eyelid, apparently of no importance. The fundus examination showed intraretinal hemorrhages not only in the eye referred by the parents but also in the other eye. It is noteworthy that the child appears drowsy and with little tone. Which of the following statements should you consider regarding this clinical picture?

It is a highly suggestive history of child abuse.

It is the normal evolution of a non-perforating intraocular trauma.

The most likely diagnosis is Berlin edema.

It is the characteristic picture of Purstcher's traumatic retinal angiopathy.

History of head trauma in a 6-year-old boy: maybe more than meets the eye (and head).

It is spring and you are meeting for the first time, Eddie, a recently turned 6-year-old boy who moved to the area in September of the previous year and is here for his 6-year-old health maintenance visit. Eddie's mother is concerned that although he is "only" in kindergarten, he is not retaining any information at school. His mother reports he knew some of his letters before kindergarten. Currently, when he is trying to write a word, for example, "daddy" he will need to ask his mother: "what letter is the letter D?" Before kindergarten, he knew his numbers 1 to 10. At times now, Eddie will forget these numbers. For example, "if he is counting he will forget what comes after 4 and what comes after 9." Mother reports he will start crying for no apparent reason and if she asks why, he will say "I don't know why." Mother is worried that Eddie is sad, although she denies suicidal ideation. She reports he used to like making noise with other kids, and now he cannot stand when the children are noisy. Eddie will comment he does not want to go to school because the kids make lots of noise and his head hurts. He complains of headaches as often as 2 to 3 times a month. She next states, "This was not an issue before his head trauma." At this point, she reveals to you that in August, before the family relocated, Eddie fell from a 7-foot deck onto concrete while playing. He struck his head on the left side and lost consciousness for several seconds until shaken awake. He was nauseous and disoriented initially but without emesis or incontinence. He was taken to the local emergency department where he was admitted for 1 day and diagnosed with closed head injury, left frontal epidural hematoma, and question of postconcussive syndrome. Eddie has gone back to see the neurosurgeon twice over the last 6 months for scheduled visits and since the accident has had no further treatment.Eddie's mother reports that before the accident, if she read him a story from a book, he could remember the details from the story. Currently, he does not have good memory recall. Before the trauma, he did not attend a preschool program but stayed home with his mother full time. Eddie's first formal schooling has been kindergarten this year. When they moved, the neurosurgeon recommended he start school at the end of September given his head trauma in August. He had a recent computed tomography completed 3 months ago showing the epidural hematoma had completely resolved and the study was otherwise normal. His mother reports he had an evaluation the spring before the accident for a kindergarten screening test and was reported as "excellent." Eddie's birth and medical history are otherwise unremarkable except for some seasonal allergies. He has not had a loss in language skill, although his mother reports he did not speak during his hospitalization. He would just stare and nod his head if someone would ask him a question. No family history of any learning or behavioral difficulties on either side of the family. Eddie has 2 older brothers, 10 and 7 years of age, with no learning issues.What would you do next?

[Ocular pathology of child abuse].

In spite of a growing awareness in the population most cases of child abuse remain probably undetected. Ocular changes in this syndrome are manifold. Sometimes ocular signs can help to substantiate the suspicion of child abuse. On the other hand the ophthalmologist may be the first physician to be contacted. Thus, he plays an important role in diagnosis. Though there are a couple of clinical descriptions morphological data are almost completely missing in the German literature. A two-year-old girl died two days after severe abuse because of widespread intracranial hemorrhages with brain stem insufficiency. At autopsy both eyes were enucleated and sent for histological investigation. The anterior segments were unremarkable. Multiple hemorrhages were found in the inner retina bilaterally. Moreover there were preretinal, intrachoroidal, intrascleral (area of the circle of Zinn-Haller) and subdural hemorrhages. One eye showed a circular, perimacular fold of the central retina and a hemorrhagic retinoschisis. Intraretinal hemorrhages alone are typical though not pathognomonic for the "battered-child syndrome". However, in combination with a crater-like appearance of the central retina, a hemorrhagic retinoschisis; and intrascleral hemorrhages in the area of the circle of Zinn-Haller they suggest child abuse almost with certainty. The pathogenic mechanisms leading to the observed fundus changes lack definite clarification. The date of violence which is essential for legal prosecution can be difficult to evaluate on morphological grounds alone.

[Avulsion of the optic nerve: two case studies].

Avulsion of the optic nerve is a rare and serious injury. The authors report two cases of optic nerve avulsion. The first one concerns a 5-year-old boy who presented ocular trauma after falling on the handlebars of a bicycle. His visual acuity was light perception in the right eye, and his right pupil was unresponsive to light. The anterior segment was normal. The ophthalmoscopic examination showed a total separation of the optic nerve head from the sclera with peripapillary hemorrhage. The second case concerns a 30-year-old man who was hit in the right eye with a stick. On admission, he had no light perception in the right eye, a right afferent pupil defect, a small laceration of the right lower eye lid and no abnormalities on the anterior segment. The fundus examination showed a mild vitreous hemorrhage. Ocular ultrasonography showed vitreous hemorrhage coming directly from the optic nerve head in a mushroom pattern. A CT scan of the orbit revealed a thickened optic nerve. Color Doppler ultrasonography documented slowing of blood flow in the central retinal artery. The two patients received 1 mg/kg/day of prednisone for 2 weeks. No improvement was noted. Optic nerve avulsion is often caused by sudden and forceful rotation of the eye with tearing of the optic nerve as it exits the globe. The nerve can be partially or totally avulsed. The prognosis is usually poor.

Shaken baby syndrome: intending to harm or attempting to help?

To describe the role of ophthalmologists in shaken baby syndrome evaluation. Case report. A 3.5-month-old girl was admitted to the Pediatrics Clinic with lethargy. The mother, who brought in the baby, claimed that the baby had fallen from her cradle 6 hours ago. Clinical examination showed signs of head injury. Ophthalmologic examination was requested and revealed extensive retinal hemorrhages bilaterally covering the whole fundus, and retrohyaloid hematoma in the right eye. Computerized tomography neuroimaging documented large subdural hematomas exerting force on the brain parenchyma. The sum of the results of the clinical and neuroimaging examination-retinal hemorrhages and subdural hematomas-was indicative of violent shaking of the baby. Coronal evaluation was unable to determine whether the baby was abused by her parents or whether she was accidentally hurt. Ophthalmologic examination is necessary to document shaken baby syndrome since it reveals the retinal hemorrhages which together with the neuroimaging findings are almost always present in such cases. However, even when all the signs of shaken baby syndrome are present, it is difficult and sometimes destructive for a parent to be falsely accused of abusing his or her own child.

Parents seek early intervention services for a two-year-old without autism.

Sam is a 27-month-old boy who you have followed since birth. He lives with his parents in a small resort town approximately 90 miles outside a major city. Both his parents are professionals in their late 30s and have been highly involved in his care since birth. At the 12-month visit, they were concerned about his difficulty regulating. He was not sleeping through the night and had significant difficulty with baths. His physical examination and growth were normal. His eye contact was good, although it was difficult to see him smile. He had 1 or 2 words and was beginning to walk independently.At the 15-month checkup, they continued to be concerned about his poor regulation. He napped sporadically, and he was very difficult to take out on errands as he did not like his car seat. He now had approximately 10 single words, was using his fingers to point, and very clearly waved "bye bye" as soon as you entered the room.At the 18-month checkup, they state that he has not yet learned the word "no." He will follow a 1-step command when he wants to but now has 15 single words without any combinations. He points for his needs and to show them something. He has become increasingly "shy" around strangers and prefers to play with one other child as opposed to a larger group. He does not like loud noises and prefers to go barefoot constantly. His physical examination was again normal as was his growth. He is referred for a full hearing evaluation, which is also normal. The family was referred to early intervention, and he began receiving speech and language therapy and occupational therapy for his sensory challenges as well as a play group.At the 24-month checkup, his language continued to consist of single words-now approximately 30. When the parents do not understand what he wants, he will often tantrum and has started banging his head on the floor when frustrated. He has no repetitive behaviors and is starting to demonstrate imaginative play. Bath time has becoming increasingly challenging because he does not like the sensation of soap and the water temperature must be "just right." You refer the child to a Developmental and Behavioral Pediatrician for evaluation and at 28 months he is seen. During his testing visit, he had decreased eye contact and followed his own agenda but improved significantly as testing progressed. As he got more comfortable, he began making good eye contact, social referenced, and exhibited joint attention with his parents and the examiner. He did not meet criteria for an autism spectrum disorder or specifically pervasive developmental disorder-not otherwise specified (PDD-NOS). He was given a diagnosis of mixed receptive and expressive language delay and disruptive behavior disorder with sensory processing problems.The parents come to you a month after their evaluation visit asking you to give him a "listed diagnosis of PDD-NOS" that could be removed when he turns 3 years so that he may qualify for increased hours of services-up to 15 hours per week-as well as applied behavioral analysis therapy. A behavioral therapist through early intervention has told the family that he would benefit from this increased intervention, specifically applied behavioral analysis but the only way he can receive it is with a "medical diagnosis" on the autism spectrum. What do you do next?

List of 2004 This American Life episodes

Act 3: Admissions – Katia Dunn Episode 271 - "Best Interests" Act 1: I'd Rather Not – Ira Glass Act 2: Exodus of One – Alex Kotlowitz Episode 272 - "Big Tent" Show description: On the Republican Party during the campaign season preceding the U.S. presidential election, 2004 Act 1: Pink Elephant – Patrick Howell Act 2: Right and Righter – Alex Blumberg Act 3: Indecent Proposal – Shane DuBow Act 4: It's My Party Episode 273 - "Put Your Heart In It" Show description: On motivation and passion, especially regarding career choices Act 1: Farm Eye for the Farm Guy – George DeVault Act 2: Diary of a Long-shot – Teal Krech Act 3: Contrails of My Tears – Brett Martin Episode 274 - "Enemy Camp '04" Show description: On the Iraq war and the War on Terrorism (a discussion with James Fallows and Richard Perle), the Roman Catholic Church sex abuse scandal, and parasites Act 1: Our Own Worst Enemy? – Ira Glass Act 2: Confession – Carl Marziali Act 3: Blood Agent – Ira Glass

Purtscher-like retinopathy following valsalva maneuver effect: case report.

Purtscher's retinopathy is a rare condition that is noted in cases related to various types of trauma. The characteristic finding in the fundus is the presence of multiple Purtscher flecken. Purtscher-like retinopathy has a similar presentation in the fundus, but without an association with trauma. A 43-year old Malay man presented with a sudden onset of central foggy vision in the left eye after holding his breath for two minutes while catching a falling object. It was not associated with floaters, flashes of light, or head trauma. His vision in the right eye was 6/6, and in his left eye it was finger counting. He had bilateral temporal sub-conjunctival hemorrhages. An examination of his left fundus revealed multiple white cotton wool spots and dot-blot retinal hemorrhages with diffuse retinal edema at the posterior pole. His right fundus was noted to have only mild temporal peri-papillary edema associated with a few dot-blot hemorrhages. Fundus fluorescein angiography showed good arterial perfusion and no evidence of leaking or neo-vascularization. A diagnosis of Purtscher-like retinopathy was made, and the patient was treated with indomethacin tablets for six weeks. At his six-week follow-up examination, his left eye visual acuity had improved to 6/12. His bilateral sub-conjunctival hemorrhage had resolved. His left fundus showed residual multiple cotton wool spots and reduced retinal edema. Treatment with non-steroidal anti-inflammatory drugs seems to be effective in reducing edema in patients with Purtscher-like retinopathy.

Retinal Hemorrhages: Abusive Head Trauma or Not?

Abusive head trauma is an important cause of morbidity and mortality in infants and young children. Retinal hemorrhages (RHs) are frequently seen, particularly during dilated eye examination of these children. This review focuses on the evaluation of children with RH, with emphasis on the differential diagnosis, pathophysiology, and distinguishing features of RHs due to abusive head trauma. Many causes exist for RHs in infants and children. Most medical and accidental traumatic causes result in a pattern of RH that is nonspecific and not typical of the pattern and distribution of RHs seen in children with abusive head trauma. In children with intracranial hemorrhage and concerns for abuse, the finding of severe, multilayered RHs extending to the periphery of the retina is very specific for abuse as the cause of the findings, especially if retinoschisis is present. There are few other accidental traumatic mechanisms associated with retinoschisis, and the history of such a traumatic event is readily apparent. The indications for ophthalmologic consult, optimal timing of the eye examination, and significance of the findings are specifically discussed.

[Ophthalmological complications of the asphyxiophilic "scarf game" in a 12-year-old child].

To report a first case of Terson-like syndrome associated with asphyxiophilic practices in an adolescent. A 12-year-old boy was referred for decreased visual acuity in his right eye. His father had been diagnosed 3 weeks before with subarachnoidal hemorrhage. Fundus examination showed a dense preretinal hemorrhage in the right eye suggestive of Terson syndrome. Angio-magnetic resonance imaging eliminated aneurysm and arteriovenous malformation from the diagnosis. After questioning the boy further, he reported that he had participated in the "scarf game", a very popular (but lethal) asphyxiophilic practice in middle school, some hours before he noticed a sharp drop in the visual acuity of his right eye. After 2 months of follow-up, he recovered 20/20 vision in his right eye. Retinal hemorrhages are quite rare in children. When the cause is not clear (subarachnoidal hemorrhage, arteriovenous malformation, shaken baby syndrome), it must be determined whether the patient has participated in the asphyxiophilic "scarf game" in order to prevent its lethal consequences.

The natural history of retinal hemorrhage in pediatric head trauma.

Ophthalmologists are commonly asked to interpret appearance of retinal hemorrhages (RH) in children with suspected traumatic head injury. We sought to determine the natural history of RH in young children with head trauma and to identify patterns suggestive of chronicity in order to help establish timing of suspected traumatic injury. The medical records of children <2 years of age with abusive or accidental head trauma and RH on initial fundus examination who had 1 or more follow-up examination were retrospectively reviewed. Types of RH (intraretinal, preretinal) were noted; intraretinal hemorrhage (IRH) severity was graded as mild (0-10), moderate (10-20), or severe (>20, too numerous to count [TNTC]). A total of 91 eyes of 52 children were studied. All eyes had IRH (62 eyes with TNTC). In all but one eye, IRH resolved to none or mild within 1-2 weeks. TNTC IRH did not persist beyond a few days. The longest an isolated IRH persisted was 32 days. Preretinal hemorrhage (PRH) was present in 68 eyes, persisting 5-111 days. On initial examination, 25% of eyes had only IRH, 75% both PRH and IRH; no eyes had only PRH. At 2 weeks, 3% had only IRH, 18% both, and 45% only PRH. In no eyes did RH worsen. IRH clears rapidly, whereas PRH may persist for many weeks. The presence of TNTC IRHs indicates that trauma occurred within a few days prior to examination, whereas the presence of PRH with no or few IRHs suggests days to weeks since trauma. To accurately identify these patterns, eye examinations should be completed as soon as possible after admission, preferably within 24-48 hours.

Bilateral fungal infection inducing a serpiginous-like picture.

To report the clinical findings of a patient who presented with an atypical bilateral fungal retinitis that was established by retinochoroidal biopsy. Case report. A 56-year-old systemically healthy man presented with progressive visual loss in his left eye for 3 weeks. Visual acuity was 20/40 in the left eye, and 20/20 in the right eye and fundus examination showed macular retinal pigmented epithelium changes in his left eye. Over the following four months, his lesions progressed to serpiginous-like widespread retinal pigmented epithelium atrophy and his visual acuity decreased to 20/100, but no signs of ocular inflammation were found. Treatment with oral corticoids, valganciclovir and trimethoprim/sulfamethoxazole showed no efficacy. Blood analysis and cultures, laboratory investigations, and imaging tests were carried out looking for infectious and inflammatory diseases, but all tests were negative. Two months later, the patient presented with the same kind of lesions in the other eye (right eye), so he was subjected to retinochoroidal biopsy. Histopathological examination of specimen revealed the presence of intraretinal and choroidal fungal hyphae. Oral voriconazole was initiated achieving clinical remission, but no visual improvement was obtained. The source of the infection remains unknown since all tests results were negative. However, his profession as brewmaster might be related to the origin of the infection. Diagnosis of intraocular fungal infection can be challenging. Retinochoroidal biopsy may be useful to establish the diagnosis in those atypical cases with nonrevealing workup and inflammation localized to the retina.

The eye examination in the evaluation of child abuse.

Retinal hemorrhage is an important indicator of possible abusive head trauma, but it is also found in a number of other conditions. Distinguishing the type, number, and pattern of retinal hemorrhages may be helpful in establishing a differential diagnosis. Identification of ocular abnormalities requires a full retinal examination by an ophthalmologist using indirect ophthalmoscopy through a pupil that has been pharmacologically dilated. At autopsy, removal of the eyes and orbital tissues may also reveal abnormalities not discovered before death. In previously well young children who experience unexpected apparent life-threatening events with no obvious cause, children with head trauma that results in significant intracranial hemorrhage and brain injury, victims of abusive head trauma, and children with unexplained death, premortem clinical eye examination and postmortem examination of the eyes and orbits may be helpful in detecting abnormalities that can help establish the underlying etiology.

[Traumatic enucleation of the eye ball--report of a case and considerations concerning the pathogenic mechanism of intracranial complications].

A 48-year-old man had his left eye ball enucleated by fingers of an assailant. The optic nerve, measuring 4 cm in length, was attached to the enucleated eye ball, but there was neither a wound in his eyelids nor cerebrospinal fluid leakage from inside the orbit. He was confused, but responsive and was able to recognize other persons with his right eye. His right-eye vision deteriorated within 24 hours and was almost totally lost for about one month. Three months after the trauma his vision recovered to 0.1, but his visual field showed severe concentric narrowing. An emergency CT on admission showed a small subarachnoid hemorrhage in the suprasellar cistern, and follow-up CT scanning on day 7 demonstrated a small infarction in the left globus pallidus and putamen. Cerebral angiography performed on day 17 showed residual vasospasm of the horizontal portion of left anterior cerebral artery. Left ophthalmic artery was patent and there was no aneurysm formation either on the intracranial or on the intraorbital arteries. Literature review yielded only three cases of eye ball enucleation by an assailant. Intracranial complications reported in the literature, including those associated with eye ball enucleation caused by other mechanisms, are; contralateral visual field defect: seven cases, hypothalamic involvement: two cases, subarachnoid hemorrhage: two cases, cerebrospinal fluid leakage: one case, and meningitis: one case. The optic nerve, from just behind the eye ball to the chiasm, is reported to be 40-50 mm long, and eye ball enucleation with the optic nerve measuring 4 cm or more is quite likely to cause intracranial complications such as are cited above.

A case series from a single family of familial retinal arteriolar tortuosity with common history of sudden visual loss.

To report family members with familial retinal arteriolar tortuosity (FRAT) identified after sudden visual loss. A 15-year-old boy had sudden visual loss in his left eye while playing on a horizontal bar. He was referred to Nagoya City University Hospital from an eye clinic. The ophthalmologic examination showed retinal hemorrhage bilaterally. His best-corrected visual acuity (BCVA) was 20/17 in the right eye and 20/67 in the left eye. Bilateral retinal arteriolar tortuosity as well as retinal hemorrhage was seen. Since his mother with 54 years of age also had a history of retinal hemorrhage that improved spontaneously, fundus examination was performed, revealing tortuosity of the retinal arterioles. Consequently, the patient and his mother were diagnosed as FRAT. He was followed without intervention. Retinal hemorrhage gradually decreased and resolved after 3 months. The BCVA of his left eye gradually improved and reached 20/20 after 1 year. In this case, the family history was very useful for early diagnosis. Immediate and accurate diagnosis allowed the patient to be followed without intervention and achieve subsequent resolution of retinal hemorrhage and improved vision. FRAT should be considered in cases of sub-internal limiting membrane hemorrhages in young patients even in the presence of discrete retinal arteriolar tortuosity.

The Eye Examination in the Evaluation of Child Abuse.

Child abuse can cause injury to any part of the eye. The most common manifestations are retinal hemorrhages (RHs) in infants and young children with abusive head trauma (AHT). Although RHs are an important indicator of possible AHT, they are also found in other conditions. Distinguishing the number, type, location, and pattern of RHs is important in evaluating a differential diagnosis. Eye trauma can be seen in cases of physical abuse or AHT and may prompt referral for ophthalmologic assessment. Physicians have a responsibility to consider abuse in the differential diagnosis of pediatric eye trauma. Identification and documentation of inflicted ocular trauma requires a thorough examination by an ophthalmologist, including indirect ophthalmoscopy, most optimally through a dilated pupil, especially for the evaluation of possible RHs. An eye examination is helpful in detecting abnormalities that can help identify a medical or traumatic etiology for previously well young children who experience unexpected and unexplained mental status changes with no obvious cause, children with head trauma that results in significant intracranial hemorrhage and brain injury, and children with unexplained death.

Missed Opportunities and the Impact of the Pandemic.

Benjamin is a 9-month-old, former 36-week gestation infant who presented to the high-risk infant follow-up clinic with parental concern for developmental regression. His mother reported that Benjamin seemed to be developing typically, but over the past 2 months, he has lost the ability to visually track objects, is not as engaged with her as he once was, and now only rarely makes babbling sounds. His mother also reported episodes of intermittent "bursts" of stiffening of his extremities and brief staring spells. Benjamin's mother described him as a "good, quiet baby." She commented that he used to laugh and cry more frequently but has recently been "very peaceful and calm." Benjamin's mother recently relayed her concerns for developmental regression to his pediatrician during an audio-only telehealth visit. Benjamin was referred to a pediatric neurologist, and the consultation visit is pending.His mother is a 28-year-old single parent whose pregnancy was complicated by pre-eclampsia, gestational diabetes, and anxiety. Benjamin required admission to the neonatal intensive care unit because of initial feeding difficulties. After 1 week, Benjamin was discharged to home and was referred for early intervention services. Owing to the pandemic, there were delays with initiating intervention, but bimonthly virtual interaction with a representative from the infant development program was eventually provided.Benjamin's mother expressed significant concerns regarding the potential of exposing him to a pandemic-related illness because of bringing her son to in-person medical visits. In fact, because of her concerns, she attended only virtual well-child pediatric visits over the past 6 months. A thorough social history revealed that she is a former dance studio instructor. The studio closed and she lost her primary source of income because of the pandemic. As a result, she decided to not send Benjamin to child care and maintained isolation from extended family members.On physical examination, pertinent findings included poor truncal tone, lack of orientation toward sounds, and limited eye contact. The Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III) was administered, and the results indicated severe delays across all developmental areas, consistent with a diagnosis of global developmental delay.Benjamin's clinical presentation to the HRIF clinic and a history of developmental regression and intermittent body movements raised concerns for infantile spasms. He was transferred to the emergency department for evaluation and consideration for admission to the neurology service. An electroencephalogram confirmed epileptiform abnormalities consistent with infantile spasms, and he was immediately started on treatment.Impacts of the pandemic on the medical care of vulnerable/at-risk pediatric patients have included delayed receipt of early intervention services, parental fear regarding potential exposure to pandemic-related illness while seeking preventative care, increased use of virtual visit platforms for medical care and developmental intervention services, etc. What factors should be considered when providing support for these vulnerable/at-risk patients?

Manifestations of the shaken baby syndrome.

Retinal hemorrhages are the most common fundus finding in the shaken baby syndrome. They vary in type and location; no particular type is pathognomonic for the condition. Retinal hemorrhages are not needed to make a diagnosis of shaken baby syndrome. However, in a child under age 3 years, the presence of extensive bilateral retinal hemorrhages raises a very strong possibility of abuse, which must be investigated. The other possible causes for hemorrhages in this age child can be investigated and eliminated. The diagnosis of abuse should be made by someone particularly trained in this area, who can put together the entire picture of inadequate or changing history, fractures of various ages, particularly rib fractures, subdural hematoma of the brain, and retinal hemorrhages. Photographs of retinal hemorrhages are very helpful to child advocacy experts who take these cases to court.

Massive vitreous gel incarceration into the subretinal space following traumatic retinal detachment in a young patient: a case report.

This paper reports a young patient with a traumatic rhegmatogenous retinal detachment and massive vitreous gel incarceration into the subretinal space, who was successfully treated with 23-gauge transconjunctival vitrectomy. An 11-year-old boy was referred to the authors' clinic with traumatic retinal detachment in the right eye, 2 weeks after ocular contusion in a baseball accident. At the time of the injury, emergency fundus examination by his local doctor had revealed vitreous hemorrhage in the inferior quadrant of the right eye. Visual acuity was 1.5. He had continued to play baseball as usual for 2 weeks after the injury. At his first visit to the authors' clinic, fundus examination showed a highly bullous retinal detachment involving the inferior two quadrants, associated with multiple irregular retinal breaks. There was an oval hole in the inferior quadrant which was 10-disc diameter × 5-disc diameter in size and was surrounded by edematous and hemorrhagic retina. The macula remained attached. Absolute rest for 4 hours in the supine position with binocular occlusion did not diminish the height of the retinal detachment. A 23-gauge three-port pars plana vitrectomy combined with 360° circumferential buckling was performed under general anesthesia. The lens was retained. Incarceration of massive vitreous gel, including vitreous hemorrhage into the subretinal space through the largest break, was observed during vitrectomy. Reattachment of the retina was achieved by fluid-air exchange and internal tamponade using SF(6) gas. At follow-up at 9 months, the retina remained attached and visual acuity in the right eye was 1.2.

A historical vignette (19). An orbital trauma in the 16th century.

An orbital trauma in the 16th century. On 30 June 1559, during a jousting tournament, King Henri II of France incurred an injury to the eye from a shattered lance, dying ten days later. Trepanation was discussed briefly before being rejected. The autopsy on the King confirmed that it would have been justified. Even though there was no skull fracture, there was a secondary rebound trauma resulting in a subdural haematoma in the occipital area. This paper examines why the trepanation option was rejected (Figure 1).

[Not-always-apparent abuse: the shaken baby syndrome].

The authors report 3 cases of infants presenting with cerebral lesions related to violent head shaking. They emphasize the diagnostic difficulties when the classical signs of the battered child (marks of blows, fractures) are lacking. The traumatism is rarely recognized: only the negativity of the usual medical causes of subdural hematoma, meningeal or retinal hemorrhage and a peculiar familial history lead to the possible diagnosis of shaken baby syndrome. The value of skull CT-scan is major, showing intracranial lesions which could not be found before. Because of the observed lesions, evolution is often severe.

Case report: Partial visual recovery from incomplete traumatic optic nerve avulsion caused by a badminton shuttle.

Blunt ocular trauma rarely results in optic nerve avulsion. Here, we report a case of incomplete optic nerve avulsion caused by the impact of a badminton shuttlecock. The patient was a 16-year-old healthy male. A badminton shuttlecock hit his right eye from a short distance. On his first visit to the local eye clinic, his visual acuity in the right eye was hand motion. About 4-mm hyphema in height was observed in the right eye. Three days after the injury, visual acuity improved to 20/50, but the intraocular pressure increased to 40 mmHg; hence, intraocular pressure (IOP)-lowering medication was initiated. Five days after the injury, although hyphema had decreased gradually, he noticed a worsening of vision and was referred to our department. In his right eye, visual acuity was reduced to finger-counting, IOP was 38 mmHg. Slit-lamp examination of the right eye revealed a dilated pupil, hyphema, and angle recession. Fundus examination revealed dilation of the central retinal vein and edematous changes around the optic nerve head. Optical coherence tomography showed a very deep depression of the optic nerve head and partial rupture of the optic nerve axons. B-mode ultrasonography showed hypolucency just posterior to the optic nerve head. Goldmann perimetry revealed a central visual field defect in the right eye. Computed tomography showed no signs of optic canal fracture. These findings suggest that incomplete optic nerve avulsion had occurred. We performed IOP-lowering and anti-inflammatory therapy. After treatment, visual acuity was restored to 20/50, and the deep depression of the optic nerve head recovered to an almost normal range. It was assumed that the impact of the badminton shuttlecock caused irreversible changes in the optic nerve head, but the visual function partially improved with IOP-lowering and anti-inflammatory therapy. Because eye injury in badminton can cause severe damage to visual function, every badminton player needs to wear an appropriate eye shield, and rules or guidelines to prevent untoward accidents are needed in badminton.

Retinal hemorrhages: replicating the clinician's view of the eye.

The authors describe a technique for the gross examination of postmortem eyes of children who are suspected to have been the victims of deliberate trauma. By removing the anterior segment (cornea, iris, lens and pars plicata of the ciliary body) en bloc by a coronal incision through the pars plana just anterior to the ora serrata, the pathologist may view and photograph the fundus exactly as it would have been seen clinically. The photographs obtained with this technique correlate more closely with antemortem clinical examinations and photographs than conventional gross examination procedures and have been introduced as evidence in trials concerning the issue of retinal hemorrhages in injured children. The anterior segment and optic nerve are also examined to facilitate a comprehensive description of ocular findings.

Hemorrhagic occlusive retinal vasculitis after inadvertent intraocular perforation with gentamycin injection.

To report a case of hemorrhagic occlusive retinal vasculitis (HORV) secondary to intraocular toxicity due to inadvertent intraocular injection of gentamycin. A 21-year-old woman was referred to our department because of severe ocular pain and sudden visual loss in her left eye after she received a subconjunctival gentamycin injection for chronic infectious keratitis. At presentation, best-corrected visual acuity was 20/20 in the right eye and counting fingers in the left eye. Fundus examination showed diffuse intraretinal and perivascular hemorrhages, vascular cuffing, white-centered hemorrhages, and diffuse retinal edema. Fluorescein angiography confirmed occlusive retinal vasculitis with capillary nonperfusion and spectral-domain optical coherence tomography revealed ischemic macular edema. The clinical diagnosis was compatible with HORV secondary to retinal toxicity due to high dose of intraocular gentamycin. We report a case of HORV secondary to inadvertent subconjunctival gentamycin injection. Ocular perforation and high dose of intravitreal gentamycin administration should be considered as a potential cause of HORV following subconjunctival injection.

[Retinal haemorrhages in non-accidental head injury in childhood].

Retinal haemorrhages are one of the three cardinal manifestations of the "shaken baby syndrome" or "non-accidental head injury" in childhood. The role of an ophthalmologist in suspected non-accidental head injury has not only medical but also legal aspects and has been discussed controversially in the literature. The differential diagnosis and the specificity of retinal haemorrhages in childhood for an abusive head trauma will be pointed out in this paper.

Missed Diagnosis of an Intraorbital Foreign Body of Homemade Fireworks Origin: A Case Report.

We report a rare case of traumatic injury to the eye caused by homemade fireworks in a Chinese juvenile patient with a metal ring left in the orbit after having been sutured at the Emergency Department. An 11-year-old boy presented with a traumatic injury to the right eye from homemade fireworks. Following initial assessment involving maxillofacial computed tomography (CT) and suturing at the Emergency Department, he was transferred to our department for further evaluation because of his poor sight 1 day later. On examination, a skin laceration beneath the right eyebrow was noted, but the superior orbit was not fully visible on the maxillofacial CT performed 1 day previously. Therefore, an orbital CT scan was carried out on the second day, which showed a hyperdense ring embedded in the superior border of the orbital wall; the ring was surgically removed. On postoperative day 7, a fundus examination revealed resolving vitreous hemorrhage, blunt traumatic retinal detachment, and a large retinal tear superior to the macula. The patient refused to take surgery for retinal detachment into consideration. Therefore, we opted for oral steroids and careful observation. After 2 months' observation, the large retinal tear had healed and white fibrous scar tissue had developed, and the retinal detachment superior to the macula had reattached itself spontaneously. The patient's vision had further improved to 20/200. During 1 year of follow-up, he remained clinically stable. To avoid missing the diagnosis, a complete history of the mechanism of injury and accurate imaging still prove most useful. Complete removal of the foreign body by the emergency physician is necessary because of the ocular toxicity of an iron-containing foreign body. As evidenced by the current case, oral steroids and observation for a period of several months is a management of choice for traumatic retinal detachment and retinal tear superior to the macula associated with homemade fireworks in children.

[Traumatic vitreous-retinal hemorrhage in infants].

After a short review of the non-traumatic, and rare, causes of vitreoretinal hemorrhages in infants, we analyze the 4 situations where a traumatic hemorrhage can be found: accidental head trauma, which has to be very severe and is then an unfrequent etiology, head trauma in child abuse or the so-called "shaken baby syndrome", which is the most frequent cause, and where we point out the key role of the ophthalmologist in the diagnosis and the prognostic evaluation, the perinatal trauma, which is a frequent, benign, and ephemeral cause, and finally, cardiopulmonary resuscitation, which is a controversial and unlikely cause.

Subgaleal Hemorrhage Secondary to Child Physical Abuse in a 4-Year-Old Boy.

Subgaleal hemorrhage is commonly described in the neonatal population but is a rare injury in young children and adolescents. Though infrequently seen, it can follow blunt head trauma or hair pulling. This case report details a 4-year-old African American boy with massive subgaleal hemorrhage and bilateral periorbital swelling and ecchymosis as a result of hair pulling in the setting of child physical abuse. The patient was evaluated in the emergency department for swelling of his scalp several hours after reportedly bumping his head on a chair. He was discharged home after a head computed tomography only confirmed soft tissue hematoma. The following morning, the findings progressed and he returned to the emergency department. He was triaged as a trauma and initially evaluated by the emergency physician, pediatric trauma surgeon, and pediatric neurosurgeon. Head computed tomography scan confirmed diffuse scalp edema without skull fracture or intracranial pathology. The child abuse specialty service was consulted for suspected child physical abuse. Their examination revealed numerous scattered bruises on the trunk and thighs, several of which were patterned. Local police investigation resulted in the patient's grandfather confessing to striking the patient with a belt and picking him up from the ground by his hair, the latter of which is a mechanism consistent with the patient's dramatic scalp and facial findings. The authors encourage consultation by a specialist in child abuse pediatrics for subgaleal hemorrhage and/or raccoon eyes in the presence of minor trauma, as well as thorough head-to-toe skin examination for all children presenting with injuries.

Retinal findings after head trauma in infants and young children.

Many authorities believe that the finding of retinal hemorrhages in a child younger than 3 years of age with a history of head trauma, in the absence of an obvious cause for the injury, is pathognomonic of child abuse. To date, no studies have examined the prospective retinal examination of children who have had head trauma. The authors undertook such a study because the presence of retinal hemorrhage from any head trauma in children may have medicolegal diagnostic significance in differentiating accidental from nonaccidental trauma. Seventy-nine children younger than 3 years of age, each of whom experienced head injury, underwent an ophthalmologic assessment, which included a dilated funduscopic examination. Seventy-five children sustained accidental head injuries and had normal funduscopic examinations. Three children had nonaccidental head injuries and all were found to have varying degrees of retinal hemorrhages. One child, with a normal fundus examination, had injuries that were of indeterminate cause. The finding of retinal hemorrhages in a child with a head injury suggests a nonaccidental cause.

The language and culture of delay.

Satish is a 3 (1/2)-year-old boy you are seeing in your primary care office for a "sick visit" due to parental concerns about his language development. He is the only child of a couple who immigrated to the United States from India shortly before his birth. He received early intervention services for speech and language delays for a few months before he attained 2 years of age. However, services were discontinued when the family moved back to India for a year. After the family returned to the United States, they lived in a different state for several months before moving again recently to his current home, so he is relatively new to your practice. Satish's mother is concerned not only about his communication skills but also about his attention and social skills. She notes that he often plays alone or in parallel with other children. She was also told by his first pediatrician that Satish had "a limited imagination." His parents feel that he has pretend play, in that he will pretend to get his haircut, talk on the phone, or ride on a train. Satish was born at term without complications. He passed his newborn hearing screen and a repeat hearing test at the age of 2 years. He has had no medical problems and takes a daily multivitamin. His parents are both of Indian descent. Satish's father is an engineer and had a history of being a late talker. His mother graduated from high school and is a homemaker. They are expecting their second child. Satish's developmental history is significant for language delays. He babbled at 6 months but did not have single words until he was 2 years. When he was 2 (1/2) years, he had 2 to 3 word sentences. He responded to his name at 15 months and could follow single step commands by the age of 2 years. Currently, Satish is noted to have difficulty with "back and forth conversation." He sometimes repeats what others are saying.The family speaks Hindi, their native language, exclusively at home. When Satish speaks, he usually speaks in Hindi. His parents describe him as using "odd language" in that he will often mix up his pronouns. Satish is in an English-speaking preschool. His preschool teachers report concerns that he seems to "withdraw into his own world," and does not interact well with the other children. They also report attentional problems and poor eye contact.In the office, Satish makes good eye contact with the examiner and his parents. He looks to his parents for approval when completing a task requested of him. He seems to like an Elmo toy that is in the room but holds it and looks at it closely rather than pretend to do anything with it. You ask him to feed Elmo, and he says, "Feed Elmo." Because it is not clear whether he understands the verbal cues given to him, his parents repeat English directions to him in Hindi several times. He eventually complies but then leaves his chair to explore the room. His parents continue to translate your questions to him with variable results. He becomes increasingly difficult to engage, despite repeated attempts, in both English and Hindi, to attract his attention. Where do you go from here?

The eye in child abuse: key points on retinal hemorrhages and abusive head trauma.

This review presents an up-to-date overview of ocular injuries resulting from child abuse, with a spotlight on abusive head trauma. Retinal hemorrhage is a principle finding of inflicted head trauma. The specific pattern of hemorrhages holds valuable diagnostic information, which can help to guide multidisciplinary assessments of the likelihood of abuse. Indirect ophthalmoscopy through dilated pupils by an ophthalmologist is necessary for adequate examination and documentation of retinal findings. Initial pediatrician evaluation of the eye and indications for ophthalmological consultation are reviewed. Focus is then placed upon understanding retinal hemorrhage patterns, their diagnostic significance and likely pathophysiological mechanisms. The differential diagnosis of retinal hemorrhage in young children is discussed, highlighting key distinctions among retinal hemorrhage patterns, severity and frequencies, as well as other ocular findings. The most common cause of retinal hemorrhage in an infant is trauma, and most other causes can be identified by considering the hemorrhage pattern, ocular or systemic signs and the results of laboratory and imaging tests, when indicated.

Attached to a diagnosis:  the quandary of social deficits and reactive attachment disorder.

: Alex is a 9-year-old boy brought to you, his primary care provider, for a "fifth opinion." You have cared for Alex since he was adopted from a Romanian orphanage at 3 years of age. He has been physically healthy with normal growth parameters and no evidence of fetal alcohol syndrome. Alex has long-standing history of social difficulties, impulsivity, lying, controlling, manipulative behaviors, violent outbursts at home with subsequent lack of remorse, and excessive chatter. You referred Alex to an interdisciplinary child development clinic 2 years ago, where he was diagnosed with reactive attachment disorder (RAD) and attention deficit hyperactivity disorder (ADHD). He was noted to have normal cognitive and language skills. Attachment therapy, stimulant therapy, and school accommodations for ADHD were recommended.Alex received some individual counseling with the school psychologist for a year after the first evaluation, with little improvement in core behaviors. The following year, Alex established care with a psychiatrist and a private counselor. The psychiatrist prescribed a succession of stimulants, each of which worked for only a short time and then had waning effect. The counselor worked with Alex and his parents on managing Alex's behavior, which the family reports has been somewhat helpful.Alex's parents express great frustration and sadness that parenting Alex has been such an ongoing struggle since he was adopted. They note that Alex is superficially friendly, chatty, and charming, with everyone he encounters, including strangers, but he never progresses past such superficial interaction, even with his adoptive parents. The parents express that they are deeply wounded that Alex is not more loving and is not more appreciative of the fact that they rescued him from the orphanage.His parents asked his pediatric clinician about Autism as they observe Alex's lack of real affection and social connection with parents or peers. They also note that Alex has difficulty verbalizing his feelings and that he lies frequently, chatters tangentially, and he can watch the Discovery channel for hours. A neurologist, to whom Alex was referred to evaluate staring spells, reassured the family that the spells did not seem to be epilepsy and also diagnosed Alex with "Asperger's syndrome." The school psychologist, after 2 years of equivocation, recently made Alex eligible for autism spectrum services.During the interview and examination, Alex is funny, friendly, and a bit silly. He uses normal eye contact, seems to enjoy the neuromotor examination, and is eager to show you his cool, new handshake. He engages in easy banter, using normal vernacular and prosody. After the visit, you call the therapist to express your opinion that the RAD diagnosis is valid after all and to ask whether the family is engaged in attachment therapy. The therapist refutes the RAD diagnosis, endorsing Asperger's syndrome (AS) instead and notes that Alex is making good progress in school and in therapy, where he is learning pragmatic skills and basic social skills with the use of social stories.Where do you head next?

[Retinal haemorrhages as a symptom of child abuse].

Inflicted traumatic brain injury (ITBI) - a possible result of child abuse - is difficult to diagnose, yet the diagnosis bears great impact on patients and their relatives. The purpose of this paper is to describe ophthalmologic findings that can be seen in relation to ITBI. For exemplification, three different cases are described in detail. ITBI is diagnosed through a multidisciplinary approach by exclusion of other causes that could explain the clinical findings, and by linking factors that together raise a high suspicion of ITBI. The typical triad of ITBI includes intracerebral haemorrhage, encephalopathy and retinal haemorrhages. Therefore, detailed fundus examination by an ophthalmologist is important when ITBI is suspected. A pattern of bilateral, multiple retinal haemorrhages present in different retinal layers and widespread from posterior pole to the retinal periphery, is highly suspicious for ITBI, and contributes to the final diagnosis.


Any of the 4 options can be the cause of erythroderma, although the description of nail lesions highly suggestive of psoriasis makes this diagnosis the most likely.

Any of the 4 options can be the cause of erythroderma, although the description of nail lesions highly suggestive of psoriasis makes this diagnosis [HIDDEN].

A patient comes to the emergency department with erythroderma with fever and general malaise. On examination, the nails show the presence of nail pitting and distal yellowish areas in an oil stain. What is the primary disease that caused the condition?

DERMATOLOGY, VENEREOLOGY AND PLASTIC SURGERY

Exfoliative dermatitis. Erythroderma can be a sign of a significant underlying disorder.

64-year-old man presented with a 3-week history of a diffuse, pruritic rash that had started on his trunk and then spread to his entire cutaneous surface, including the palms of his hands and soles of his feet. Physical examination revealed widespread fine scaling and diffuse erythema. Generalized lymphadenopathy was noted. No fever, hair loss, onycholysis, or nail shedding was detected. The patient had neither a personal history of skin disorders or, specifically, atopic eczema or psoriasis nor a family history of eczema or psoriasis. He also had no history of malignancy and was taking no medications. The patient's complete blood cell count with differential was unremarkable. He was treated with moisturizers, topical corticosteroids, and antihistamines and was advised to avoid possible irritants. One week later, the patient returned because of a worsening of his erythroderma. He also reported malaise and chills. Three 4-mm biopsy specimens were obtained from representative areas (ie, back, arm, and abdomen), and a 2-week course of oral corticosteroids was prescribed. The erythroderma greatly improved but worsened shortly after the steroid dose was tapered. The specimens showed psoriasiform hyperplasia with features suggestive of psoriasis vulgaris. The patient was treated with 25 mg of oral acitretin once a day. His erythroderma slowly resolved over 6 months, at which time the acitretin dose was tapered. The patient reported no recurrence of the erythroderma.

Erythroderma. A clinical and etiological study of 103 patients.

Erythroderma is an uncommon and severe dermatological manifestation of a variety of diseases. It is commonly challenging to find the underlying cause. The aim of this study was to analyze the causes of the disease in patients with erythroderma. Data including the clinical symptoms, laboratory examinations, histopathology and follow-up information were collected from patients with erythroderma admitted to our department between 2000 and 2010. One-hundred and three patients diagnosed with erythroderma were identified during this period (11.9% of all hospitalized patients; hospital incidence = 9.4 cases/year). The mean age of onset was 54.4 years (range: 17-89 years) with a male:female ratio of 1.5:1. The most frequent cause of erythroderma was exacerbation of preexisting dermatoses (65.0%), including psoriasis (44.7%) and eczema (16.5%). Drugs (18.4%) and cutaneous T-cell lymphomas (11.7%) induced most of the remaining cases. No cause could be identified in four cases (3.9%). Apart from erythema and scaling, that were present in all patients, clinical findings were dominated by pruritus (97.1%), followed by edema (56.3%), fever (54.4%), palmoplantar keratoderma (50.5%), nail changes (42.7%), liver or spleen enlargement (41.7%) and lymphadenopathy (40.8%). Although numerous clinical features and laboratory values were abnormal, most findings were non-specific. The skin biopsy yielded a positive clinical correlation in most cases. Our study had a high percentage of erythroderma secondary to preexisting skin disease and a relatively low percentage of idiopathic erythroderma.

Clinical presentation of psoriasis.

Psoriasis is a chronic, inflammatory disease affecting 1-3% of the world's population. Joints can be affected in up to 30% of patients. About one third of patients have either severe or moderate (involving more than 10% of body surface area) disease. Patients affected with extensive psoriasis have an impaired quality of life. Psoriasis has a large spectrum of clinical features and evolution, so no complete agreement on the classification of the clinical variants exists. Plaque psoriasis is the commonest form (more than 80% of affected patients). The course of plaque psoriasis varies. Spontaneous resolution is possible, but rarely occurs. Plaques tend to remain static or slowly enlarge. Flexural (inverse, intertriginous) psoriasis manifests with lesions thinner than those of plaque form with no or minimal scaling, and is localized in the skin folds. Guttate (eruptive) psoriasis has frequently a sudden onset and frequently appears abruptly after a bacterial or viral febrile episode of inflammation of the upper ways. Pustular and erythrodermic psoriasis are the most severe clinical variants. In the diffuse pustular form recurrent episodes of fever occur, followed by new outbreaks of pustules. Erythrodermic psoriasis corresponds to the generalized form of the disease. The entire skin is bright red and is covered by superficial scales. Fatigue, myalgia, shortness of breath, fever and chills may also occur. In sebopsoriasis (seborrheic dermatitis + psoriasis) the lesions tend to occur at the same sites as seborrheic dermatitis; greasy scales predominate, but silvery scales can be found in some areas. Nail psoriasis shows various features: nail pits; oil spots; subungual hyperkeratosis; onycholysis. Rare forms include psoriasis circinata, lip psoriasis and oral psoriasis. Differential diagnosis includes many other dermatological conditions.

Erythroderma: a clinico-etiologic study of 90 cases.

The difficulty with erythroderma lies in finding the underlying cause. Almost all the published original clinical series of erythroderma originate from western countries. Our aim was to evaluate various causes of exfoliative dermatitis in our community and compare the findings with previous studies. Ninety patients with erythroderma of either sex and any age, were studied at the Dermatology Department, Mayo Hospital, Lahore, Pakistan, between April 1992 and May 1995. A through clinical examination and relevant laboratory investigations, including skin biopsies, were performed. The mean age of onset was 41.6 years with a male:female ratio of 2.8:1. The onset was acute in 69% of patients. The salient features included nail changes (80%), mucosal involvement (36.6%), alopecia (30%), islands of normal skin (14.4%), and the "deck chair sign" (5.5%). The most frequent cause of erythroderma was pre-existing dermatoses (74.4%), including psoriasis (37.8%), dermatitis (12.2%), ichthyoses (7.8%), and pemphigus foliaceus (5.6%). Drugs and malignancy each induced erythroderma in 5.5% of cases. No cause could be found in 14.6% of cases. Etiologically, pre-existing dermatoses showed the highest incidence and drugs the lowest compared with previous studies. Dermatitis was less common. There was a greater variety of causes of erythroderma in our series. Hair and nails were more frequently involved. Mucosal involvement, not mentioned in other studies, was present in 36.6% of our cases. The "deck chair sign" and islands of normal skin were seen in dermatoses not reported previously.

Erythroderma in children: a clinico-etiological study.

Although there are various published studies on erythroderma from western and Asian countries, most of them have only included patients in the adult age groups. As we have an exclusively pediatric dermatology unit, we thought it would be intriguing to study the clinical, etiological and laboratory parameters of erythroderma in children. Seventeen erythroderma patients of both sexes were inducted into the study between 1993 to 1998. The mean age of onset was 3.3 years and the male:female ratio was 0.89:1. Eight (47%) of the patients were infants; 9 (53%) others belonged to the preschool and school going age group (age range between 1 to 12 years). An acute onset of the disease was seen in 47% of the patients while 53% of the patients had a chronic onset. The main presenting complaints were itching in 41% and burning in 18% of patients. Scalp involvement (71%), nail involvement (18%), and alopecia (6%) were the main cutaneous features observed while fever (53%), tachycardia (53%), pedal edema (12%), lymphadenopathy (18%), and hepatomegaly (12%) were the main systemic features observed in this study. Etiologically, drugs (29%), showed the highest incidence, followed equally (18%) by genodermatoses, psoriasis, and staphylococcal scalded skin syndrome (SSSS). Two (12%) patients had erythroderma due to atopic dermatitis, while one was (5%) due to infantile seborrheic dermatitis coexisting with dermatophytosis. Laboratory parameters contributed little towards diagnosis of the underlying dermatological condition. Thus, though erythroderma is a striking entity, it is yet uncommon in the pediatric age group. Because the drug induced group was the largest in this study, we recommend that drugs should be suspected as important causative factors of erythroderma in children.

Psoriasis in a 3-month-old infant with Kawasaki disease.

Kawasaki disease (KD) or mucocutaneous lymph node syndrome is a systemic vasculitis of unknown etiology affecting young children. Typical cutaneous manifestations of KD are polymorphous, including maculopapular or morbilliform rash and erythroderma. Occurrence of psoriasis following KD is rare. Herein we report a case of new onset of psoriasis in a 3-month-old that flared after a typical clinical case of KD, manifesting spiking fever, diffuse redness and fissuring of the lips, bilateral conjunctiva injection, injected throat, left cervical lymphadenopathy, erythema and desquamation of the lips, cheeks, hands, feet and perianal area, and a generalized maculopapular eruption. In addition, erythema and induration of the BCG vaccination site and coronary artery dilatation were noted. After fading of the initial rash, the patient developed widespread psoriasiform papules and plaques involving the face and extremities. The cheeks, lips and nail involvement with subunqual hyperkeratosis and pincer nail deformity were particularly striking. The diagnosis of psoriasis was confirmed by skin biopsy. The eruption resolved after one month of topical momentasone furoate treatment. The role of superantigens in KD-associated psoriasis is discussed.

An Elusive Case of Mycosis Fungoides: Case Report and Review of the Literature.

Erythroderma refers to a spectrum of skin diseases resulting in diffuse erythema and scaling encompassing ≥ 90% of the body surface area. The differential diagnosis ranges from primary dermatologic diseases such as atopic dermatitis and psoriasis to potentially deadly causes such as staphylococcal toxic shock syndrome, toxic epidermal necrolysis, and malignancy. Cutaneous T cell lymphoma (CTCL) is an uncommon but highly morbid cause of erythroderma. This non-Hodgkin lymphoma remains a diagnostic challenge due to its variable clinical presentation and varied histologic features. Mycosis fungoides (MF) is the most common form of CTCL. Making a timely diagnosis is challenging as it may mimic inflammatory diseases of the skin including eczema, psoriasis, lichen planus, and cutaneous lupus. We present a case of a 58-year-old man who presented with 5 years of cutaneous symptoms and several months of fevers and night sweats, ultimately diagnosed as MF. Owing to diffuse CD30 positivity, he was a candidate for brentuximab vedotin, an antibody-drug conjugate medication that selectively targets the CD30 antigen. This resulted in an excellent therapeutic response.

The nails in adult type 1 pityriasis rubra pilaris. A comparison with Sézary syndrome and psoriasis.

The fingernails of twenty-four patients with classical adult (type 1) pityriasis rubra pilaris were examined for changes in nail morphology and a comparison was made with the fingernail morphology of twenty-seven consecutive psoriatic patients with nail changes. Distal yellow-brown discoloration, subungual hyperkeratosis, nail plate thickening, and splinter hemorrhages indicate a diagnosis of type 1 pityriasis rubra pilaris rather than psoriasis, while onycholysis (particularly marginal), salmon patches, small pits, and larger indentations of the nail plate indicate a diagnosis of psoriasis. Histology demonstrated that a nail biopsy would be a useful diagnostic procedure if nails were involved in isolation but provided no additional diagnostic features to those found from biopsy specimens of involved skin in the two conditions. The similarity in nail morphology between the type 1 pityriasis rubra pilaris patients and five patients with chronic erythroderma resulting from Sézary syndrome indicated that these changes may represent a nonspecific reaction pattern that may result from prolonged erythema of the proximal nail bed and matrix. The rough nails (trachyonychia) described in advanced Sézary syndrome were not observed in any of our patients.

Erythroderma

Erythroderma is an inflammatory skin disease with redness and scaling that affects nearly the entire cutaneous surface. This term applies when 90% or more of the skin is affected. In ICD-10, a distinction is made between "exfoliative dermatitis" at L26, and "erythroderma" at L53.9. Causes Erythroderma is generalized exfoliative dermatitis, which involves 90% or more of the patient's skin. The most common cause of erythroderma is exacerbation of an underlying skin disease, such as psoriasis, contact dermatitis, seborrheic dermatitis, lichen planus, pityriasis rubra pilaris or a drug reaction, such as the use of topical steroids. Primary erythroderma is less frequent and is usually seen in cases of cutaneous T-cell lymphoma, in particular in Sézary's disease.

Erythroderma: A clinicopathological study of 47 cases from 2018 to 2020.

Erythroderma, or exfoliative dermatitis, is an inflammatory disorder characterized by erythema and scaling, affecting most of the skin surface. It may be a result of many different causes such as previous dermatoses (psoriasis, eczema, atopic dermatitis [AD], pityriasis rubra pilaris, and pemphigus foliaceous), drug reactions, malignancies (mycosis fungoides [MF], Sézary syndrome, adult T cell leukemia/lymphoma), infections, and idiopathic disorders. Regardless of the etiology, the clinical appearance of erythroderma is similar in all patients. The most prominent physical examination findings in almost all patients are diffuse erythema and scaling. In a 2-year period, 47 patients who were hospitalized and treated in our department were included in the study. We classified patients into seven subgroups: psoriasis, AD, drug-induced erythroderma, MF, pityriasis rubra pilaris, bullous pemphigoid, and polymorphous light eruption. All patients had a biopsy during the acute stage and diagnoses were histopathologically confirmed. Some patients had multiple biopsies for histopathological confirmation. In our study, the majority of the patients were men over the age of 54. The most common etiological cause of erythroderma is psoriasis. We aim to analyze clinical, laboratory, and histopathological findings of erythrodermic inpatients prospectively in Istanbul University-Cerrahpasa Cerrahpasa Medical Faculty between January 2018 and 2020.

Erythroderma

The most common causes of exfoliative dermatitis are best remembered by the mnemonic device ID-SCALP. The causes and their frequencies are as follows: Idiopathic - 30% Drug allergy - 28% Seborrheic dermatitis - 2% Contact dermatitis - 3% Atopic dermatitis - 10% Lymphoma and leukemia - 14% Psoriasis - 8%

InternalMed_Harrison

aDiscussed in detail in Chap. 71; cardiovascular disease and the metabolic syndrome are comorbidities in psoriasis; primarily in Europe, hepatitis C virus is associated with oral lichen planus. bAssociated with chronic sun exposure more often than exposure to arsenic; usually one or a few lesions. cSee also Red Lesions in “Papulonodular Skin Lesions.” dAlso cutaneous lesions of HTLV-1-associated adult T cell leukemia/lymphoma. eSee also Red-Brown Lesions in “Papulonodular Skin Lesions.” (Table 72-2) Erythroderma is the term used when the majority of the skin surface is erythematous (red in color). There may be associated scale, erosions, or pustules as well as shedding of the hair and nails. Potential systemic manifestations include fever, chills, hypothermia, reactive lymphadenopathy, peripheral edema, hypoalbuminemia, and high-output cardiac failure. The major etiologies of erythroderma are (1) cutaneous diseases such as psoriasis and dermatitis (Table 72-3); (2) drugs; (3) systemic

Psoriasis

Diagnosis A diagnosis of psoriasis is usually based on the appearance of the skin. Skin characteristics typical for psoriasis are scaly, erythematous plaques, papules, or patches of skin that may be painful and itch. No special blood tests or diagnostic procedures are usually required to make the diagnosis. The differential diagnosis of psoriasis includes dermatological conditions similar in appearance such as discoid eczema, seborrheic eczema, pityriasis rosea (may be confused with guttate psoriasis), nail fungus (may be confused with nail psoriasis) or cutaneous T cell lymphoma (50% of individuals with this cancer are initially misdiagnosed with psoriasis). Dermatologic manifestations of systemic illnesses such as the rash of secondary syphilis may also be confused with psoriasis.

Dermatopathic lymphadenopathy

In pathology, dermatopathic lymphadenopathy, is lymph node pathology due to skin disease. Cause Also known as lipomelanotic reticulosis or Pautrier-Woringer disease, represents a rare form of benign lymphatic hyperplasia associated with most exfoliative or eczematoid inflammatory erythrodermas, including pemphigus, psoriasis, eczema, neurodermatitis, and atrophia senilis. Diagnosis Dermatopathic lymphadenopathy is diagnosed by a lymph node biopsy. It has a characteristic pattern of histomorphology and immunohistochemical staining: Paracortical histiocytosis Melanin-laden macrophages Eosinophils Plasma cells (medulla of lymph node) Differential diagnosis Cutaneous T cell lymphoma Hodgkin's lymphoma Melanoma Treatment The treatment is based on the underlying cause. See also Skin disease List of cutaneous conditions References External links Dermatopathic lymphadenitis - pathconsultddx.com. Cutaneous conditions

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When pustular psoriasis, a less common form, is generalized, it can be life threatening, presenting with fever, electrolyte abnormalities, and loss of serum proteins. AB FIGURE 2.2-4. Psoriasis. (A) Skin changes. The classic sharply demarcated plaques with silvery scales are commonly located on the extensor surfaces (e.g., elbows, knees). (B) Nail changes. Note the pitting, onycholysis, and “oil spots.” (Reproduced, with permission, from Hur witz RM. Pathology of the Skin: Atlas of Clinical-Pathological Correlation, 2nd ed. Stamford, CT: Appleton & Lange, 1998: 15, 18.) Clinical impression is usually sufficient for diagnosis. Classically presents with the Auspitz sign (bleeding when scale is scraped), but biopsy can be useful. Histology classically shows a thickened epidermis, elongated rete ridges, an absent granular cell layer, preservation of nuclei, and a sterile neutrophilic infiltrate (Munro’s microabscess) in the stratum corneum.

Koilonychia

Koilonychia, also known as spoon nails, is a nail disease that can be a sign of hypochromic anemia, especially iron-deficiency anemia. It refers to abnormally thin nails (usually of the hand) which have lost their convexity, becoming flat or even concave in shape. In a sense, koilonychia is the opposite of nail clubbing. In early stages nails may be brittle and chip or break easily. Koilonychia is associated with Plummer–Vinson syndrome and iron deficiency anemia. It has also been associated with lichen planus, syphilis, and rheumatic fever. The term is from the Greek: κοῖλος, koilos, "hollow", ὄνυξ, onyx, "nail". Even though Koilonychia has been associated with iron deficiency in case reports, it is more likely seen as an occupational change in nails and may be idiopathic; ruling out iron deficiency anemia in these patients is the only work-up necessary in this condition. See also Kyrle disease List of cutaneous conditions References External links

Diagnosis of nail psoriasis: importance of biopsy and histopathology.

Involvement of the nail is quite common in psoriasis and at times may be the sole diagnostic clue. However, the histopathology of nail psoriasis has not been adequately evaluated. A confirmation of the diagnosis is required in cases suspected to have nail psoriasis in order to plan long-term therapy. To assess the diagnostic significance and safety profile of nail biopsy in cases with nail psoriasis. Clinical and mycological features were studied in 42 patients with nail psoriasis. Of these, 22 patients gave consent for nail biopsies to be taken and the histopathological changes were assessed. Males were affected more commonly (57%) with a peak incidence in the age group of 10-20 years (29%). Distal onycholysis, discoloration of nail plate, subungual hyperkeratosis and fine nail pitting were the predominant clinical features. In the 22 biopsies done, hyperkeratosis with parakeratosis (91%) was found to be the most common and hypergranulosis was the least common histological finding (36%). Clinicohistological correlation was possible only in 55% cases. Periodic acid-Schiff (PAS) staining was done for all biopsies. Histopathological examination of nails is a valuable diagnostic aid, especially in the absence of skin lesions. Examination of the PAS-stained sections is necessary before making a histological diagnosis of nail psoriasis because onychomycosis and psoriasis may show similar histology.

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The color, texture, configuration, location, and distribution of the lesion should be recorded. A localized or grouped eruption may suggest a cutaneous infection, whereas widespread, symmetrical involvement of extensor surfaces may suggest a primary skin disorder, such as psoriasis. Herpesvirus lesions are usually grouped lesions. Annular lesions may suggest Lyme disease, syphilis, and fungal infections. Lesions on mucous membranes are usually short-lived, and lesions in thick-skinned areas, such as the palms and soles, may be particularly difficult to characterize. A thorough history and physical examination are usuallysufficient for diagnosis because of the visibility of the skin.Adjunctive tests at the time of examination include potassiumhydroxide (KOH) examination for fungi and dermatophytes,skin scrapings for scabies, cytologic examination (Tzancktest) for herpesvirus and varicella-zoster virus infection, andWood light examination for the yellowish gold fluorescence

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Psoriasis Papules and plaques with silvery scaling H , especially on knees and elbows. Acanthosis with parakeratotic scaling (nuclei still in stratum corneum), Munro microabscesses.  stratum spinosum,  stratum granulosum. Auspitz sign ( I )—pinpoint bleeding spots from exposure of dermal papillae when scales are scraped off. Associated with nail pitting and psoriatic arthritis. Rosacea Inflammatory facial skin disorder characterized by erythematous papules and pustules J , but no comedones. May be associated with facial flushing in response to external stimuli (eg, alcohol, heat). Phymatous rosacea can cause rhinophyma (bulbous deformation of nose).

Topographic Differential Diagnosis of Chronic Plaque Psoriasis: Challenges and Tricks.

Psoriasis is an inflammatory skin disease presenting with erythematous and desquamative plaques with sharply demarcated margins, usually localized on extensor surface areas. To describe the common differential diagnosis of plaque psoriasis classified according to its topography in the scalp, trunk, extremities, folds (i.e., inverse), genital, palmoplantar, nail, and erythrodermic psoriasis. A narrative review based on an electronic database was performed including reviews and original articles published until 1 September 2020, assessing the clinical presentations and differential diagnosis for psoriasis. Several differential diagnoses could be considered with other inflammatory, infectious, and/or neoplastic disorders. Topographical differential diagnosis may include seborrheic dermatitis, tinea capitis, lichen planopilaris in the scalp; lupus erythematosus, dermatomyositis, cutaneous T-cell lymphomas, atopic dermatitis, syphilis, tinea corporis, pityriasis rubra pilaris in the trunk and arms; infectious intertrigo in the inguinal and intergluteal folds and eczema and palmoplantar keratoderma in the palms and soles. Diagnosis of psoriasis is usually straightforward but may at times be difficult and challenging. Skin cultures for dermatophytes and/or skin biopsy for histological examination could be required for diagnostic confirmation of plaque psoriasis.

Erythroderma in adults: a report of 80 cases.

Erythroderma is a generalized erythema of the skin accompanied by a variable degree of scaling. However, most of the published series originate from Western countries. There is only one report from Africa, conducted in Dakar in 1979. The aim of our study was to provide information about this condition in our country. Our study was retrospective, dealing with 80 erythrodermic adults, examined between January 1981 and December 2000. Patient information included clinical, laboratory, histopathologic and therapeutic data. We also noted patients' outcomes within an average follow-up period of 30 months. Thus, we calculated the mortality rate and estimated the probability of survival without relapses according to the Kaplan-Meier method. The frequency of erythroderma in our dermatology department was 0.3. The sex ratio (male/female) was 2.2. The average age of our patients was 53.78 +/- 18 years. Previous history of skin disease was found in 49/80 patients (61.2%) and 32 of them were suffering from psoriasis. Hyperthermia was significantly associated with drug reactions (P = 0.013). Hypereosinophilia was not a specific finding. The mortality rate was higher than that of an age-matched population. Adult erythroderma is a rare condition. Its most common cause in our study was psoriasis. No cases of atopic dermatitis were found. Prognosis was adversely affected by the presence of erythroderma.

Plummer's nail

Plummer's nail is a clinical sign in which there is onycholysis, or separation of the nail from the nail bed, particularly affecting the ring and little fingers. It occurs in patients with thyrotoxicosis. About 5% of hyperthyroid patients display abnormal nail changes. Plummer's nail is also associated with psoriasis, traumatic injury, and allergic contact dermatitis. The sign is named after Henry Stanley Plummer. See also Pili bifurcati List of cutaneous conditions References External links Conditions of the skin appendages

Onychoscopy -- Clinical Significance -- Inflammatory Diseases

Onycholysis has a distinct erythematous or bright yellow-orange border at the proximal end of the onycholytic band, which is relatively straight. In psoriasis, pitting of the nails and splinter hemorrhages have been observed as the most common feature, followed by onycholysis. [80] [81] The oil drop sign or salmon patch is an irregularly-shaped red-orange patch present in nail psoriasis. [82] The splinter hemorrhages appear as bright red to blackish longitudinal fusiform streaks. [82] [83] The nail bed compact hyperkeratosis in psoriasis is unique compared with distal lateral subungual onychomycosis. [12]

Malassezia Furfur -- Differential Diagnosis

Although the diagnosis of SD is usually clinical, clinicians should consider other skin conditions when the presentation is atypical or not responsive to treatment. SD can be challenging to distinguish from psoriasis. Cutaneous manifestations of psoriasis are typically more erythematous with prominent silvery scaling, and plaques are well demarcated. Psoriatic arthritis and nail changes may be present, and it is essential to determine a family history. Rosacea also causes facial erythema, but papules, pustules, and telangiectasis with no scaling occur on the nose and malar and perioral areas. Although atopic dermatitis should be a consideration when presumed SD is refractory to treatment, significant pruritis may be a distinguishing factor, and patch testing can confirm the diagnosis. Secondary syphilis, "the great imitator," may present as multiple psoriasiform lesions and should be tested for with serologic testing when the index of suspicion is high. The malar erythema seen in acute systemic lupus erythematosus may be mistaken for SD, although the former does not affect the nasolabial folds or cross the bridge of the nose. Pemphigus foliaceous presents with erythematous lesions on the head and scalp that extend to the trunk. Prominent features include scaling, crusting, erosions, and pain. Pathohistological and serologic testing secure the diagnosis. In children, tinea infections and diaper dermatitis merit consideration. [11]

Psoriasis -- History and Physical

Erythrodermic psoriasis presents with widespread inflammation in the form of erythema and exfoliation of the skin covering more than 90% of the body area. It is associated with severe itching, swelling, and pain. It is the result of an exacerbation of unstable plaque psoriasis, following the abrupt withdrawal of systemic steroids. Complications of erythroderma include impairment in barrier functions of the skin, disturbance in basal metabolic rate, and increased cutaneous circulation in turn affecting the heart with cardiac failure. Nail changes in psoriasis are seen as pitting, oil spots, subungual hyperkeratosis, nail dystrophy, and anchylosis. Fissured tongue is the most common finding of oral psoriasis and has been reported to occur in 6.5% to 20% of people with psoriasis affecting the skin.

Nail psoriasis: a review of the literature.

Nails are considered epidermal appendages, and as such, are commonly affected in patients with psoriasis, 80% of whom are likely to develop nail psoriasis as a result of their condition. Two patterns of nail disorders have been shown to be caused by psoriasis. Nail matrix involvement can result in features such as leukonychia, pitting (punctures or cupuliform depressions), red spots in the lunula and crumbling. Nail bed involvement, on the other hand, can cause onycholysis, salmon or oil-drop patches, subungual hyperkeratosis and splinter hemorrhages. Nail disease causes aesthetic and functional impairment, and is indicative of more severe forms of psoriasis as well as of joint involvement. The treatment for nail psoriasis involves behavioral interventions, topical medications, or systemic therapy in case of extensive skin or joint involvement. This article presents a review of the main features of nail psoriasis, its clinical presentation, diagnostic and assessment methods, clinical repercussions, and of its available treatment options.

Patterns of clinical nail appearances in patients with cutaneous psoriasis.

Nail manifestations are often an overlooked aspect in psoriatic disease, cutaneous and joint involvement being far more often reported and investigated. The reported prevalence of nail changes varies in literature, specific fingernail clinical features having different degrees of occurrence. The aim of this study was to describe specific clinical patterns of fingernail alterations in adult patients with plaque-type psoriasis in a university hospital in the North-West of Romania. Clinical data of 35 patients with fingernail psoriasis were collected and analyzed. Psoriasis Area and Severity Index (PASI) and Nail Psoriasis Severity Index (NAPSI) scores were used to quantify disease extension in each patient. PASI score proved linearly correlated with NAPSI score (p<0.05). The age of onset of fingernail psoriasis was positively correlated with age of onset cutaneous psoriasis (p<0.0001). Furthermore, the duration of cutaneous involvement and NAPSI proved significantly related (p<0.05). The third fingernail in the right hand and first fingernail in the left hand were in most of the cases severely affected. The most common observed nail pattern was pitting, followed by salmon patches and subungual hyperkeratosis. Important nail changes appear even in moderate forms of cutaneous psoriasis. Particular localization of specific fingernail psoriasis pattern enables the possibility of detecting early stage disease.

Stippled nails

Stippled nails are characterized by small, pinpoint depressions in an otherwise normal nail, and may be an early change seen in psoriasis. See also Nail anatomy List of cutaneous conditions References Conditions of the skin appendages

Systemic disease

For example, pitting looks like depressions in the hard part of the nail. Pitting is to be associated with psoriasis, affecting 10% - 50% of patients with that disorder. Pitting also may be caused by a variety of systemic diseases, including reactive arthritis and other connective tissue disorders, sarcoidosis, pemphigus, alopecia areata, and incontinentia pigmenti. Because pitting is caused by defective layering of the superficial nail plate by the proximal nail matrix, any localized dermatitis (e.g., atopic dermatitis or chemical dermatitis) that disrupts orderly growth in that area also can cause pitting. See also Disease Disseminated disease Fred Siguier List of systemic diseases with ocular manifestations Localized disease Marfan syndrome Systemic autoimmune diseases Systemic inflammation Oral manifestations of systemic disease References Diseases and disorders Medical terminology

Palmoplantar Dermatoses- A Clinical Study of 300 Cases.

Dermatoses affecting palms and soles are among the most difficult of all dermatological therapeutic problems. Many previous studies have focused on the specific diseases of palmoplantar dermatoses. However, none of them have included a comprehensive study of palmoplantar dermatoses. To study the epidemiological aspects like age distribution, sex distribution, the dermatoses affecting the palms & soles and the frequency of involvement of palms, soles or both palms & soles, in patient with palmoplantar dermatoses. This cross sectional study was conducted in the Department of Dermatology between October 2011 to September 2013. First 300 cases attending the department of dermatology primarily with complaints pertaining to palms and soles were enrolled in the study. After taking consent a detailed history and clinical examination pertaining to the aim of the study was recorded and analysed, which included inspection of morphology and distribution of lesions and palpation of any swelling. Direct microscopic examination of scrapings, wet mounted with 10% potassium hydroxide was done for cases with scaly lesions. Those who had a pustule, gram staining was done. Patch testing using Indian Standard Battery Series was done for those cases of eczema. A sample for biopsy was taken when diagnosis could not be arrived clinically, and subjected to histopathological examination. In our study of 300 patients with palmoplantar dermatoses, 164 were females and 136 were males, the ratio observed being 1.2:1. The peak incidence was found in the age group 21-30 years, with 41 females (25%) and 35 males (25.7%). Most frequently affected individuals in this study were housewives (30%). The most common five diseases of palmoplantar dermatoses were palmoplantar psoriasis (20.7%), moniliasis (19%), palmoplantar hyperhidrosis (7%), keratolysis exfoliativa (6%) and pitted keratolysis (6%). Majority of patients had involvement of both palms and soles (44.3%) as compared to patients with involvement of only palm (28%) and only sole (27.3%). The commonest palmoplantar dermatoses with only palm involvement was keratolysis exfoliativa (16.7%), with only sole involvement was moniliasis (41%) and with both palms and soles involvement was palmoplantar psoriasis (41.4%). Associated nail changes were seen in 80 cases (26.6%), with maximum incidence in palmoplantar psoriasis (62.5%). Associated dermatological conditions were observed in 43 patients (14.3%). Palmoplantar dermatoses are frequently encount-ered in the dermatologic field. Further investigation with a wider and larger population is necessary to understand the epidemiology, based on which accurate diagnosis and proper treatment could be achieved.

Trachonychia

Trachyonychia, is a condition characterized by rough accentuated linear ridges (longitudinal striations) on the nails of the fingers and toes. When the condition occurs on all the twenty nails of the fingers and toes, it is known as twenty-nail dystrophy, most evident in childhood, favoring males. Trachyonychia causes the nails to become opalescent, thin, dull, fragile, and finely longitudinally ridged, and, as a result, distally notched. It can be a manifestation of lichen planus, psoriasis, alopecia areata, immunoglobulin A deficiency, atopic dermatitis, and ichthyosis vulgaris.

The role of histological presentation in erythroderma.

Erythroderma is a serious medical condition characterized by inflamed red skin involving over 90% of the body. It can be the common presentation of different diseases, therefore clinical diagnosis can be problematic. Controversial data are reported regarding the diagnostic value of histological examination in erythroderma subjects. A retrospective study was performed, investigating histological skin specimens of patients with a clinical diagnosis of erythroderma admitted to the Department of Dermatology of State Pediatric Medical University, Saint Petersburg, from 2001 to 2014. Histopathology examination was performed in each case by a pathologist with a special interest in the skin disease who was blind to any clinical information as well as to final diagnosis. Blinded histopathology examination alone was able to give the correct diagnosis in 61% (n = 50/82) of cases when compared to final diagnosis. A diagnosis of psoriasis was made in 23.2% (n = 19/82) of subjects, spongiotic dermatitis/eczema in 20.7% (n = 17/82), mycosis fungoides in 8.5% (n = 7/82), and drug eruption in 8.5%; histological diagnosis was inconclusive or not matching the final diagnosis when available in the remaining 39.1% of cases (n = 32/82). Erythroderma remains a condition difficult to study and treat. We showed that a correct judgment about its cause can be based on objective histopathological criteria in up to 60% of cases. More studies are needed to try to find out further histological and/or immunohistochemical markers that could help the clinician with the erythroderma etiology diagnostic process.