Letters to the Editor
Author’s Response – The efficacy of azithromycin in pityriasis rosea: A randomized, double‑blind, placebo‑controlled trial Sir, We would like to thank Drago et al. for their interest in our publication.[1] The authors also point out that macrolides including azithromycin are known to have antiinflammatory and immuno‑modulatory actions and therefore, their efficacy does not necessarily support bacterial infection (s) or exclude viral infection (s) from being the cause of pityriasis rosea (PR).[2] In 2000, Sharma et al.[3] published a study that showed great success with oral erythromycin in inducing resolution of pityriasis rosea in a group of 45 patients. Similarly, Villarama et al. also found erythromycin to be effective in a randomized double‑blind control trial (unpublished).[2] There was a dearth of randomized double‑blind control trials of macrolides in pityriasis rosea. Amer et al.[4] reported the only randomized double‑blind placebo‑controlled published trial in which azithromycin was not found to be effective. Their study comprised only 49 pediatric patients (mean age: 8 years) while the present study comprised a larger sample size of 70 and included patients with a mean age of 23.3 years (range 2–44 years). Further there were 2 other differences: pityriasis rosea was diagnosed by dermatologists and the objective pityriasis rosea severity score (PRSS) was employed in our study.[4] Chuh et al., in their comprehensive systematic review of interventions in pityriasis rosea, had recommended more randomized controlled trials in particular to investigate the efficacy of oral erythromycin or other macrolide antibiotics.[2] Also, it is pertinent to note that there have been several recent published case reports reporting successful treatment of pityriasis rosea with various macrolides including clarithromycin and roxithromycin.[5,6] The aim of our study was not to find the ideal treatment for pityriasis rosea but to evaluate the efficacy of azithromycin in a double‑blind placebo‑controlled trial. The negative results obtained by us do not favor the prescription of azithromycin for pityriasis rosea.[1] The excellent results of acyclovir obtained by other workers can also be validated by similar double‑blind placebo‑controlled trial using a tool such as pityriasis rosea severity score (PRSS) in a large cohort of patients.[6,7] Finally we concur with the author’s statement that as of now no treatment can be recommended on the basis of
evidence‑based medicine, and pityriasis rosea remains a self‑limiting exanthematous disease that probably just needs reassurance of the patient, which significantly was also the concluding statement of our study.
Deepika Pandhi, Prashant Verma, Archana Singal, Reena Sharma Department of Dermatology and STD, University College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, Delhi, India Address for correspondence: Dr. Deepika Pandhi, B‑1/1101, Vasant Kunj,Delhi ‑ 110 070, India. E‑mail: [email protected]
REFERENCES 1. Pandhi D, Singal A, Verma P, Sharma R. The efficacy of azithromycin in pityriasis rosea: A randomized, double‑blind, placebo‑controlled trial. Indian J Dermatol Venereol Leprol 2014;80:36‑40. 2. Chuh AA, Dofitas BL, Comisel G, Reveiz L, Sharma V, Garner SE, et al. Interventions for pityriasis rosea. Cochrane Database Syst Rev 2007. Available from: http://www.mrw.interscience.wiley. com/cochrane/clsysrev/articles/CD005068/frame.html[Last accessed on 2007 Apr 18]. 3. Sharma PK, Yadav TP, Gautam RK, Taneja N, Satyanarayana L. Erythromycin in pityriasis rosea: A double‑blind, placebo controlled clinical trial. J Am Acad Dermatol 2000;42:241‑4. 4. Amer A, Fischer H. Azithromycin does not cure pityriasis rosea. Pediatrics 2006;117:1702‑5. 5. Singh V, Sharma M, Narang T, Madan M. Vesicular palmoplantar pityriasis rosea. Skinmed 2012;10:116‑8. 6. Ehsani A, Esmaily N, Noormohammadpour P, Toosi S, Hosseinpour A, Hosseini M, et al. The comparison between the efficacy of high dose acyclovir and erythromycin on the period and signs of pityriasis rosea. Indian J Dermatol 2010;55:246‑8. 7. Drago F, Vecchio F, Rebora A. Use of high‑dose acyclovir in pityriasis rosea. J Am Acad Dermatol 2006;54:82‑5. Access this article online Quick Response Code:
Website: www.ijdvl.com DOI: 10.4103/0378-6323.148573 PMID: *****
Cutaneous mercury granuloma following accidental occupational exposure Sir, Inorganic mercury exists as a liquid metal at room temperature. This silver‑colored substance is
Indian Journal of Dermatology, Venereology, and Leprology | January-February 2015 | Vol 81 | Issue 1
57
Letters to the Editor
still routinely used in India in thermometers and sphygmomanometers. Exposure to metallic mercury can have local as well as potentially serious systemic effects. We report a case of accidental occupational exposure, which highlights the need to use alternatives to mercury thermometers. A 28‑year‑old hospital staff nurse presented with complaints of redness, itching and swelling over the dorsum of her left hand 12 days after accidental injury from a mercury thermometer. The lesion had been progressively increasing in size since the injury. There was no history of abdominal pain, nausea, vomiting, diarrhea, breathlessness, cough, decreased urine output, visual disturbances or changes in affect. Cutaneous examination revealed a curvilinear, pink, fleshy plaque with surrounding edema over the left third knuckle [Figure 1]. She was initially treated with potent topical steroids for 2 days, after which an excision biopsy was performed (2 weeks after the injury). Histopathologic examination revealed a dense lympho‑histiocytic infiltrate in the dermis, centered around blood vessels and sweat glands. Also visualized in the deep dermis were black opaque globules indicative of mercury, surrounded by a foreign body granulomatous reaction [Figures 2 and 3]. No polarizable material suggestive of glass fragments was detected. The overlying epidermis showed hyperkeratosis and mild acanthosis.
Accidental inoculation of metallic mercury can have local as well as systemic effects. Local cutaneous reactions include erythema, indurated nodules and plaques with or without ulceration.[1] Gradual absorption from the inoculation site can lead to systemic mercury poisoning. Slow oxidization of metallic mercury to mercury salts occurs on contact with tissue, which then rapidly get distributed systemically and inhibit thiol‑containing enzymes.[2] Oral ingestion of inorganic mercury salts or inhalation of mercury vapors can also lead to systemic mercury poisoning. Systemic effects include acute respiratory failure, renal failure, neurologic features and psychiatric problems.[1] Rarely, systemic contact dermatitis (baboon syndrome) following mercury exposure in previously sensitized individuals can also occur.[3] Metallic mercury, on histopathology, is seen as dark, opaque, spherical globules.[4] Histologically, early reactions show acute inflammation, necrosis and abscess formation with or without ulceration of the overlying skin. Late reactions show granuloma formation with foreign body giant cells around the mercury deposits, perivascular lymphocytic infiltrates, fibrosis and fat necrosis.[5] Our patient had a late granulomatous reaction. Management of mercury inoculation includes prompt and complete surgical excision to halt local reaction and systemic absorption. Blood and urine levels of
Following the excision, the swelling and irritation subsided. The patient did not develop any systemic or psychiatric symptoms. Blood mercury levels were not measured.
Figure 1: Curvilinear, faintly erythematous plaque with surrounding edema over the dorsum of left hand 58
Figure 2: The covering epidermis shows hyperkeratosis and mild acanthosis. The dermis shows a dense lympho-histiocytic infiltrate around blood vessels and sweat glands. Black mercury pigment is visible in the deep dermis (red arrows). (H and E, ×40)
Indian Journal of Dermatology, Venereology, and Leprology | January-February 2015 | Vol 81 | Issue 1
Letters to the Editor
REFERENCES 1.
Figure 3: High power view showing dark spherical mercury pigment surrounded by a granulomatous reaction with multinucleated giant cells. (H and E, ×400)
mercury should be monitored where available, and regular assessment for systemic signs and symptoms of mercury poisoning should be done, including evaluation for neuropsychiatric manifestations.[5] Blood and urine levels indicate mercury exposure but do not correlate well with toxicity.[2] Systemic toxicity can be treated with dimercaprol, d‑penicillamine or meso‑2,3‑dimercaptosuccinic acid.[6] Hemodialysis with or without l‑cysteine as a chelating agent can be used in patients with acute renal failure. Since mercury thermometers carry the hazard of accidental inoculation and systemic toxicity, digital thermometers have been recommended as an alternative, which also have the added advantage of being more accurate.[7] The mercury‑free hybrid blood pressure monitor also seems to be a reliable alternative to the currently used mercury sphygmomanometers, with the same level of accuracy.[8] Hospitals could therefore switch over to mercury‑free gadgets to prevent accidental exposure to mercury. We also recommend that the mercury‑containing devices currently in use be disposed of in an environment‑friendly manner.[9]
Anisha George, Kanwardeep Singh Kwatra1, Sirish Chandra2 Department of Dermatology, Christian Medical College, Ludhiana, 1 Department of Pathology, Christian Medical College, Ludhiana, 2 Department of Surgery, Christian Medical College, Ludhiana, Punjab, India Address for correspondence: Dr. Anisha George, Department of Dermatology, Christian Medical College, Ludhiana - 141 008, Punjab, India. E-mail: [email protected]
Jun JB, Min PK, Kim DW, Chung SL, Lee KH. Cutaneous nodular reaction to oral mercury. J Am Acad Dermatol 1997;37:131‑3. 2. Altmeyer MD, Burgdorf MR, Newsome RE, Wang AR. Cutaneous mercury granuloma: A case report. Cutis 2011;88:189‑93. 3. Wen L, Yin J, Ma D‑L, Lanier B. Baboon syndrome induced by mercury ‑ first case report in China. Contact Dermatitis 2007;56:356‑7. 4. Lupton GP, Kao GF, Johnson FB, Graham JH, Helwig EB. Cutaneous mercury granuloma: A clinicopathologic study and review of the literature. J Am Acad Dermatol 1985;12:296‑303. 5. Ellabban MG, Ali R, Hart NB. Subcutaneous metallic mercury injection of the hand. Br J Plast Surg 2003;56:47‑9. 6. Graeme KA, Pollack CV Jr. Heavy metal toxicity, Part I: Arsenic and mercury. J Emerg Med 1998;16:45‑56. 7. Fadzil FM, Choon D, Arumugam K. A comparative study on the accuracy of noninvasive thermometers. Aust Fam Physician 2010;39:237‑9. 8. Stergiou GS, Karpettas N, Kollias A, Destounis A, Tzamouranis D. A perfect replacement for the mercury sphygmomanometer: The case of the hybrid blood pressure monitor. J Hum Hypertens 2012;26:220‑7. 9. DiCarlo M, Ruck B, Marcus S. How should a fever mercury thermometer be disposed of? A survey of those likely to be asked. Pediatrics 2002;109:E71‑1. Access this article online Quick Response Code:
Website: www.ijdvl.com DOI: 10.4103/0378-6323.148574 PMID: *****
Subcutaneous human dirofilariasis Sir, We present a case of human subcutaneous dirofilariasis, a zoonosis of clinical importance. Dirofilariasis is a potentially fatal infection in dogs and certain other animals. Accidental infection occurs in humans due to bites from mosquitoes carrying the infective microfilariae. Human ocular and pulmonary dirofilariasis are more common than subcutaneous involvement. We report a case to focus attention on this rare cause of a subcutaneous nodule which is often misdiagnosed or overlooked. In December 2013, a 40‑year‑old carpenter presented to our tertiary care center in Kerala with a painful swelling over the right side of his abdomen, present since 2 weeks. There was no history of contact with dogs or other animals.
Indian Journal of Dermatology, Venereology, and Leprology | January-February 2015 | Vol 81 | Issue 1
59
Copyright of Indian Journal of Dermatology, Venereology & Leprology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Author’s Response – The efficacy of azithromycin in pityriasis rosea: A randomized, double‑blind, placebo‑controlled trial Sir, We would like to thank Drago et al. for their interest in our publication.[1] The authors also point out that macrolides including azithromycin are known to have antiinflammatory and immuno‑modulatory actions and therefore, their efficacy does not necessarily support bacterial infection (s) or exclude viral infection (s) from being the cause of pityriasis rosea (PR).[2] In 2000, Sharma et al.[3] published a study that showed great success with oral erythromycin in inducing resolution of pityriasis rosea in a group of 45 patients. Similarly, Villarama et al. also found erythromycin to be effective in a randomized double‑blind control trial (unpublished).[2] There was a dearth of randomized double‑blind control trials of macrolides in pityriasis rosea. Amer et al.[4] reported the only randomized double‑blind placebo‑controlled published trial in which azithromycin was not found to be effective. Their study comprised only 49 pediatric patients (mean age: 8 years) while the present study comprised a larger sample size of 70 and included patients with a mean age of 23.3 years (range 2–44 years). Further there were 2 other differences: pityriasis rosea was diagnosed by dermatologists and the objective pityriasis rosea severity score (PRSS) was employed in our study.[4] Chuh et al., in their comprehensive systematic review of interventions in pityriasis rosea, had recommended more randomized controlled trials in particular to investigate the efficacy of oral erythromycin or other macrolide antibiotics.[2] Also, it is pertinent to note that there have been several recent published case reports reporting successful treatment of pityriasis rosea with various macrolides including clarithromycin and roxithromycin.[5,6] The aim of our study was not to find the ideal treatment for pityriasis rosea but to evaluate the efficacy of azithromycin in a double‑blind placebo‑controlled trial. The negative results obtained by us do not favor the prescription of azithromycin for pityriasis rosea.[1] The excellent results of acyclovir obtained by other workers can also be validated by similar double‑blind placebo‑controlled trial using a tool such as pityriasis rosea severity score (PRSS) in a large cohort of patients.[6,7] Finally we concur with the author’s statement that as of now no treatment can be recommended on the basis of
evidence‑based medicine, and pityriasis rosea remains a self‑limiting exanthematous disease that probably just needs reassurance of the patient, which significantly was also the concluding statement of our study.
Deepika Pandhi, Prashant Verma, Archana Singal, Reena Sharma Department of Dermatology and STD, University College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, Delhi, India Address for correspondence: Dr. Deepika Pandhi, B‑1/1101, Vasant Kunj,Delhi ‑ 110 070, India. E‑mail: [email protected]
REFERENCES 1. Pandhi D, Singal A, Verma P, Sharma R. The efficacy of azithromycin in pityriasis rosea: A randomized, double‑blind, placebo‑controlled trial. Indian J Dermatol Venereol Leprol 2014;80:36‑40. 2. Chuh AA, Dofitas BL, Comisel G, Reveiz L, Sharma V, Garner SE, et al. Interventions for pityriasis rosea. Cochrane Database Syst Rev 2007. Available from: http://www.mrw.interscience.wiley. com/cochrane/clsysrev/articles/CD005068/frame.html[Last accessed on 2007 Apr 18]. 3. Sharma PK, Yadav TP, Gautam RK, Taneja N, Satyanarayana L. Erythromycin in pityriasis rosea: A double‑blind, placebo controlled clinical trial. J Am Acad Dermatol 2000;42:241‑4. 4. Amer A, Fischer H. Azithromycin does not cure pityriasis rosea. Pediatrics 2006;117:1702‑5. 5. Singh V, Sharma M, Narang T, Madan M. Vesicular palmoplantar pityriasis rosea. Skinmed 2012;10:116‑8. 6. Ehsani A, Esmaily N, Noormohammadpour P, Toosi S, Hosseinpour A, Hosseini M, et al. The comparison between the efficacy of high dose acyclovir and erythromycin on the period and signs of pityriasis rosea. Indian J Dermatol 2010;55:246‑8. 7. Drago F, Vecchio F, Rebora A. Use of high‑dose acyclovir in pityriasis rosea. J Am Acad Dermatol 2006;54:82‑5. Access this article online Quick Response Code:
Website: www.ijdvl.com DOI: 10.4103/0378-6323.148573 PMID: *****
Cutaneous mercury granuloma following accidental occupational exposure Sir, Inorganic mercury exists as a liquid metal at room temperature. This silver‑colored substance is
Indian Journal of Dermatology, Venereology, and Leprology | January-February 2015 | Vol 81 | Issue 1
57
Letters to the Editor
still routinely used in India in thermometers and sphygmomanometers. Exposure to metallic mercury can have local as well as potentially serious systemic effects. We report a case of accidental occupational exposure, which highlights the need to use alternatives to mercury thermometers. A 28‑year‑old hospital staff nurse presented with complaints of redness, itching and swelling over the dorsum of her left hand 12 days after accidental injury from a mercury thermometer. The lesion had been progressively increasing in size since the injury. There was no history of abdominal pain, nausea, vomiting, diarrhea, breathlessness, cough, decreased urine output, visual disturbances or changes in affect. Cutaneous examination revealed a curvilinear, pink, fleshy plaque with surrounding edema over the left third knuckle [Figure 1]. She was initially treated with potent topical steroids for 2 days, after which an excision biopsy was performed (2 weeks after the injury). Histopathologic examination revealed a dense lympho‑histiocytic infiltrate in the dermis, centered around blood vessels and sweat glands. Also visualized in the deep dermis were black opaque globules indicative of mercury, surrounded by a foreign body granulomatous reaction [Figures 2 and 3]. No polarizable material suggestive of glass fragments was detected. The overlying epidermis showed hyperkeratosis and mild acanthosis.
Accidental inoculation of metallic mercury can have local as well as systemic effects. Local cutaneous reactions include erythema, indurated nodules and plaques with or without ulceration.[1] Gradual absorption from the inoculation site can lead to systemic mercury poisoning. Slow oxidization of metallic mercury to mercury salts occurs on contact with tissue, which then rapidly get distributed systemically and inhibit thiol‑containing enzymes.[2] Oral ingestion of inorganic mercury salts or inhalation of mercury vapors can also lead to systemic mercury poisoning. Systemic effects include acute respiratory failure, renal failure, neurologic features and psychiatric problems.[1] Rarely, systemic contact dermatitis (baboon syndrome) following mercury exposure in previously sensitized individuals can also occur.[3] Metallic mercury, on histopathology, is seen as dark, opaque, spherical globules.[4] Histologically, early reactions show acute inflammation, necrosis and abscess formation with or without ulceration of the overlying skin. Late reactions show granuloma formation with foreign body giant cells around the mercury deposits, perivascular lymphocytic infiltrates, fibrosis and fat necrosis.[5] Our patient had a late granulomatous reaction. Management of mercury inoculation includes prompt and complete surgical excision to halt local reaction and systemic absorption. Blood and urine levels of
Following the excision, the swelling and irritation subsided. The patient did not develop any systemic or psychiatric symptoms. Blood mercury levels were not measured.
Figure 1: Curvilinear, faintly erythematous plaque with surrounding edema over the dorsum of left hand 58
Figure 2: The covering epidermis shows hyperkeratosis and mild acanthosis. The dermis shows a dense lympho-histiocytic infiltrate around blood vessels and sweat glands. Black mercury pigment is visible in the deep dermis (red arrows). (H and E, ×40)
Indian Journal of Dermatology, Venereology, and Leprology | January-February 2015 | Vol 81 | Issue 1
Letters to the Editor
REFERENCES 1.
Figure 3: High power view showing dark spherical mercury pigment surrounded by a granulomatous reaction with multinucleated giant cells. (H and E, ×400)
mercury should be monitored where available, and regular assessment for systemic signs and symptoms of mercury poisoning should be done, including evaluation for neuropsychiatric manifestations.[5] Blood and urine levels indicate mercury exposure but do not correlate well with toxicity.[2] Systemic toxicity can be treated with dimercaprol, d‑penicillamine or meso‑2,3‑dimercaptosuccinic acid.[6] Hemodialysis with or without l‑cysteine as a chelating agent can be used in patients with acute renal failure. Since mercury thermometers carry the hazard of accidental inoculation and systemic toxicity, digital thermometers have been recommended as an alternative, which also have the added advantage of being more accurate.[7] The mercury‑free hybrid blood pressure monitor also seems to be a reliable alternative to the currently used mercury sphygmomanometers, with the same level of accuracy.[8] Hospitals could therefore switch over to mercury‑free gadgets to prevent accidental exposure to mercury. We also recommend that the mercury‑containing devices currently in use be disposed of in an environment‑friendly manner.[9]
Anisha George, Kanwardeep Singh Kwatra1, Sirish Chandra2 Department of Dermatology, Christian Medical College, Ludhiana, 1 Department of Pathology, Christian Medical College, Ludhiana, 2 Department of Surgery, Christian Medical College, Ludhiana, Punjab, India Address for correspondence: Dr. Anisha George, Department of Dermatology, Christian Medical College, Ludhiana - 141 008, Punjab, India. E-mail: [email protected]
Jun JB, Min PK, Kim DW, Chung SL, Lee KH. Cutaneous nodular reaction to oral mercury. J Am Acad Dermatol 1997;37:131‑3. 2. Altmeyer MD, Burgdorf MR, Newsome RE, Wang AR. Cutaneous mercury granuloma: A case report. Cutis 2011;88:189‑93. 3. Wen L, Yin J, Ma D‑L, Lanier B. Baboon syndrome induced by mercury ‑ first case report in China. Contact Dermatitis 2007;56:356‑7. 4. Lupton GP, Kao GF, Johnson FB, Graham JH, Helwig EB. Cutaneous mercury granuloma: A clinicopathologic study and review of the literature. J Am Acad Dermatol 1985;12:296‑303. 5. Ellabban MG, Ali R, Hart NB. Subcutaneous metallic mercury injection of the hand. Br J Plast Surg 2003;56:47‑9. 6. Graeme KA, Pollack CV Jr. Heavy metal toxicity, Part I: Arsenic and mercury. J Emerg Med 1998;16:45‑56. 7. Fadzil FM, Choon D, Arumugam K. A comparative study on the accuracy of noninvasive thermometers. Aust Fam Physician 2010;39:237‑9. 8. Stergiou GS, Karpettas N, Kollias A, Destounis A, Tzamouranis D. A perfect replacement for the mercury sphygmomanometer: The case of the hybrid blood pressure monitor. J Hum Hypertens 2012;26:220‑7. 9. DiCarlo M, Ruck B, Marcus S. How should a fever mercury thermometer be disposed of? A survey of those likely to be asked. Pediatrics 2002;109:E71‑1. Access this article online Quick Response Code:
Website: www.ijdvl.com DOI: 10.4103/0378-6323.148574 PMID: *****
Subcutaneous human dirofilariasis Sir, We present a case of human subcutaneous dirofilariasis, a zoonosis of clinical importance. Dirofilariasis is a potentially fatal infection in dogs and certain other animals. Accidental infection occurs in humans due to bites from mosquitoes carrying the infective microfilariae. Human ocular and pulmonary dirofilariasis are more common than subcutaneous involvement. We report a case to focus attention on this rare cause of a subcutaneous nodule which is often misdiagnosed or overlooked. In December 2013, a 40‑year‑old carpenter presented to our tertiary care center in Kerala with a painful swelling over the right side of his abdomen, present since 2 weeks. There was no history of contact with dogs or other animals.
Indian Journal of Dermatology, Venereology, and Leprology | January-February 2015 | Vol 81 | Issue 1
59
Copyright of Indian Journal of Dermatology, Venereology & Leprology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
