Letters to the Editor
Vesiculobullous viral exanthem due to chikungunya in an infant Sir, Chikungunya is an self‑limiting arboviral disease caused by the chikungunya virus. It is transmitted mainly by the mosquito vectors Aedis aegypti and Aedis albopictus that breed in urban and semi‑urban settings on clean standing (but stagnant) water.[1] Various dermatologic manifestations of chikungunya reported in infants include generalized erythema, maculopapular rash, vesiculobullous lesions, and skin peeling.[2] A 6‑month‑old child presented with high grade fever of three days and vesiculobullous rash of one day duration. Rash was initially erythematous and later turned dusky by the third day with associated blistering. Discrete, black flaccid vesicles and bullae were then noted on the trunk and perineum and spread to the extremities, sparing the face and mucosae [Figures 1 and 2]. The child was otherwise unremarkable with no history of associated seizures, joint swelling, vomiting, or loose stools. There was no history of any medication intake prior to onset of blistering. Hemogram, liver function tests, renal function tests, and cerebrospinal fluid analysis were within normal limits. Blood culture and blister fluid culture were sterile. Serology for chikungunya by IgM antibody capture enzyme‑linked immunosorbent assay (MAC‑ELISA) (National Institute of Virology, Pune, India) was found to be positive from the serum sample sent on the sixth day of fever. An early vesicle was biopsied which on histopathological examination revealed intraepidermal bulla, dilated dermal blood vessels filled with fibrin and epidermal necrosis [Figure 3]. Child was treated
Figure 1: Purpuric vesicles and bullae over the trunk and extremities Indian Dermatology Online Journal - 2014 - Volume 5 - Supplement Issue 2
symptomatically with paracetamol and fever subsided by the seventh day. Vesiculobullous rash started exfoliating by the sixth day and subsided completely without any pigmentary change by the tenth day. In chikungunya, generalized erythematous rash develops abruptly during the first two days of fever followed by maculopapular rash in a centrifugal distribution on the second day of fever usually disappearing by the sixth day. Palms and soles are involved in around two‑thirds of infants, but facial involvement is rare. Vesiculobullous eruptions in infants with chikungunya have been reported.[2‑4] They usually present as sudden onset of flaccid vesicles and bullae usually on the fourth day of fever over the lower limbs that then spread to the perineum, abdomen, chest, and upper limb sparing the face and scalp. Lesions exfoliate by the sixth day and heal by the tenth day sometimes leaving behind pigmentary changes.[2] Clinical diagnosis can be confirmed by virus isolation, viral RNA by real‑time polymerase chain reaction, virus specific immunoglobulin M antibodies by MAC‑ELISA in a single serum sample collected in an acute state or four‑fold increase in immunoglobulin G values in samples collected at least three
Figure 2: Purpuric vesicles and bullae over the gluteal region
S119
Letters to the Editor
Nidhi Singh, Laxmisha Chandrashekar, Deepthi Konda, Devinder Mohan Thappa, Bheemanathi Hanuman Srinivas1, Rahul Dhodapkar2 Departments of Dermatology, 1Pathology, and 2Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India Address for correspondence: Dr. Laxmisha Chandrashekar, Department of Dermatology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 006, India. E-mail: [email protected]
REFERENCES 1. 2.
3.
4. Figure 3: Histopathology of vesicle demonstrating intraepidermal cleft and dilated dermal blood vessels filled with fibrin and epidermal necrosis (H and E, ×100)
weeks apart.[5] There is no specific antiviral therapy. Supportive treatment with paracetamol or other nonsalicylate analgesics is the mainstay of management. All suspected cases should be kept in mosquito nets during the febrile period and mosquito control measures should be adopted.[4]
5.
Kalantri SP, Joshi R, Riley LW. Chikungunya epidemic: An Indian perspective. Natl Med J India 2006;19:315-22. Valamparampil JJ, Chirakkarot S, Letha S, Jayakumar C, Gopinathan KM. Clinical profile of Chikungunya in infants. Indian J Pediatr 2009;76:151-5. Inamadar AC, Palit A, Sampagavi VV, Raghunath S, Deshmukh NS. Cutaneous manifestations of chikungunya fever: Observations made during a recent outbreak in south India. Int J Dermatol 2008;47:154-9. Robin S, Ramful D, Zettor J, Benhamou L, Jaffar-Bandjee MC, Rivière JP, et al. Severe bullous skin lesions associated with Chikungunya virus infection in small infants. Eur J Pediatr 2010;169:67-72. Preparedness and response to chikungunya virus introduction in Americas. CDC Guidelines. Washington, DC: Pan Americal Health Organisation; 2011. Available from: http://www.cdc.gov/ chikungunya. [Last accessed on 2013 Jun 19]. Access this article online Quick Response Code: Website: www.idoj.in
We report this case to highlight the interesting presentation of chikungunya in an infant in the form of vesiculobullous lesions. Chikungunya should be included in the differential diagnosis of febrile vesiculobullous eruption in infants.
Imatinib causing drug rash with eosinophilia and systemic symptoms: A rare cutaneous reaction Sir, Chronic myeloid leukemia (CML) is a myeloproliferative disorder characterized by reciprocal translocation between the long arms of chromosomes 9 and 22 generating the Philadelphia chromosome, that leads to the formation of Bcr-Abl oncogene.[1] This encodes Bcr-Abl protein, leading to constitutive activation of the Abl tyrosine kinase. Imatinib
S120
DOI: 10.4103/2229-5178.146188
mesylate, the first selective tyrosine kinase inhibitor (TKI) targeting Bcr-Abl protein, is effective in the treatment of CML by inducing complete remission and decreased mortality. Most common side effects of TKI include myelosuppression, nausea, vomiting, diarrhea, and skin rashes.[2] Herein we report a case CML who developed features of drug induced rash with eosinophilia and systemic symptoms (DRESS) on initiation of imatinib along with a review of literature regarding its frequency, confirmation of diagnosis and management issues. A 53-year-old male diagnosed with CML in 2005 was treated with hydroxyurea only as he could not afford TKI. He was otherwise asymptomatic except for mild weakness. He had no residual organomegaly or lymphadenopathy. Complete blood counts (CBC) were unremarkable with normal total and differential leucocyte counts. In 2013, cytogenetic re-evaluation Indian Dermatology Online Journal - 2014 - Volume 5 - Supplement Issue 2
Copyright of Indian Dermatology Online Journal 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.
Vesiculobullous viral exanthem due to chikungunya in an infant Sir, Chikungunya is an self‑limiting arboviral disease caused by the chikungunya virus. It is transmitted mainly by the mosquito vectors Aedis aegypti and Aedis albopictus that breed in urban and semi‑urban settings on clean standing (but stagnant) water.[1] Various dermatologic manifestations of chikungunya reported in infants include generalized erythema, maculopapular rash, vesiculobullous lesions, and skin peeling.[2] A 6‑month‑old child presented with high grade fever of three days and vesiculobullous rash of one day duration. Rash was initially erythematous and later turned dusky by the third day with associated blistering. Discrete, black flaccid vesicles and bullae were then noted on the trunk and perineum and spread to the extremities, sparing the face and mucosae [Figures 1 and 2]. The child was otherwise unremarkable with no history of associated seizures, joint swelling, vomiting, or loose stools. There was no history of any medication intake prior to onset of blistering. Hemogram, liver function tests, renal function tests, and cerebrospinal fluid analysis were within normal limits. Blood culture and blister fluid culture were sterile. Serology for chikungunya by IgM antibody capture enzyme‑linked immunosorbent assay (MAC‑ELISA) (National Institute of Virology, Pune, India) was found to be positive from the serum sample sent on the sixth day of fever. An early vesicle was biopsied which on histopathological examination revealed intraepidermal bulla, dilated dermal blood vessels filled with fibrin and epidermal necrosis [Figure 3]. Child was treated
Figure 1: Purpuric vesicles and bullae over the trunk and extremities Indian Dermatology Online Journal - 2014 - Volume 5 - Supplement Issue 2
symptomatically with paracetamol and fever subsided by the seventh day. Vesiculobullous rash started exfoliating by the sixth day and subsided completely without any pigmentary change by the tenth day. In chikungunya, generalized erythematous rash develops abruptly during the first two days of fever followed by maculopapular rash in a centrifugal distribution on the second day of fever usually disappearing by the sixth day. Palms and soles are involved in around two‑thirds of infants, but facial involvement is rare. Vesiculobullous eruptions in infants with chikungunya have been reported.[2‑4] They usually present as sudden onset of flaccid vesicles and bullae usually on the fourth day of fever over the lower limbs that then spread to the perineum, abdomen, chest, and upper limb sparing the face and scalp. Lesions exfoliate by the sixth day and heal by the tenth day sometimes leaving behind pigmentary changes.[2] Clinical diagnosis can be confirmed by virus isolation, viral RNA by real‑time polymerase chain reaction, virus specific immunoglobulin M antibodies by MAC‑ELISA in a single serum sample collected in an acute state or four‑fold increase in immunoglobulin G values in samples collected at least three
Figure 2: Purpuric vesicles and bullae over the gluteal region
S119
Letters to the Editor
Nidhi Singh, Laxmisha Chandrashekar, Deepthi Konda, Devinder Mohan Thappa, Bheemanathi Hanuman Srinivas1, Rahul Dhodapkar2 Departments of Dermatology, 1Pathology, and 2Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India Address for correspondence: Dr. Laxmisha Chandrashekar, Department of Dermatology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 006, India. E-mail: [email protected]
REFERENCES 1. 2.
3.
4. Figure 3: Histopathology of vesicle demonstrating intraepidermal cleft and dilated dermal blood vessels filled with fibrin and epidermal necrosis (H and E, ×100)
weeks apart.[5] There is no specific antiviral therapy. Supportive treatment with paracetamol or other nonsalicylate analgesics is the mainstay of management. All suspected cases should be kept in mosquito nets during the febrile period and mosquito control measures should be adopted.[4]
5.
Kalantri SP, Joshi R, Riley LW. Chikungunya epidemic: An Indian perspective. Natl Med J India 2006;19:315-22. Valamparampil JJ, Chirakkarot S, Letha S, Jayakumar C, Gopinathan KM. Clinical profile of Chikungunya in infants. Indian J Pediatr 2009;76:151-5. Inamadar AC, Palit A, Sampagavi VV, Raghunath S, Deshmukh NS. Cutaneous manifestations of chikungunya fever: Observations made during a recent outbreak in south India. Int J Dermatol 2008;47:154-9. Robin S, Ramful D, Zettor J, Benhamou L, Jaffar-Bandjee MC, Rivière JP, et al. Severe bullous skin lesions associated with Chikungunya virus infection in small infants. Eur J Pediatr 2010;169:67-72. Preparedness and response to chikungunya virus introduction in Americas. CDC Guidelines. Washington, DC: Pan Americal Health Organisation; 2011. Available from: http://www.cdc.gov/ chikungunya. [Last accessed on 2013 Jun 19]. Access this article online Quick Response Code: Website: www.idoj.in
We report this case to highlight the interesting presentation of chikungunya in an infant in the form of vesiculobullous lesions. Chikungunya should be included in the differential diagnosis of febrile vesiculobullous eruption in infants.
Imatinib causing drug rash with eosinophilia and systemic symptoms: A rare cutaneous reaction Sir, Chronic myeloid leukemia (CML) is a myeloproliferative disorder characterized by reciprocal translocation between the long arms of chromosomes 9 and 22 generating the Philadelphia chromosome, that leads to the formation of Bcr-Abl oncogene.[1] This encodes Bcr-Abl protein, leading to constitutive activation of the Abl tyrosine kinase. Imatinib
S120
DOI: 10.4103/2229-5178.146188
mesylate, the first selective tyrosine kinase inhibitor (TKI) targeting Bcr-Abl protein, is effective in the treatment of CML by inducing complete remission and decreased mortality. Most common side effects of TKI include myelosuppression, nausea, vomiting, diarrhea, and skin rashes.[2] Herein we report a case CML who developed features of drug induced rash with eosinophilia and systemic symptoms (DRESS) on initiation of imatinib along with a review of literature regarding its frequency, confirmation of diagnosis and management issues. A 53-year-old male diagnosed with CML in 2005 was treated with hydroxyurea only as he could not afford TKI. He was otherwise asymptomatic except for mild weakness. He had no residual organomegaly or lymphadenopathy. Complete blood counts (CBC) were unremarkable with normal total and differential leucocyte counts. In 2013, cytogenetic re-evaluation Indian Dermatology Online Journal - 2014 - Volume 5 - Supplement Issue 2
Copyright of Indian Dermatology Online Journal 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.
