Unilateral refractory (erosive) conjunctivitis: a peculiar manifestation of pemphigus vulgaris

A woman aged 57 years had conjunctivitis of the right eye since February 2003. It had started with a pinhead-sized blister at the margin of the upper eyelid and was progressive in nature. Intense redness of the right eye, lacrimation, and severe pain confined to the right forehead were the major complaints. She had been under medical care ever since, without any tangible outcome. Its refractory nature impelled the ophthalmologist to seek dermatologic consultation, for apparently the diagnosis seemed to have eluded the consultant. Accordingly, she reported on March 2, 2004 for the opinion of severe incessant itching, profuse lacrimation, and pain that was confined only to the right eye and forehead. The very fact that she had reported with continuous rubbing of the right eye re-enforced the suspicion of the episode being an exclusive expression of pemphigus vulgaris of the eye that probably was the reason for ineffectiveness of the drugs given thus far to her. Examination of the right eye was marked by intense inflammation of the palpebral and bulbar conjunctiva, apparent in the form of severe redness (Figure 1). The conjunctiva was studded with several scattered minute erosions. Corneal opacity and cataract were its accompaniment, whereas the left eye was normal. Mucous membrane of the oral cavity was thoroughly scanned for blister and/or erosions but was normal. The rest of the skin surface was also unaffected. Nikolsky's sign was elicited by asking the patient to rub the eye. In fact, this was responsible for periodic recurrence of the episode. Tzanck test was performed by preparing, fixing, and Giemsa staining the smear from one of the erosions over the conjunctiva. The stained slides were examined under oil-immersion, which revealed plentiful acantholytic cells characterized by large nucleus containing nucleoli and occupying almost the entire eosinophilic cytoplasm and basophilic cell wall. The two biopsies from the conjunctiva were also taken with the help of a 3-mm punch. One of the biopsies was subjected to serial sections. The sections were stained with hematoxylin and eosin stain and examined by light microscopy. The presence of split/cleavage in the epidermis (intraepidermal) above the basal (suprabasal) was cardinal. The cleavage was filled with acantholytic cells of characteristic morphology (vide supra) (Figure 2). The other biopsy was subjected to direct immunofluorescence and was found complementary to the preceding microscopic pathology. Routine investigations comprising total and differential leukocyte count, liver and kidney function tests, chest skiagram, and electrocardiogram were normal. The preceding findings were fairly conducive to form the diagnosis of erosive conjunctivitis emanating from pemphigus vulgaris. Accordingly, pulse therapy (intermittent high-dose) containing 100 mg dexamethasone in 5% glucose daily by slow IV infusion on 3 consecutive days, along with 500 mg of cyclophosphamide on Day 1 only followed by continuous low-dose 50 mg cyclophosphamide, was administered. The patient has since recovered completely and is now under surveillance.     

Arsenic-related health problems among hospital patients in southern Bangladesh

To assess the health effects of arsenic poisoning and to determine the relationship among duration and severity of skin lesions, exposure dose of arsenic, and nutritional status of people, 150 patients attending the Dermatology Outpatients Department of Sher-e-Bangla Medical College Hospital, Barisal, Bangladesh, were included in this cross-sectional study. The study was conducted during January-December 2000. Records of patients were collected prospectively using a pre-tested questionnaire, which included information on demography, sources of water for drinking and cooking, duration and amount of drinking-water obtained from shallow tubewells, clinical presentations, complications, and physical and laboratory findings. Water samples from tubewells currently being used by individual patients were examined. Nine percent of the patients were unaware that arsenic-contaminated water causes diseases. Due to lack of alternative water supplies, 25% of the subjects were still drinking water from contaminated tubewells. About 18% did not complain of any clinical symptoms, except that their skin lesions were ugly-looking, and 82% had moderate or severe skin lesions. Thirty-one percent of the water samples had arsenic concentrations 10-fold higher than the permissible limit of 0.05 mg/L in Bangladesh and 50-fold higher than the WHO guideline value of 0.01 mg/L. The mean arsenic concentration in water was significantly associated with the severity of disease. Body mass index correlated inversely (r = -0.298, p = 0.013) with the duration of disease after controlling for age. The findings suggest the need to enhance public awareness on negative health effects of arsenic poisoning in rural Bangladesh. From a public-health perspective, effective intervention strategies need to be developed to curb the exposure, strengthen rapid diagnostic facilities, establish effective treatment facilities in rural areas, and improve the nutritional status of people.     

Identification of pyrogallol as an antiproliferative compound present in extracts from the medicinal plant Emblica officinalis: effects on in vitro cell growth of human tumor cell lines

In this study we compared the in vitro antiproliferative activity of extracts from medicinal plants toward human tumor cell lines, including human erythromyeloid K562, B-lymphoid Raji, T-lymphoid Jurkat, erythroleukemic HEL cell lines. Extracts from Emblica officinalis were the most active in inhibiting in vitro cell proliferation, after comparison to those from Terminalia arjuna, Aphanamixis polystachya, Oroxylum indicum, Cuscuta reflexa, Aegle marmelos, Saraca asoka, Rumex maritimus, Lagerstroemia speciosa, Red Sandalwood. Emblica officinalis extracts have been studied previously, due to their hepatoprotective, antioxidant, antifungal, antimicrobial and anti-inflammatory medicinal activities. Gas chromatography/mass spectrometry analyses allowed to identify pyrogallol as the common compound present both in unfractionated and n-butanol fraction of Emblica officinalis extracts. Antiproliferative effects of pyrogallol were therefore determined on human tumor cell lines thus identifying pyrogallol as an active component of Emblica officinalis extracts.     

Ocular scrofuloderma with unilateral proptosis

Proptosis due to an extraconal orbital abscess of tubercular origin with lacrimal gland involvement, representing ocular scrofuloderma, is a rare entity. This association has not been reported earlier in the literature. We describe a 7-year-old boy who presented with nodulo-ulcerative lesions of tubercular etiology with discharging sinuses on right side of the face and a similar lesion on the right lower eyelid along with proptosis of 4 months duration. Computerized tomography (CT) scan of the head confirmed the extraconal, intraorbital, hyperdense, homogeneously enhancing mass separated from the lateral rectus muscle and further revealed involvement of lacrimal gland along with erosion of the temporal bone. The patient showed marked improvement of his dermatological and ophthalmological lesions with anti-tubercular treatment. Subsequent ultrasound examinations of the orbit revealed regression in the size of the abscess from 10.7 mm to 5.0 mm and then complete disappearance of the abscess obviating surgical intervention.     

Seasonal variation in acne vulgaris--myth or reality

A traditional opinion proposed by Western dermatologists is that acne improves in summer and worsens in winter. We studied 452 patiens with acne vulgaris and asked them about seasonal variation in their acne. A total of 229 patients (50.67%) complained of a seasonal variation; a significant proportion (56.33%) noticed an aggravation in summer, while 16.16% improved in summer and only 11.35% worsened in winter. Apparently winters did not affect the severity of acne in a majority of patients (64.20%). Significantly, a majority (80.62%) of patients noticed a summer aggravation due to sweating and increased humidity. Thus our study is at variance with the existing literature, with summer aggravation being the predominant complaint. We would like to propose that the increased temperature, marked humidity, and sweating might explain the results seen in our region.     

Intra- and Extracellular Water Dynamics on Rehydration in Cholera and Noncholera Patients

To estimate the intra- and extracellular bodywater compartments during rehydration of patients withcholera and noncholera diarrhea by bioimpedanceanalyzer, we studied 30 patients with acute waterydiarrhea. Total body water (TBW), intracellular water(ICW), and extracellular water (ECW) of severelydehydrated adult patients were measured with a dualfrequency bioimpedance analyzer at different phases ofrehydration. Fluid compartments between cholera andnoncholera patients were compared. Cholera patientsgained more TBW than noncholera patients duringrecovery. Unlike patients with noncholera diarrhea, thegain in cholera patients was mainly contributed by theICW (1.5 ± 1.6 vs 3.0 ± 1.2 liters,respectively, P < 0.01). It was also observed thatthe recovery of the ICW compartment in cholera patientsoccurred rapidly within the first 2 hr after infusion.Differential dynamics of body water compartments incholera compared to noncholera patients as observed inthis study may contribute further to understanding the mechanism of dehydration in diarrhealdisease, which might help in improving casemanagement.