The relative mildness of the symptoms, which do not seriously interfere with daily activities, excludes in principle the diagnosis of major depression. There is no evidence of hypomanic phases to justify a bipolar II disorder. Dysthymia requires a duration of at least two years. Cyclothymia is a very rare diagnosis nowadays (because, as Castilla del Pino said in an interview, what used to be cyclothymics are now called bipolar, contributing to one of the multiple psychiatric epidemics of our time), which consists of oscillations between the depressive pole and the manifest, mild. But there are no data on such oscillations. The correct answer is, in all probability, 3. The adaptive disorder appears within 3 months after the stressful event and does not last more than 6 months if the stressful event or its consequences have ceased (which is not the case because the brother of the imaginary patient is still dead). Mild anxious-depressive symptoms fit such a diagnosis. One more example of how to conceptualize as illness what are facts (albeit painful) of life. Surely the imaginary patient takes some antidepressant because maybe something helps (1).

The relative mildness of the symptoms, which do not seriously interfere with daily activities, excludes in principle the diagnosis of major depression. There is no evidence of hypomanic phases to justify a bipolar II disorder. Dysthymia requires a duration of at least two years. Cyclothymia is a very rare diagnosis nowadays (because, as Castilla del Pino said in an interview, what used to be cyclothymics are now called bipolar, contributing to one of the multiple psychiatric epidemics of our time), which consists of oscillations between the depressive pole and the manifest, mild. But there are no data on such oscillations. [HIDDEN] The adaptive disorder appears within 3 months after the stressful event and does not last more than 6 months if the stressful event or its consequences have ceased (which is not the case because the brother of the imaginary patient is still dead). Mild anxious-depressive symptoms fit such a diagnosis. One more example of how to conceptualize as illness what are facts (albeit painful) of life. Surely the imaginary patient takes some antidepressant because maybe something helps [HIDDEN].

A 36-year-old patient from another culture who has been living in Spain for the last 4 years presents at a National Health Service office. He reports presenting with anxious symptoms and depressive mood for the last 10 months. This condition moderately interferes with her daily activities. She has no previous psychiatric history. This situation is the result of the death, in a car accident, of an older brother with whom he was very close. Indicate which of the following diagnoses is appropriate:

When Dementia Kills Before One Passes Away: Case Report of Cotard's Syndrome.

Cotard's Syndrome (CS), among the noncognitive changes in the forms of dementia, is a seldom-found manifestation (1). This syndrome is characterized by the delusion of having lost organs (the individual experiences huge changes in the body and believes that he/she no longer has one or more organs) and by nihilistic delusion (the individual believes he/she or everyone in the world has died or been destroyed) (2). In 1880, Jules Cotard (1840-1889) described a clinical condition that he believed corresponded to a new subtype of depression, which he called anxious melancholia. He proposed that a state of acute depression and morbid anxiety could foster the development of structured delusions of hypochondria. Two years later he referred to the same clinical condition using the term délires des négations for the first time (3). The eponym CS was only introduced in 1893 by Emil Regis, who stated that Cotard had not described a new clinical entity but rather a syndrome - a cluster of symptoms that could also be found in other mental illnesses apart from depression and in which anxiety was the central characteristic (4). The most prominent symptoms found in an analysis of one hundred cases were: depressed mood (89%), nihilistic delusion (69%), anxiety (65%), delusion of guilt (63%), delusion of immortality (55%) and hypochondriacal delusions (58%) (12). Currently, CS is not classified as an isolated disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) of the American Psychiatric Association or in the International Statistical Classification of Diseases and Related Health Problems (ICD-10). There is a growing consensus to consider it a secondary syndrome of an underlying disorder, of which the most associated disorders are: unipolar depression, bipolar depression and primary psychotic disorders. Other conditions have also been described, such as dementia, severe intellectual disability, cerebrovascular accident, brain tumor, and Parkinson's disease, among others (5).

[Importance of DSM IV (APA) and ICD-10 (WHO) in diagnosis and treatment of mood disorders].

Since 1993, with ICD-10 (WHO), and 1994, with DSM IV (APA), practitioners have had at their disposal two (practically compatible) classifications of mental disorders containing operational criteria for diagnosis, and helpful in guiding clinical and therapeutic approach. Moreover, the use of one of these classifications (ICD-10) is compulsory in French state psychiatric institutions. We shall try to convince that these manuals are useful, and indeed unavoidable, henceforth, not only for researchers but also for practitioners, for the following reasons: "Any form of order is preferable to chaos" (Lévi Strauss); An implicit classification is always at work, even where the clinician feels he is working by intuition and treating each patient as a unique and individual case. It is not necessarily a bad thing to compare one's own stereotypes with currently held beliefs; All efforts to evaluate treatments, both psychotherapeutic and chemotherapeutic, are now based on these clinical definitions and models. Particularly as regards mood disorders, DSM III and DMS IV have managed to rid us of the uncertainties and contradictions surrounding etiopathogenesis (endogenous? psychogenic? reactive? defensive? adaptive? biological? etc.) which previously ruled out any explanatory classification. There still remain a number of pathological pictures of proven existence but with different levels of significance and different treatments. The bipolar/unipolar distinction (BP/UP) has been strengthened. Major depression (actual "depression", of moderate severity) remains the central model, and exists in both the unipolar and bipolar forms. There is also chronic (more than 2 years) progressive dysthymia (UP) which corresponds almost exactly to "Depressive personality". For bipolar disorders, the distinction between bipolar I disorders and bipolar II disorders, which is now well-documented, has been retained. Cyclothymia (lasting over 2 years) is in a sense the bipolar equivalent of dysthymia. Mixed disorders are distinguished from rapid-cycling bipolar disorders. It is now known that the range of bipolar disorders requires treatment with thymoleptic drugs and that antidepressants should be used only in unipolar disorders, and occasionally in bipolar forms to treat certain acute episodes of depression. Furthermore, many specific clinical forms are defined: postnatal depression, seasonal depression, adaptive difficulties with depressive mood or anxiety and depression, iatrogenic depression or depression related to medication or to intercurrent illnesses. Moreover, criteria are also suggested "for future studies" of post-psychotic depression in schizophrenic patients, minor depression, brief recurrent depressive episodes and anxio-depressive syndrome.

Transfers to psychiatry through the consultation-liaison psychiatry service: 11 years of experience.

There are only a few reports on issues related to patient transfer from medical and surgical departments to the psychiatric ward by the consultation-liaison psychiatry service, although it is a common practice. Here, we present a study assessing the factors that influence such transfers. We examined the demographic and clinical backgrounds of a group of patients transferred from internal medicine and surgery to the psychiatric ward over an 11-year period. A comparison was made of this data with data obtained from a group of non-transferred patients, also seen by the same consultation-liaison psychiatry service. According to our findings, the typical transferred patient, either female or male, is single, divorced or widowed, lives alone, belongs to a lower socioeconomic class, presents initially with (on the whole) a disturbed and disruptive behaviour, has had a recent suicide attempt with persistent suicidal ideas, suffers from a mood disorder (mainly depressive and dysthymic disorders), has a prior psychiatric history as well as a prior psychiatric inpatient treatment, and a positive diagnosis on axis II of the five axis system used for mental health diagnosis. The transfer of a patient to the psychiatric ward is a decision depending on multiple factors. Medical diagnoses do not seem to play a major role in the transfer to the psychiatric ward. From the psychiatric diagnosis, depressive and dysthymic disorders are the most common in the transferred population, whilst the transfer is influenced by social factors regarding the patient, the patient's behaviour, the conditions in the ward she/he is treated in and any recent occurrence(s) that increase the anxiety of the staff.

The Occurrence of Funeral Mania After Bereavement: A Case Report.

Stressful or traumatic life events can lead to emergence of mood episodes. Events such as migration, relocation, job loss, bankruptcy, economic loss, divorce, natural disasters, accidental injury, or the loss of a loved one can trigger the first episode of bipolar disorder. After such life events, symptoms of depressive episodes often appear. Funeral mania, on the other hand, is defined as the emergence of manic episodes following the death of a close family member. Information on funeral mania, which occurs shortly after the loss of a loved one, is limited with a few case reports. In this study, a 26-year-old female patient who presented with the symptoms of a manic episode for the first time after her father's death and who had no previous psychiatric disease or treatment history was presented in the light of findings in the literature. It is noteworthy that the patient, who was followed up with the diagnosis of bipolar disorder (mania period) according to DSM-5 diagnostic criteria, had a temporal closeness between her mood symptoms and her father's death, and had not developed such a reaction to previous traumatic life events. Therefore, the diagnosis was evaluated as funeral mania. It should be kept in mind that, although rare, symptoms of mania can be seen among possible grief reactions.

List of people with bipolar disorder

J Jesse Jackson, Jr., former member of the United States House of Representatives, has stated he's been diagnosed with bipolar II disorder. Kay Redfield Jamison, American clinical psychologist, professor of psychiatry and writer, has written extensively about her personal experiences with bipolar disorder, including in An Unquiet Mind. Jang Keun Suk, South Korean actor and singer. Jill Janus, American heavy metal singer. Adam Jasinski, winner of the U.S. series Big Brother 9. Andrew Johns, Australian rugby league player. Publicly announced his condition following retirement. "Fast" Eddie Johnson, American basketball player, was diagnosed with manic depression. Daniel Johnston, musician, singer-songwriter and visual artist. Lucia Joyce, daughter of writer James Joyce, was diagnosed with cyclothymia. Sarah Joyce, British singer–songwriter. Helmi Juvonen, American artist and painter, hospitalized and diagnosed with manic-depression.

Major depressive disorder

To confirm major depressive disorder as the most likely diagnosis, other potential diagnoses must be considered, including dysthymia, adjustment disorder with depressed mood, or bipolar disorder. Dysthymia is a chronic, milder mood disturbance in which a person reports a low mood almost daily over a span of at least two years. The symptoms are not as severe as those for major depression, although people with dysthymia are vulnerable to secondary episodes of major depression (sometimes referred to as double depression). Adjustment disorder with depressed mood is a mood disturbance appearing as a psychological response to an identifiable event or stressor, in which the resulting emotional or behavioral symptoms are significant but do not meet the criteria for a major depressive episode. Bipolar disorder, previously known as manic–depressive disorder, is a condition in which depressive phases alternate with periods of mania or hypomania. Although depression is currently categorized as a

Darvon dependence: three case studies.

Several shared symptoms are evident among the subjects described here. First of all, each subject complained of feelings of depression, consistently and frequently. In other words, in each case, the subject described him/herself as "being depressed." The detailed examination of the case notes kept by the counselors who treated these individuals indicates a more specific symptomology associated with their depression. On a more specific level, each of the subjects expressed feelings of worthlessness, hopelessness, despair, and self-destruction. In at least two of the cases, self-destructive feelings were translated into potentially suicidal actions. In addition, each of the three subjects experienced pronounced mood swings. Alternating between periods of deep depression (associated with stagnant or regressive behavior) and periods of relative optimism when at least temporary progress in therapy was evident. During these apparent periods of improvement, the subjects often related major plans of action intended to improve their lot, including new jobs, furthering their education, withdrawing entirely from drug use, patching up marital and family disorder, etc. In each case before these major improvements could be initiated, the subjects would relapse into depressed states and their plans would dissolve like so many fantasies. These cyclical mood swings and their accompanying polar manifestations would seem, superficially, indicative of a type of manic-depressive illness. It should be noted, however, that at no time did any of the subjects undergo thorough psychological testing. Such testing is planned for Subject B, who remains in treatment at this time. Each subject complained of experiencing acute anxiety attacks during his periods of depression.(ABSTRACT TRUNCATED AT 250 WORDS)

Dysthymia

In children and adolescents, mood can be irritable, and duration must be at least one year, in contrast to two years needed for diagnosis in adults. Early onset (diagnosis before age 21) is associated with more frequent relapses, psychiatric hospitalizations, and more co-occurring conditions. For younger adults with dysthymia, there is a higher co-occurrence in personality abnormalities and the symptoms are likely chronic. However, in older adults suffering from dysthymia, the psychological symptoms are associated with medical conditions and/or stressful life events and losses. Dysthymia can be contrasted with major depressive disorder by assessing the acute nature of the symptoms. Dysthymia is far more chronic (long lasting) than major depressive disorder, in which symptoms may be present for as little as 2 weeks. Also Dysthymia often presents itself at an earlier age than Major Depressive Disorder.

Death of John Carthy

Background John Carthy, born 9 October 1972, was the only son of John and Rose Carthy. He had one sister, Marie, who was two years his junior. He was an avid Handballer and member of Abbeylara Handball Club. His father, with whom he was very close, died on 12 April 1990. In 1992 John was diagnosed with clinical depression and, subsequently with bipolar affective disorder. John's general employment was in the construction industry. He resided with his mother in an old three-bedroom house in Toneymore, Abbeylara. She and John were due to move from this old house to a new home that had been built on their land by Longford County Council as part of a rural housing scheme. The old house was due to be demolished. On 19 April 2000, the day prior to his death, John stayed in the family home all day with his mother. His mother's testimony to the Barr Tribunal indicated that John was very hostile to the move and that this was the primary topic of their discussions that day.

"Is It Her Hormones?": Psychiatric Diagnoses and Polycystic Ovarian Syndrome.

Beth, whom you have cared for in your primary care practice since she was born, is a 15-year-old adolescent girl with no prior psychiatric history who developed significant symptoms of clinical depression, associated with self-injurious behavior (cutting on wrists, arms, and thighs). She denied any known precipitant for her depression.She is a ninth grade honors student in the gifted program at a local high school and is described as a talented musician, playing multiple musical instruments as well as soccer and basketball. She has good family support, was sociable, and had several close friends. She denied any history of trauma and denied ever using recreational drugs or other mood-altering substances.At this visit, she reported feeling "sad and anxious." Family history was significant for maternal depression, which persisted through her teens and twenties. Her older sister had been diagnosed with Social Anxiety Disorder. Beth reported anhedonia, fatigue and irritable mood, lack of motivation, impaired concentration, and anxiety related to failing grades.You decide to begin medication because of the severity of her symptoms, and 1 week after starting fluoxetine 10 mg, she reportedly overdosed on an unknown quantity of acetaminophen. Within a few days of switching to escitalopram (due to persistent gastrointestinal complaints while taking fluoxetine), she developed homicidal ideation. She reported feeling grandiose, empowered, invincible, elated, and "crazy," although she never demonstrated or endorsed psychotic symptoms. She became fixated upon the idea that she could kill someone and "get away with it." At the time she tried to suffocate a peer with her hands, she was described as having "a glazed over look in her eyes." Moods were now described as alternating between depressed and elated, with mood shifts occurring every few days. These symptoms did not improve after the antidepressant medication was discontinued.Subsequently, patient was admitted for acute psychiatric care, at which time she was described as depressed, but with an "expansive and irritable" mood, and with obsessive suicidal ideation. She had developed a plan to hang herself in the home. She started to believe that her mother was trying to give her "poison." She reported panic attacks and said that she wanted to be in the hospital where she could feel "safe." She claimed to have an "entity inside of her body who was a bully" and who was "taking over her body" and stated that he put her hand over her peer's mouth, as she watched.Psychological testing included the Minnesota Multiphasic Personality Inventory-Adolescent, showed significant paranoia, bizarre mentation, and poor reality testing. Along with interview and observation, it was determined that patient met criteria for the DSM-IV-TR clinical diagnosis of Other Specified Bipolar Disorder, with psychotic features.Aripiprazole was initiated at a dosage of 2 mg; however, moods were still described as fluctuating between extremes every few hours. It was discontinued after reaching 5 mg due to affective blunting. Risperidone 0.5 mg twice daily helped patient to feel and act "more like herself"; however, she continued to report significant depression. The addition of lamotrigine 25 mg daily, in addition to individual Dialectical Behavior Therapy, finally led to improvement of mood and a gradual return of her normal baseline, with reportedly stable emotional, social, and academic functioning.The patient's mother remained convinced that this adolescent's mood instability was caused by underlying hormonal problems so you refer her to endocrinology. Beth developed puberty at age 8, with menses occurring on average of twice yearly. She was found to have elevated free testosterone level of 8.6 (reference range, 1.2-7.5). She was of normal weight (body mass index = 21.85 kg/m) and did not manifest acne, male pattern hair thinning, or hirsutism. Thyroid functions, 17-OH progesterone, follicle-stimulating hormone/luteinizing hormone, and estradiol were within normal limits. Prolactin elevation (46.3) was assumed to be due to Risperidone. Patient refused ovarian ultrasound.After starting oral contraceptives to establish monthly menses, patient's emotional and behavioral symptoms continue to remain stable. After Beth decided on her own to discontinue psychotropic medications, she continued for 17 months following her initial visit to remain free of neuropsychiatric symptoms.Now that her symptoms seem resolved; you wonder what the medical diagnosis for Beth was? You wonder if "hormones" may have caused or contributed to her psychiatric presentation.

[Bipolarity among unipolar affective disorder patients--uniDEP-BI national multi-site study].

The main objective of the study was to evaluate the occurrence of bipolarity among outpatients with a recurrent major depressive disorder. The uniDEP-BI study was conducted throughout Poland by 96 psychiatrists from 16 sites, who were trained in the study instruments. The sample was selected from the population of outpatients with at least one depressive episode (n = 880). The final study group included 246 working age adults (75.2% of females) treated for recurrent unipolar disorder. The study questionnaire consisted in the DSM-IV criteria of major depressive episode, (hypo)manic episode, criteria for bipolar spectrum disorder by Ghaemi et al. Unipolar mood disorder was confirmed in 32.9% cases, bipolar I disorder was found in 19.5%, bipolar II in 35% and bipolar spectrum disorder in 12.6% of the assessed patients. Patients with bipolar compared to the unipolar mood disorder had significantly more frequently a family history of bipolar disorder, short (hypo)manic episodes after antidepressive treatment, premorbid cyclo-, hyperthymic or impulsive (borderline type) personality, recurrent depressive episodes, atypical depressive symptoms, early onset of depression (< 25 yrs), distracted attention and panic attacks. Subjects with confirmed recurrent depressive disorder were significantly more often working (37.2% vs. 22.7%). Duration of the illness was significantly shorter and the number of previous depressive episodes was significantly lower in this group. The findings showed that the bipolarity features are more common among patients with unipolar mood disorders. It also points to a need of proper and deeper diagnostics of affective disorders and verification of rules and period of antidepressive and normothymic treatment.

Outline of bipolar disorder

Bipolar spectrum – Bipolar I – bipolar disorder with at least one manic episode (with or without psychosis), possibly with hypomanic and/or depressive episodes as well Bipolar II – bipolar disorder with at least one depressive and at least one hypomanic episode, without any full mania Cyclothymia – "mild" bipolar disorder, with symptoms of hypomania and depression not severe enough to be classified as bipolar I or II Dysthymia – akin to depression, with symptoms that are long-lasting but less severe Major depressive disorder – a mood disorder involving low mood, low energy, poor self-esteem, lack of interest in enjoyable activities, and/or aches and pains Schizoaffective disorder – mood swings combined with psychosis; has subtypes bipolar type and depressive type Mania – a state of hyperactivity, heightened mood (euphoric or irritable), low sleep, pressured speech, grandiosity, and/or racing thoughts; may include psychotic features like delusions or hallucinations

An 11-year follow-up study of 110 depressed patients.

In 1972 the World Health Organization organized a cross-cultural five-centre study of depressive disorders. This report is concerned with data collected, after an 11-year follow-up period, in the sample of 110 depressed patients in Montreal, Canada. Eighty-five percent were traced and 59% were interviewed. Of 93 patients, 20 were dead at the follow-up date, 11 by suicide. Fifty-two percent of patients were receiving psychiatric treatment at follow-up, but there was no relation between psychiatric morbidity and treatment-seeking. Moderate or severe impairment of social functioning was present in 32%; in women, a trend linking the presence of social impairment and the time spent in episodes was observed. Of the episodes of psychiatric illness recorded after the index episode, 86% were diagnosed as depressive, 14% as unspecified affective disorder. The mean durations of the index and four subsequent episodes were 10, 11, 7, 11, and 2 months respectively. At least one recurrence after the index episode was reported by 78%, at least four recurrences by 19%. Episodes lasted at least one year in 5%, 4%, 6%, and 6% in the first, second, third and fourth episodes respectively. Sixteen percent were depressed for at least one year and 31% for at least 2 years. There was a marked trend from inpatient to outpatient treatment and from ECT to drug therapy over time. Twenty-two percent reported either moderate or severe problems with alcohol or substance abuse. There was a statistically significant association between the amount of time patients spent in depressive episodes and the number of life events they reported.(ABSTRACT TRUNCATED AT 250 WORDS)

Cyclothymia

Diagnosis Cyclothymia is classified in DSM-5 as a subtype of bipolar disorder. The criteria are: Periods of elevated mood and depressive symptoms for at least half the time during the last two years for adults and one year for children and teenagers. Periods of stable moods last only two months at most. Symptoms create significant problems in one or more areas of life. Symptoms do not meet the criteria for bipolar disorder, major depression, or another mental disorder. Symptoms are not caused by substance use or a medical condition.

[Triangular reflections on manic-depressive disorder. Apropos of 72 cases].

In 72 cases of unipolarity or bipolarity depression followed at least three years the subsequent elements are questioned. What is the proportion of the different diagnostic types and what have been the most frequent life events of the first access, deaths, occupational and emotional failures, pregnancy, births, etc? In this population of patients between 23 and 80 years old reluctance or ignorance of the life events are important. We also investigated the level of our patients socio-professional insertion. As for the hetero ou auto aggressive acting out we tried to quantify them according to the chosen classification and the therapy followed by the patients of this group. In the hypothesis of a possible link with the hospital management evaluation and computer program we have briefly analyzed the incidence of lithium therapy on the number of hospitalisation days, without being able to draw a final conclusion as to the interest of this therapy in this very specific issue.

When to Raise Our White Flag-A Discussion of Scope of Practice in a Resource Scarce World.

Thomas is a 13-year-old boy with autism spectrum disorder, attention deficit hyperactivity disorder (ADHD), generalized anxiety disorder, separation anxiety disorder, and major depressive disorder who presented for a follow-up to his developmental and behavioral pediatrician (DBP). His mother describes an increase in symptoms of anxiety and depression for the last 6 weeks, accompanied by suicidal ideation and thoughts of self-mutilation.Before this increase in symptoms, he had been doing well for the last several months with the exception of increasing weight gain, and Abilify was decreased from 5 mg to 2.5 mg at his last visit. Other medications at that time included Zoloft 100 mg twice daily, Focalin XR 40 mg every morning, and Focalin 5 mg every night. Without seeking the guidance of our developmental and behavioral pediatrics clinic, his mother increased his intake of Zoloft to 150 mg each morning and continued 100 mg each evening because of worsening anxiety and depression.Religion is very important to Thomas and his family. He acknowledges that he does not want to die and feels badly because "suicide is against our religion."Helping Thomas receive appropriate care has been a challenge. He was diagnosed with ADHD and Asperger disorder at the age of 5. Thomas is homeschooled and is very attached to his mother. His parents have very different parenting styles, with his mother being more permissive and his father more authoritarian. At the time of initial diagnosis, the behavioral health services (BHS) in Thomas' community, which is about an hour away from the DBP, were limited to older children, and he was followed by a DBP for ADHD medication management. At the age of 11, he expressed passive suicidal ideation and described that he imagined his mother as "the devil with fire coming out of her eyes" when she corrected him. He was evaluated by BHS, diagnosed with anxiety disorder, and started on Lexapro. BHS linked to the DBP were out of network for his insurance. The family was unable to pay out of pocket, so care was subsequently transferred to a DBP clinic that was in network. Soon after, Thomas developed auditory hallucinations, and Abilify was added after consultation with BHS.Over the last few years, Thomas' symptoms have waxed and waned. He did well for a short time and then again developed auditory hallucinations, worsening symptoms of anxiety and depression, and increasing somatic symptoms including vomiting and penile pain. Medications were adjusted with input from BHS, and further attempts were made to link him to local BHS but were unsuccessful. With his current concerns of suicidal ideation and self-mutilation, what would be your next steps?

Dienogest-induced major depressive disorder with suicidal ideation: A case report.

Dienogest is a type of progestin used for the treatment of endometriosis (EM). However, a significant adverse effect of dienogest is depression; therefore, assessing for a history of mood disorders is recommended before prescribing the drug. Herein, we present the case of a patient with no history of psychiatric disorders who was diagnosed with dienogest-induced major depressive disorder. This case emphasizes the importance of close monitoring for negative mood changes in patients taking dienogest. A 41-year-old woman underwent surgery for EM. Postoperatively, her gynecologist prescribed dienogest (2 mg/d) to control EM symptoms. Two months after the initiation of dienogest, she manifested insomnia almost daily, gradually became depressed, lost interest in all activities, had incessant cries, and repeatedly thought of death. She had no history of major physical or psychiatric disorders. Major depressive disorder, single episode, severe. A psychiatric consultation was recommended, an antidepressant was prescribed, and dienogest was discontinued. Two weeks later, there was significant improvement in the symptoms, and after 4 weeks, she remained in a stable mood with no suicidal thoughts. She was followed up for 13 months with a maintenance dose of escitalopram (5 -10mg/d), until the psychiatrist recommended treatment discontinuation, with a confirmed state of remission. This was a case of dienogest-induced depression in a patient with no history of mood disorders. Clinicians should be aware of the possibility of the occurrence of severe depression in progestin users regardless of their previous history.

Late-life chronic depression: a 399-case study in private practice.

Aims of the study were to find the prevalence of chronic depression in elderly patients compared with younger patients, and to compare chronic depression between elderly and younger patients, to find if there were clinical differences. A major feature of the study was the inclusion of a large number of bipolar II patients, usually not included in previous studies. Three hundred and ninety-nine consecutive unipolar (N=200) and bipolar II (N=199) depression outpatients were interviewed with the Structured Clinical Interview for DSM-IV and depression rating scales in a private practice. Chronic depression was more common in elderly patients than in younger patients (53.6% vs 40.1%, p=0.0299). Late-life chronic depression patients had later age at onset, longer duration of illness, fewer bipolar II cases, more unipolar cases and more relapses than younger chronic depression patients. Results suggest that late-life depression is more likely to be chronic than depression in younger patients. The subtyping of chronic depression according to age seems supported by a different age at onset and some clinical differences.

Cyclothymia

Cyclothymia, also known as cyclothymic disorder, is a mental and behavioural disorder that involves numerous periods of symptoms of depression and periods of symptoms of elevated mood. These symptoms, however, are not sufficient to indicate a major depressive episode or a manic episode. Symptoms must last for more than one year in children and two years in adults. The cause of cyclothymia is unknown. Risk factors include a family history of bipolar disorder. Cyclothymia differs from bipolar in that major depression and mania are not found. Treatment is generally achieved with counseling and mood stabilizers such as lithium. It is estimated that 0.4-1% of people have cyclothymia at some point in their life. The disorder's onset typically occurs in late childhood to early adulthood. Males and females are affected equally often.

'Interrupted by fits of weeping': Cicero's major depressive disorder and the death of Tullia.

The letters of Marcus Tullius Cicero (106-43 Bc), the Roman statesman, lawyer, orator and author, were analysed as part of a larger study that systematically examined ancient Greek and Roman literature to recover descriptions of mental illness. A degree of necessary caution was exercised, but the wealth of material revealed in the letters about Cicero's physical and emotional state enable a diagnosis of Major Depressive Disorder to be made with some certainty according to the DSM-IV-TR. Cicero appears to have experienced increasingly severe bouts of suicidal depression that seriously impaired his relationships with his friends, family and political colleagues, and possibly shortened his life. His last depressive episode following the death of his daughter Tullia is addressed here in some detail.

Bipolar II disorder

BP-II is diagnosed according to the criteria established in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). In addition, alternative diagnostic criteria is established in the World Health Organization's International Classification of Diseases-10th Revision (ICD-10). The diagnostic criteria are established from self-reported experiences from patients or their family members, the psychiatric assessment, and the mental status examination. In addition, Screening instruments like the Mood Disorders Questionnaire are helpful tools in determining a patient's status on the bipolar spectrum. In addition, certain features have been shown to increase the chances that depressed patients have a bipolar disorder, including atypical symptoms of depression like hypersomnia and hyperphagia, a family history of bipolar disorder, medication-induced hypomania, recurrent or psychotic depression, antidepressant refractory depression, and

[Suicide attempts in elderly people. Data from the Hospital Italiano de Buenos Aires].

[corrected] The aim of this paper is to analyze some characteristics of 25 patients, over 60, who attempted suicide and were hospitalized in the Department of Psychiatry of a general hospital in Buenos Aires. This is a retrospective study using data from the medical records of patients (1999 to 2002); based on a protocol comprising an analysis of attempted suicides, demographic and clinical variables. Patients were diagnosed following the DSM-IV criteria by two trained GPs and were confirmed by MMPI and Rorschach. 72% were women. The average age was 73,8 % were divorced, 20% never married, 32% widowed and 32% married. The most frequent diagnosis was Major Depressive Disorder of late onset followed by Personality Disorder ( 96%; 48%). The most frequent method was intoxication, (68.75% BDZ). Almost half of the attempts were highly severe. We may infer that the elderly person who attempts suicide: is female, 68-78 years old, does not have a partner, lives with someone, has Major Depressive Disorder (at least half of them had Personality Disorder) and a clinical disease. This is her first attempt, is alone at home, and she does not advise others. Reduced hearing is a very frequent co-morbidity.

Depression (mood)

A number of psychiatric syndromes feature depressed mood as a main symptom. The mood disorders are a group of disorders considered to be primary disturbances of mood. These include major depressive disorder (MDD; commonly called major depression or clinical depression) where a person has at least two weeks of depressed mood or a loss of interest or pleasure in nearly all activities; and dysthymia, a state of chronic depressed mood, the symptoms of which do not meet the severity of a major depressive episode. Another mood disorder, bipolar disorder, features one or more episodes of abnormally elevated mood, cognition, and energy levels, but may also involve one or more episodes of depression. When the course of depressive episodes follows a seasonal pattern, the disorder (major depressive disorder, bipolar disorder, etc.) may be described as a seasonal affective disorder.

[Selected demographic and clinical characteristics of patients with affective disorder treated in the Tworki Hospital in the years 1919- 1938 and 1947-1990].

On the basis of medical records of 353 patients with affective disorder from the years 1919-1938 and 1947-1990 it was found that some demographic and clinical changes occurred. Amongst others there was observed a rise in the percentage of patients with depression from 1/3 to 2/3 and a fall in the number of patients suffering from mania.

Mood disorder

Bipolar I is distinguished by the presence or history of one or more manic episodes or mixed episodes with or without major depressive episodes. A depressive episode is not required for the diagnosis of Bipolar I Disorder, but depressive episodes are usually part of the course of the illness. Bipolar II consisting of recurrent intermittent hypomanic and depressive episodes or mixed episodes. Cyclothymia is a form of bipolar disorder, consisting of recurrent hypomanic and dysthymic episodes, but no full manic episodes or full major depressive episodes. Bipolar disorder not otherwise specified (BD-NOS), sometimes called "sub-threshold" bipolar, indicates that the patient has some symptoms in the bipolar spectrum (e.g., manic and depressive symptoms) but does not fully qualify for any of the three formal bipolar DSM-IV diagnoses mentioned above.

A retrospective case-note study of bipolar disorder in old age.

In a replication of an earlier published study, case notes of 75 elderly in-patients with bipolar affective disorder were examined. Few of the patients had experienced a manic episode before the age of 40. Mean age of onset of affective disorder was 46 years, and first manic episode at 60 years. Cerebral insults before the first manic attacks were recorded in a substantial number of cases, and a family history of mental illness was less common among this group. Bipolar affective disorder is relatively common as a reason for admission of elderly patients.

[Late onset first manic episode: role of lithium].

This case reports on a first manic episode occurring to a 68 year old patient. Until now this male patient had been diagnosed with a recurrent depressive disorder. This depressive illness started 29 years ago and was punctuated by several depressive episodes. During one of these episodes associated to psychotic features, following the lithium discontinuation, the patient committed a homicide-suicide. He was found not to be responsible for his crime and treatment was subsequently restarted. For the next fifteen years the patient was stabilized using the association of antidepressant plus lithium, then lithium alone. Until the current manic episode subsequent to a further lithium discontinuation, the patient thanks to the mood stabilizer, could enjoy a good quality of life with a very satisfying social and professional adjustment. Following the case report, an analysis of published data on epidemiological parameters and risk factors associated was conducted. Findings show that perpetrators of murder suicides are mainly males (> 85%) suffering from depression (40% to 75%). Cases of homicide-suicide more frequently involve individuals committing a violent suicide shortly after (minutes or hours) committing one or more homicides. These cases often occur within a disturbed family context with drugs or alcohol abuse, social or cultural stresses such as poor social level or unemployment being other risk factors. Fire-arms are the most frequently used in suicides. Reported annual incidence is similar every year, ranging from 0.2 to 0.3 per 100,000 in the United States and other countries. Due to suicide but also to other disorders, mortality and morbidity rates are higher with patients suffering from mood disorders. A long term treatment with lithium results in a decrease of morbidity rate and suicidal risk in the general population.

Dysthymia

"At least three-quarters of patients with dysthymia also have a chronic physical illness or another psychiatric disorder such as one of the anxiety disorders, cyclothymia, drug addiction, or alcoholism". Common co-occurring conditions include major depression (up to 75%), anxiety disorders (up to 50%), personality disorders (up to 40%), somatoform disorders (up to 45%) and substance use disorders (up to 50%). People with dysthymia have a higher-than-average chance of developing major depression. A 10-year follow-up study found that 95% of dysthymia patients had an episode of major depression. When an intense episode of depression occurs on top of dysthymia, the state is called "double depression." Double depression

[Clinical particularism of bipolar disorder: unipolar mania. About a patient's study in Tunesia].

Although present classifications (CIM, DSM) have not included the notion of a unipolar disorder to characterise the recurrence of the same type of episode, this concept conserves its pertinence for many people. Unipolar mania, in particular, is a clinical reality in our daily practice, and a predominant form of bipolarity expression. These assertions have led us to question this notion and its nosographical place: is it a subtype, distinguished by certain characteristics, or a particular category in the bipolar disorder? We conducted a retrospective, descriptive and comparative study on medical briefs of patients with type I bipolar disorder (DSM-IV criteria), who were interned for the first time between 1997 and 2001 in the Psychiatry "E" service of the Razi hospital of Tunis, and were followed up for at least five years. Two groups were identified: Group 1 or "unipolar mania": patients who presented at least two manic episodes without depression, and Group 2: the rest of the sample; and then were compared based on their sociodemographical profile, familial psychiatric antecedents, premorbid temperament, comorbidity and clinical and progressive characteristics. Seventy-two patients were included. The average age was 36. The sex ratio was three men to two women. The first episode was a manic episode in 56.9% of the cases. The average duration of illness progression was 11.6 years. Unipolar mania represented 65.3% of the sample. Between 1997 and 2001, 92% of bipolar patients interned were hospitalised for mania. Concerning recurrences, we observed nine times as many cases of manic episodes as depression. Depressive episodes of light to medium intensity had probably not been well assessed due to the families' tolerance. The high rates of both manic episodes and unipolar mania observed in this study were also found by other authors, showing the differences of bipolarity expression between the West and the other parts of the world, and in particular Africa. There was no significant difference concerning the sociodemographical features. We noticed similar results in the literature. The two groups were comparable in familial psychiatric past history and premorbid temperament. Substance abuse or dependence was observed in 5.6% of the patients. This rate was less than others found in the literature, due to the fact that it is considered as an offence in our country. We found twice as many cases of toxic consumption in bipolar as in unipolar manic patients. A recent Tunisian study has shown the absence of substance abuse in unipolar manic patients. This is probably because of the fact that substance abuse is more related to depressive manifestations. The sample starting age was 24.6 years and was significantly more precocious in the unipolar manic group (27.6 years versus 23 years, p=0.001). A significant difference in both groups was found concerning the first episode season: two extremities were observed: "summer-autumn" in Group 1 (63.6% G1 versus 29.4% G2) and "winter-spring" in Group 2 (73.6% G2 versus 36.4% G1), p=0.03. The seasonal influence on mood disorders is dealt with by other authors. Unipolar manic patients presented less affective recurrences than the rest of the group (0.37 versus 0.49 on average per year), p=0.056. Unipolar mania is still considered as a clinical variety of bipolar disorder, which is distinguished by certain features. It is a debated notion because it is based on retrospective studies that may be insufficient, although it appears as a clinical evidence and a predominant progressive variety of bipolar disorder in Tunisia.

Minor depressive disorder

Minor depressive disorder differs from major depressive disorder in the number of symptoms present with 5 or more symptoms necessary for a diagnosis of major depressive disorder. Both disorders require either depressed mood or loss of interest or pleasure in normal activities to be one of the symptoms and the symptoms need to be present for two weeks or longer. Symptoms also must be present for the majority of the length of a day and present for a majority of the days in the two-week period. Diagnosis can only occur if the symptoms cause "clinically significant distress or impairment". Dysthymia consists of the same depressive symptoms, but its main differentiable feature is its longer-lasting nature as compared to minor depressive disorder. Dysthymia was replaced in the DSM-5 by persistent depressive disorder, which combined dysthymia with chronic major depressive disorder.

Comparison of depressed patients with and without suicide attempts in their past history.

Forty-eight inpatients with the diagnosis of a Brief or Prolonged Depressive Reaction according to ICD-9 who had attempted suicide just before the admission were compared to 24 inpatients with the same diagnosis but no history of previous suicide attempts. The variables investigated included sociodemographic characteristics, family history, life events within the year prior to admission, social functioning, social support, and personality factors. The comparison of these two groups revealed that alcoholism and suicide attempts in first degree relatives, and divorce or separation of the patients' parents predispose for a depressive reaction associated with the suicidal behavior. No differences between the two patient groups were found for personality factors, number and quality of life events in the year before index admission, social functioning, and social support during the last 4 weeks. Due to the small number of patients in both groups the conclusions drawn are preliminary.

List of medical mnemonics

Indiscretion (DSM-IV's "excessive involvement in pleasurable activities") Grandiosity Flight of ideas Activity increase Sleep deficit (decreased need for sleep) Talkativeness (pressured speech) Mania: diagnostic criteria Must have 3 of MANIAC: Mouth (pressure of speech)/ Moodl Activity increased Naughty (disinhibition) Insomnia Attention (distractibility) Confidence (grandiose ideas) Parasomnias: time of onset Sleep terrors and Sleepwalking occur during Slow-wave sleep (stages 3 & 4).Nightmare occurs during REM sleep (and is remembered). Psychiatric review of symptoms "Depressed patients seem anxious, so call psychiatrists": Depression and other mood disorders (major depression, bipolar disorder, dysthymia) Personality disorders (primarily borderline personality disorder) Substance abuse disorders Anxiety disorders (panic disorder with agoraphobia, obsessive-compulsive disorder)


The patient carries out an activity in contact with soil and plants (which are not provided free of charge). The symptoms are chronic, which started distally (left thumb) and are affecting the ipsilateral arm (reddish striae). There were no systemic symptoms. They also comment that the diagnosis was made on the basis of a skin biopsy. Of the microorganisms discussed, Microsporum gypseum does not usually manifest dissemination of infection of a lymphangitic aspect, in general keratinophilic fungi (dermatophytes) do not have any ability to invade deep tissues, so we ruled out this option. Staphylococcus aureus infection can affect superficial and deep tissue layers, they can spread following a lymphangitic path, but it is not usual such a long evolution, it is usually acute (days) and usually accompanied by systemic symptoms, so we discard this option. Mycobacterium marinum (and not Mycobacterum marinum) is a non-tuberculous mycobacterium characterized by being environmental, opportunistic and photochromogenic. It has a slow growth, from 2 to 8 weeks, at a temperature ranging from 30 to 37 °C. It affects different species of fish in cold, warm, fresh or salt water, especially stagnant waters of fish tanks and pools without chlorine. Infection in humans occurs by direct contact with fish or contaminated water in the presence of a loss of continuity in the skin of the host. Our patient has no history of exposure to fish or water (they don't say), so considering that usually the diagnosis is based on a high index of suspicion and specifically asking for this history, our case is far from this possibility. The Sporothrix schenckii complex is the causative agent of Sporotrichosis, this dimorphic fungus is located in the soil, the complex is formed by 5 species, S. schenckii sensu strictu, S. brasiliensis and S. globosa, capable of causing human and animal disease; the other two are S. mexicana and S. albicana not associated with any disease. Patients are usually infected by exposure to soil by means of a sharp object (thorns, stems, animal claws, etc.) and have a slow evolution, affect deep tissues and their dissemination typically follows a pathway as described in the question.

The patient carries out an activity in contact with soil and plants (which are not provided free of charge). The symptoms are chronic, which started distally (left thumb) and are affecting the ipsilateral arm (reddish striae). There were no systemic symptoms. They also comment that the diagnosis was made on the basis of a skin biopsy. Of the microorganisms discussed, Microsporum gypseum does not usually manifest dissemination of infection of a lymphangitic aspect, in general keratinophilic fungi (dermatophytes) do not have any ability to invade deep tissues, so [HIDDEN]. Staphylococcus aureus infection can affect superficial and deep tissue layers, they can spread following a lymphangitic path, but it is not usual such a long evolution, it is usually acute (days) and usually accompanied by systemic symptoms, so [HIDDEN]. Mycobacterium marinum (and not Mycobacterum marinum) is a non-tuberculous mycobacterium characterized by being environmental, opportunistic and photochromogenic. It has a slow growth, from 2 to 8 weeks, at a temperature ranging from 30 to 37 °C. It affects different species of fish in cold, warm, fresh or salt water, especially stagnant waters of fish tanks and pools without chlorine. Infection in humans occurs by direct contact with fish or contaminated water in the presence of a loss of continuity in the skin of the host. Our patient has no history of exposure to fish or water (they don't say), so [HIDDEN]. The Sporothrix schenckii complex is the causative agent of Sporotrichosis, this dimorphic fungus is located in the soil, the complex is formed by 5 species, S. schenckii sensu strictu, S. brasiliensis and S. globosa, capable of causing human and animal disease; the other two are S. mexicana and S. albicana not associated with any disease. Patients are usually infected by exposure to soil by means of a sharp object (thorns, stems, animal claws, etc.) and have a slow evolution, affect deep tissues and their dissemination typically follows a pathway as described in the question.

A 58-year-old man reported a weeks-long history of progressive, mildly painful skin lesions on his left arm. It had started as an erythematous lesion on his left thumb. He had visible reddish striae as connecting lines between the lesions. The patient had no fever or other general symptoms. He had been working in his garden but did not remember any injuries. The etiologic diagnosis was made by culture of a skin biopsy. What is the most likely causative agent of this process?

Cutaneous infection by Staphylococcus aureus.

Cutaneous infection by Mycobacterium marinum.

Sporotrichosis -- History and Physical

Sporotrichosis has an incubation period of several days to 3 months after exposure. Infections can be divided into several syndromes including cutaneous, pulmonary, and disseminated. Cutaneous syndrome arises from minor trauma of the fungus into the skin, which is most common in rose gardeners. The initial lesions are erythematous papulonodular lesions that may be smooth or verrucous and involve lymphatic channels. [4] Lesions are typically painless even after ulceration. In this syndrome, the patient will not have systemic symptoms, and laboratory exams will be normal.

Disseminated sporotrichosis mimicking sarcoidosis.

A 40-year-old Caucasian man presented to the dermatology clinic at Baylor College of Medicine, Houston, Texas, in February 2003, for the evaluation of three nonhealing ulcers. The patient's past medical history was significant for hypothyroidism and pulmonary sarcoidosis, the diagnosis of which was made in June 2000. In March 2000, the patient had complained of cough and shortness of breath. A purified protein derivative (PPD) (Mantoux text) was negative. Computed tomography (CT) scans of the chest revealed diffuse hilar and mediastinal adenopathy and bilateral interstitial and alveolar infiltrates. Although consistent with sarcoidosis, these findings were insufficient to exclude other etiologies, including disseminated fungal infection. Cultures and stains of subsequent bronchoscopy specimens failed to reveal any organisms, and histopathologic evaluation of the specimens was nondiagnostic. Based on the imaging studies and the negative cultures, a diagnosis of sarcoidosis was made, and the patient was started on therapy with prednisone. Before coming to our clinic, the patient had been on several courses of prednisone. In May 2002, the patient had presented to a private dermatologist with a 1-year history of a nonhealing 2.4 cm x 2.0 cm ulcer on the left medial forearm. Two biopsies were reported as nondiagnostic. The patient's presentation was interpreted as most consistent with Mycobacterium marinum infection, and so he was empirically treated with minocycline. This treatment was continued for almost 3 months without improvement in the ulcer. A few months after the minocycline had been discontinued, the patient was treated empirically for 2 months with ciprofloxacin. This treatment was also unsuccessful in ameliorating the ulcer. In between the two courses of antibiotics, specimens from the lesion were sent for bacterial and fungal cultures, which revealed normal skin flora. In January 2003, the patient returned to his private dermatologist with three ulcerations. In addition to the nonhealing ulcer on his left forearm, which he had acquired several months earlier, he had also developed a 3.0 cm ulcer on his right arm and a 3.0 cm ulcer on his central back. The patient refused biopsies at this visit. Given the patient's previous diagnosis of pulmonary sarcoidosis, it was thought that the skin lesions might represent ulcerative cutaneous sarcoidosis. Pyoderma gangrenosum was also considered to be a likely diagnosis. Therefore, the patient was started on a course of oral prednisone, an effective therapy for both sarcoidosis and pyoderma gangrenosum. Despite 1 month of treatment with 60 mg/day of prednisone, the ulcers increased, and the patient was subsequently referred to our clinic. Physical examination at the time of presentation revealed steroid acne on the trunk and upper extremities and three non-tender ulcers with erythematous, undermined borders (Figs 1-3). On the left arm, there was an adjacent nodule which the patient attributed to a scar from a previously healed ulcer. Histologic examination of biopsy specimens from all three sites showed similar findings. The lesion contained diffuse, suppurative, granulomatous, inflammatory infiltrates with extensive central necrosis. The infiltrates were composed of histiocytes, multinucleated foreign-body-type giant cells, plasma cells, lymphocytes, neutrophils, and neutrophil fragments. No organisms were seen in the initial, routinely stained sections. However, periodic acid-Schiff (PAS) staining demonstrated small fungal spores (Fig. 4) morphologically consistent with sporotrichosis, within the cytoplasm of multinucleated histiocytic giant cells (Fig. 5). Additional stains for bacteria and acid-fast organisms were negative. Cultures of the biopsy specimens from all three sites grew Sporothrix schenckii. Further questioning of the patient failed to reveal an obvious source of the infection. The patient denied any history of traumatic skin inoculation and did not engage in gardening or other outdoor activities that are classically associated with sporotrichosis. The patient did admit to blackberry picking on detailed retrospective questioning. Once the diagnosis of sporotrichosis was made, the patient was given 200 mg/day of itraconazole. After 2 months, the patient's ulcers were almost completely healed. The patient's pulmonary complaints were also much improved.

Herpetic Whitlow -- History and Physical

Patients will often experience pain and tingling in the finger before any skin changes (prodromal phase). [12] This will be followed by local tenderness, erythema, and edema with an initial crop of vesicles which are most common along the pulp and lateral aspect of the finger. The infection usually involves just one finger but has rarely been noted to involve several fingers. Vesicles usually coalesce into large, honeycomb-like bullae. They may spread proximally and may involve the nail bed where hemorrhagic or purpuric lesions may be noted. Patients will often report a disproportionate intensity of pain, particularly if there is nailbed involvement. [2] Fever, lymphadenitis, epitrochlear and axillary lymphadenopathy may be present. [13] Rarely, lymphedema of the hand and forearm may be present, although reports favor bacterial superinfection in most of these cases.

Dermoscopy of Mycobacterium marinum Skin infection: A Challenging Diagnosis.

Dear Editor, Mycobacterium (M.) marinum is a slow-growing atypical mycobacterium found mainly in saltwater environments. Infection occurs following inoculation of a skin lesion and manifests as a localized granuloma; in fact, the most common cause of infection with M. marinum is the exposure of traumatized skin to affected aqueous environments (1), and it most commonly involves individuals with occupational and recreational exposure to non-chlorinated water (2). An erythematous or bluish 0.5 to 3.0 cm nodule usually develops at the inoculation site, while ulceration can occur later and subsequent lesions may be present along the lymphatic drainage. We present the first case in the literature describing the dermatoscopic characteristics of a microbiologically proven Mycobacterium marinum skin infection, although more cases are certainly needed to identify the main dermatoscopic features of this infection. In January 2019, a 66-year-old patient was referred to our Dermatological Clinic reporting the appearance of two purplish nodules about 2 months earlier, located on the back of the hand and on the left thumb (Figure 1) and of erythematous purplish appearance and quite painful to palpation. Based on the clinical presentation, infection with atypical mycobacteria, botryomycosis, fungal infection (Cryptococcus neoformans, Histoplasma capsulatum) and infection with Francisella tularensis were considered in the differential diagnosis. The patient was asked if he had an aquarium at home and he confirmed this by telling us of his passion for aquariums, which made the diagnosis easier. Dermatoscopic examination performed on the two lesions at the center of the first nodule located on the hand showed a whitish area surrounded by an erythematous background with fine scaling and dotted vessels and orange-whitish central areas with looped concentric monomorphic vessels (Figure 2, a). However, the thumb lesion had a purplish background with multiple structured rounded areas with orangish appearance surrounded by looped vessels arranged in a crown-like shape (Figure 2, b). It is interesting to note the dermoscopic-histological correlation in this disease: the orangish areas in fact correspond to a granulomatous dermatitis, characterized by inflammatory nodular infiltrate within the dermis (tuberculoid granulomas) (3). Clinically and dermoscopically, the nodules had two different sets of features because they were in different stages of development: the nodule of the thumb was older than the other one on the hand, which the patient reported was of recent onset, also confirmed by the presence of suppuration and ulceration. Both lesions had orange areas in the context of an erythematous background which led us to investigate a granulomatous disease. A deep culture examination and a skin biopsy were thus performed, showing Mycobacterium marinum infection. Oral therapy with clarithromycin 500 mg twice daily for 4 weeks was started and healing occurred in about 21 days. We present this case to emphasize the role of dermoscopy in differential diagnosis of granulomatous disease and to show dermoscopic clues that have not yet been described and that can be used in the future to establish very early diagnosis of this infection, reducing the diagnostic delay.

InternalMed_Harrison

(Table 156-1) Impetigo contagiosa is caused by S. pyogenes, and bullous impetigo is due to S. aureus. Both skin lesions may have an early bullous stage but then appear as thick crusts with a golden-brown color. Epidemics of impetigo caused by MRSA have been reported. Streptococcal lesions are most common among children 2–5 years of age, and epidemics may occur in settings of poor hygiene, particularly among children in lower socioeconomic settings in tropical climates. It is important to recognize impetigo contagiosa because of its relationship to poststreptococcal glomerulonephritis. Rheumatic fever is not a complication of skin infection caused by S. pyogenes. Superficial dermatophyte infection (ringworm) can occur on any skin surface, and skin scrapings with KOH staining are diagnostic. Primary infections with dimorphic fungi such as Blastomyces dermatitidis and Sporothrix schenckii can initially present as crusted skin lesions resembling ringworm. Disseminated infection with

Microsporum gallinae

Humans Microsporum gallinae has been isolated from the scalp, and smooth skin in human populations. Microsporum gallinae infections are most commonly tinea capitis and tinea corporis. Very few human cases of M. gallinae infection have been reported, none of which were life-threatening. Of the reported cases, individuals ranged from 3–96 years old. They had cutaneous lesions on the glabrous skin or the scalp. These localized lesions are frequently accompanied by itching. The cutaneous manifestations are very similar to those of Microsporum canis therefore many cases of Microsporum gallinae could have been unreported. In rare cases, immunocompromised individuals form severe dissemination on the skin, instead of small localized lesions as a result of handling infected animals. Only one case of extensive dermatophytosis was reported involving M. gallinae infection of a person with AIDS.

A rose by any other name.

A 40-year-old man visited Haiti in the winter. His visit was uneventful, and he went swimming in the ocean. A week after his return he developed a small "pimple" on his right fifth finger. This condition progressed for several weeks, with new lesions developing over the extensor surface of his forearm and in the antecubital fossa. He had tender axillary adenopathy. The patient started a new job when he returned from Haiti, working 4 days per week in a greenhouse. He denied any fever, chills, or night sweats. He was in good health without any underlying chronic health problems. Physical examination revealed a small eschar over the distal phalanx of the patient's right fifth finger (Figure 1). There were 2 erythematous nodules over the extensor surface of his right forearm (Figure 2) as well as over the antecubital fossa (Figure 3). A punch biopsy was performed and results showed suppurative granulomatous dermatitis. Sporothrix schenckii was grown from the specimen.

An unusual cutaneous manifestation of Crohn's disease.

A 61-year-old man with a 12-year history of quiescent Crohn's disease on mesalamine presented to his gastroenterologist in April 2009, complaining of abdominal cramping, diarrhea, and a 25-lb weight loss over 6 weeks. He did not respond to prednisone 50 mg and 6-mercaptopurine 100 mg daily. Abdominal computed tomography findings revealed diffuse submucosal edema consistent with extensive colitis. Colonoscopy demonstrated diffuse inflammation with erythema, friability, and shallow ulcerations in the rectum and colon. Biopsies were consistent with Crohn's colitis. He was admitted for infliximab infusion for his unremitting diarrhea. Five days before admission, the patient noted mild swelling and redness of the left lower eyelid, which progressed to involve the right lower eyelid with frank pus draining from both eyes. He had no visual impairment or eye pain. Two days before admission, an ophthalmologist prescribed a steroid eyedrop with no relief. He also complained of seropurulent painful skin lesions on his face and scalp, which spread to involve his upper trunk and proximal arms. On admission to the hospital, dermatology, ophthalmology, and infectious disease consultations were obtained to rule out disseminated infection before initiation of infliximab therapy. The patient was afebrile and hemodynamically stable. His oral mucosa was normal. He had prominent bilateral lower eyelid edema, erythema, and superficial erosions with hemorrhagic crusting and frank green purulent drainage from both eyes, with crusting along the lower lash line and bilateral sclera injection (Figure 1). On his scalp, face, trunk, and proximal extremities, he had 25 to 30 erythematous, 4- to 8-mm papulopustules with narrow red halos, some with central necrosis and crusting (Figure 2). Cultures from the purulent ocular drainage and pustules on the trunk and arms were all negative for bacteria, virus, and fungi. Gram stain from the eye drainage showed polymorphonuclear leukocytes without organisms. Tissue cultures were negative for bacterial, fungal, and mycobacterial infection. Skin biopsy taken from the central upper back demonstrated subcorneal pustules with areas of eroded epidermis and collections of neutrophils in the superficial dermis (Figure 3). Special stains were negative for organisms. He received infliximab infusion 5 mg/kg for a total dose of 420 mg over 2 hours. Within 48 hours of infusion, there was notable decrease in size of lesions, in addition to reduction of purulent drainage from both eyes. The patient was discharged home following infliximab infusion. His skin lesions resolved during a period of 2 weeks, leaving small pink atrophic scars. He received his second infusion of infliximab 2 weeks after discharge with continued improvement in his gastrointestinal symptoms.

Correlation does not imply causation

Example 5 A historical example of this is that Europeans in the Middle Ages believed that lice were beneficial to your health, since there would rarely be any lice on sick people. The reasoning was that the people got sick because the lice left. The real reason however is that lice are extremely sensitive to body temperature. A small increase of body temperature, such as in a fever, will make the lice look for another host. The medical thermometer had not yet been invented, so this increase in temperature was rarely noticed. Noticeable symptoms came later, giving the impression that the lice left before the person got sick.

Complicated cutaneous leishmaniasis caused by an imported case of Leishmania tropica in Japan: a case report.

Leishmaniasis is not endemic in Japan, and imported cases are rare. However, there are increasing concerns regarding imported cases of cutaneous leishmaniasis from endemic countries to Japan. This report describes a case of imported cutaneous leishmaniasis that was diagnosed and treated in Japan. A 53-year-old Pakistani man presented with skin lesions on both malleoli of his right ankle and the dorsum of the left foot. The skin lesions manifested as erythematous nodules surrounding an ulcer in the center of the lesion. The lesions of the malleoli of his right ankle each measured 3 × 3 cm, and the lesion on the top of his left foot measured 5 × 4 cm. He had been living and working in Japan but had a history of a visit to Pakistan for about 2 months in 2018. The skin lesions were biopsied. Giemsa and hematoxylin and eosin staining of biopsy samples showed amastigotes of Leishmania in macrophages, and the presence of Leishmania was confirmed by skin tissue culture. Polymerase chain reaction using biopsy specimens identified Leishmania parasites, and DNA sequence analysis revealed that the species was Leishmania tropica. The patient was treated with intravenous liposomal amphotericin B for 6 days. The erythema disappeared, and the erythematous nodules resolved within 3 weeks. This is the first report of imported cutaneous leishmaniasis caused by L. tropica from Pakistan, and it is interesting that all three testing modalities showed positive results in this case.

Exanthem

The four viral exanthema have much in common, and are often studied together as a class. They are: Scarlet fever, or "second disease", is associated with the bacterium Streptococcus pyogenes. Fourth disease, also known as "Dukes' disease" is a condition whose existence is not widely accepted today. It was described in 1900 and is postulated to be related to the bacterium Staphylococcus aureus. In 1979 and 2001 a possible "seventh diease" was postulated following reports of a condition in Japan also referred to as acute febrile infantile mucocutaneous lymph node syndrome (MCLS).

Chronic nonhealing ulcer of the right thumb with multiple subcutaneous nodules.

A 60-year-old man presented with a 3-month history of nonhealing ulcer over the tip of his right thumb. The ulcer started as a blister over the tip of the thumb that later ruptured and spread proximally to cover the whole pulp area of the thumb. There was no history of trauma, fever, weight loss, or loss of appetite. He is a pensioner and an avid gardener. He has a few cats as pets. The patient initially presented to a private orthopedic surgeon with a nonhealing ulcer of the right thumb. Multiple debridements were unsuccessful in ameliorating the ulcer. Three months after the onset of the initial lesion, multiple painless erythematous nodules had developed on his right arm, and one on the right thigh. All routine blood investigations were nondiagnostic. Swab culture from the ulcer failed to grow any organism and a course of antibiotics did not resolve the problem. Cultures of the biopsy specimen using Sabouraud's dextrose agar and potato carrot medium grew dark brown plaques that microscopically appeared to be branching hyphae. A diagnosis of sporotrichosis of the right upper limb was made and the patient was started on antifungal treatment immediately (T. Itraconazole [Sporanox] 200 mg BD). One month after commencement of antifungal treatment, the ulcer began to dry up and at 3 months all the lesions including the one on the right thigh had healed.

Miliary fever

Miliary fever was a medical term in the past (Wolfgang Amadeus Mozart's death report showed this term), used to indicate a general cause of infectious disease that cause an acute fever and skin rashes similar to the cereal grain called proso millet. After subsequent advances in medicine, this term fell into disuse, supplanted by other more specific names of diseases, for example the modern miliary tuberculosis. External links . Annals of the Rheumatic Diseases, 1991; Vol.50: pp. 963–964 Obsolete medical terms

Nodular lymphangitis: Report of a case with presentation of a diagnostic paradigm.

A 54-year-old man with asthma, mitral valve prolapse, and a back injury developed erythematous nodules that progressed along the lymphatic drainage of his right arm. Skin biopsy revealed granulomatous inflammation with microabscess formation. Culture confirmed Mycobacterium marinum infection. The patient was treated with clarithromycin, ethambutol, rifampin, and topical silver sulfadiazine. Oral doxycycline hyclate was later added because of slow healing. Mycobacterium marinum is one of a group of infectious agents that can cause nodular lymphangitis. Sporotrichoid lesions most commonly develop after cutaneous inoculation with Sporothrix schenckii, Leishmania species, Nocardia species, and Mycobacterium marinum. A thorough clinical history and physical examination can narrow the differential diagnosis by eliciting information about the etiologic setting, incubation time, clinical appearance of the lesions, and presence or absence of systemic involvement for each of the causative organisms. Skin biopsy and microbiological tissue cultures are essential for diagnostic confirmation. The differential diagnosis and a suggested diagnostic paradigm will be reviewed.

Miliaria -- History and Physical

Miliaria rubra is the most prevalent form of miliaria. The obstruction of eccrine ducts occurs in the deeper layers of the skin and involves an inflammatory response. This results in larger, erythematous papules and vesicles. A critical clinical diagnostic feature that helps differentiate miliaria rubra from folliculitis is minimal follicular involvement. If pustules are present, then miliaria rubra is called miliaria pustulosa and may indicate a bacterial infection. Because an inflammatory response is involved, patients may experience pruritic and painful symptoms. These symptoms may worsen during perspiration, causing more irritation. In neonates usually between the ages of 1 to 3 weeks, the groin, axilla, and neck are the most commonly affected areas. In adults, miliaria rubra is most likely seen in places where clothes rub on the skin such as the trunk and extremities. The face is usually spared. Superinfection with staphylococci may occur, and when impetigo or multiple abscesses are involved, the condition is called periporitis staphylogenes. [19]

Sporotrichoid atypical cutaneous infection caused by Mycobacterium marinum.

A case of a sporotrichoid cutaneous infection caused by Mycobacterium marinum is reported. A 53- year-old male patient presented with red, partly purulent nodular lesions on the back of his left hand, forearm, and upper medial arm that had developed consecutively during the past 4 weeks. A mycobacterial infection with M. marinum was confirmed by molecular methods in a lesional skin biopsy. The patient was treated systemically with rifampicin (750 mg/day) and clarithromycine (1,000 mg/day), and topically with sulmycin (gentamicin sulfate). After 12 weeks of treatment the nodules regressed, leaving behind erythematous patches. M. marinum is a waterborne mycobacterium that commonly infects fish and amphibians worldwide. Transmissions to humans occur occasionally, in most cases as a granulomatous infection localized to the skin, typically following minor trauma to the hands. For this reason, infections are especially common among aquarium keepers.

InternalMed_Harrison

Rickettsialpox begins after mite-bite inoculation of Rickettsia akari into the skin. A papule with a central vesicle evolves to form a 1to 2.5-cm painless crusted black eschar with an erythematous halo and proximal adenopathy. While more common in the northeastern United States and the Ukraine in 1940–1950, rickettsialpox has recently been described in Ohio, Arizona, and Utah. Blistering dactylitis is a painful, vesicular, localized S. aureus or group A streptococcal infection of the pulps of the distal digits of the hands.

Inflammatory skin metastasis as a first sign of progression of lung cancer--a case report.

Skin metastases are present in 1-9% of cancer patients. In rare cases, skin metastases can manifest as lesions with signs of inflammation and are diagnosed as inflammatory cutaneous metastases (ICM). ICM in lung cancer are extremely rare and often misdiagnosed. We report on a 55-year-old man with metastatic lung adenocarcinoma and bone metastases in the axial skeleton and left humerus diagnosed in August 2008. He underwent 6 cycles of palliative chemotherapy with cisplatin and gemcitabine, obtaining a minor response. Five months later, he experienced increasing pain in his left arm, with erythematous oedematous lesion with poorly defined margins and an inflammatory appearance. A diagnosis of skin infection was made and he was treated by antibiotic therapy without improvement. Skin biopsy revealed skin infiltration by poorly differentiated carcinoma compatible with a primary lung tumour. He was started on second line therapy with docetaxel, however, the patient's status deteriorated rapidly and he died two months after the first appearance of ICM. Metastasis of lung carcinoma could be one of the causes of inflammatory skin lesions in cancer patients and these metastases should be considered in cancer patients with persisting cutaneous lesions with signs of inflammation and no response to antibiotic therapy.

InternalMed_Harrison

fever and chills. Erysipelas tends to occur on the malar area of the face (often with extension over the bridge of the nose to the contralateral malar region) and the lower extremities. After one episode, recurrence at the same site—sometimes years later— is not uncommon. Classic cases of erysipelas, with typical features, are almost always due to β-hemolytic streptococci, usually GAS and occasionally group C or G. Often, however, the appearance of streptococcal cellulitis is not sufficiently distinctive to permit a specific diagnosis on clinical grounds. The area involved may not be typical for erysipelas, the lesion may be less intensely red than usual and may fade into surrounding skin, and/or the patient may appear only mildly ill. In such cases, it is prudent to broaden the spectrum of empirical antimicrobial therapy to include other pathogens, particularly S. aureus, that can produce cellulitis with the same appearance. Staphylococcal infection should be suspected if cellulitis

Erosio interdigitalis blastomycetica

Erosio interdigitalis blastomycetica (EIB) is a skin condition caused by a Candida albicans infection, characterized by an oval-shaped area of macerated white skin on the web between and extending onto the sides of the fingers. Signs and symptoms It is common among bartenders and homemakers. EIB can be found on both the hands and feet.It is most common between the middle and ring finger and sometimes found between toes. Cause It is believed that EIB is caused by working with water often. It is not known exactly how long the infection will last since it varies often between people who have gotten infected. The most common symptoms are pruritus and discomfort while on rare occasions some do experience pain. History EIB was first discovered by 2 two scientists, Gougerot and Goncea in 1915. It was later named by another scientist Johannes Fabry in 1917. See also Candidiasis Skin lesion References Mycosis-related cutaneous conditions

Disseminated cutaneous histoplasmosis and AIDS: case report.

Histoplasmosis is caused by the dimorphic fungus Histoplasma capsulatum. It manifests by the presence of fever as the only symptom in most individuals. The disease may present as self-limited pneumonia, or as an hematogenous widespread fungal infection with a potentially fatal outcome in elderly individuals and people with compromised T-cell mediated immunity. Here, we report a case of disseminated cutaneous histoplasmosis in a patient with AIDS. The patient was a 33 year old male homosexual, intravenous drug user, who had been diagnosed with HIV infection 5 years earlier. He was in good health, but had erythematous papules and pustules in the skin of the scalp, face, back, thighs, abdomen, palms, and soles. He was placed on anti-retroviral therapy, fluconazole for mucosal candidiasis, trimethoprim/sulfamethoxazole for pneumocystis prophylaxis, and antibiotics for the skin pustules. The skin lesions improved remarkably within 14 days. He was discharged and soon lost to follow-up. After his discharge, skin biopsy and fungal culture results revealed H. capsulatum. He was seen again 1 year later. The interim history revealed that he had taken fluconazole 100 mg/day for 1 month and fluconazole 150 mg/week for 7 months. He had not continued anti-retroviral therapy, nor taken other antifungal drugs. The clinical evolution of the disease was exceptional in that there was disappearance of all the skin lesions attributed to histoplasmosis with fluconazole. Although itraconazole remains the drug of choice for histoplasmosis. Cutaneous histoplasmosis should be considered in the differential diagnosis of atypical cutaneous lesions in individuals infected with HIV.

Janeway lesion

Diagnosis Janeway lesions present as red, painless macules and papules on the palms and soles. They are not common and are frequently indistinguishable from Osler's nodes. Rarely, they have been reported in cases of Systemic lupus erythematosis (SLE), Gonococcemia (disseminated gonorrhoea), haemolytic anaemia and typhoid fever. They may last days to weeks before completely resolving. History Janeway lesions are named after Edward Janeway (1841–1911), a prominent American physician, pathologist and contemporary of Sir William Osler, who initially described "peculiar skin lesions" in some people with endocarditis, in a paper published in 1899. The term was first used by internist and pathologist Emanuel Libman, who reported the lesions in his paper of 1906 and explained his reasoning for using the term "Janeway lesions" in a footnote in 1923. Osler never mentioned Janeway lesions. The inclusion into Osler's 1925 textbook came six years after Osler died.

Sporotrichosis

It has been reported in cats, mules, dogs, mice and rats. Signs and symptoms Cutaneous or skin sporotrichosis This is the most common form of this disease. Symptoms of this form include nodular lesions or bumps in the skin, at the point of entry and also along lymph nodes and vessels. The lesion starts off small and painless, and ranges in color from pink to purple. Left untreated, the lesion becomes larger and look similar to a boil and more lesions will appear, until a chronic ulcer develops. Usually, cutaneous sporotrichosis lesions occur in the finger, hand, and arm. Pulmonary sporotrichosis This rare form of the disease occur when S. schenckii spores are inhaled. Symptoms of pulmonary sporotrichosis include productive coughing, nodules and cavitations of the lungs, fibrosis, and swollen hilar lymph nodes. Patients with this form of sporotrichosis are susceptible to developing tuberculosis and pneumonia

InternalMed_Harrison

CHAPTER 25e Atlas of Rashes Associated with Fever Figure 25e-51 Smallpox is shown with many pustules on the face, becoming confluent (A), and on the trunk (B). Pustules are all in the same stage of development. C. Crusting, healing lesions are noted on the trunk, arms, and hands. (Reprinted from K Wolff, RA Johnson: Color Atlas and Synopsis of Clinical Dermatology, 6th ed. New York, McGraw-Hill, 2009.) CHAPTER 26 Fever of Unknown Origin fever of unknown origin Chantal P. Bleeker-Rovers, Jos W. M. van der Meer DEFINITION Clinicians commonly refer to any febrile illness without an initially obvious etiology as fever of unknown origin (FUO). Most febrile ill-nesses either resolve before a diagnosis can be made or develop distin-26 guishing characteristics that lead to a diagnosis. The term FUO should be reserved for prolonged febrile illnesses without an established etiology despite intensive evaluation and diagnostic testing. This chapter focuses on classic FUO in the adult patient.

Lupus vulgaris

Lupus vulgaris (also known as tuberculosis luposa) are painful cutaneous tuberculosis skin lesions with nodular appearance, most often on the face around the nose, eyelids, lips, cheeks, ears and neck. It is the most common Mycobacterium tuberculosis skin infection. The lesions may ultimately develop into disfiguring skin ulcers if left untreated. Signs and symptoms It begins as painless reddish-brown nodules which slowly enlarge to form irregularly shaped red plaque. Cause Lupus vulgaris often develops due to inadequately treated pre-existing tuberculosis. It may also develop at site of BCG vaccination. Rarely, it has been shown to be associated with tattoo marks. Histopathology Histologically, it shows presence of epithelioid cell granulomas with Langhans giant cells with or without central caseation necrosis in the dermis. Diagnosis On diascopy, it shows characteristic "apple-jelly" color. Biopsy will reveal tuberculoid granuloma with few bacilli. Mantoux test is positive.

Royal touch

The touch was originally meant to cure tuberculous cervical lymphadenitis (commonly referred to as scrofula or the King's Evil), rheumatism, convulsions, fevers, blindness, goitre and other ailments. Since the reign of Elizabeth I (r. 1558–1603), however, the touch was applied only to people suffering from scrofula. The Henrician practice was rarely modified, and the changes were minor; Elizabeth I made the sign of the cross above the infected person's head, while her squeamish successor, James I (r. 1603–1625), made stroking motions above the abscesses instead of actually touching them. Frequency

Missed opportunity to diagnose subungual melanoma: potential pitfalls!

Subungual melanoma, an uncommon form of acral melanoma that arises within the nail matrix, accounts for 1%-3% of all cutaneous melanoma in Caucasians. As subungual melanoma presents in a more disguised manner than cutaneous lesions, increased vigilance is required. It most commonly presents as a discolouration of the nail, nail splitting or nail-bed bleeding. Black pigmentation of the adjacent nail fold, termed Hutchinson's sign, may be a diagnostic clue. Treatment of subungual melanoma remains surgical with wide local excision and amputation primary modalities. We present the case of a 61-year-old man with an 18-month history of a left thumb nail-bed abnormality and a 6-week history of left axillary lymphadenopathy. One year earlier, he presented to the emergency department with a purulent discharge from his left thumb but declined nail-bed ablation. He was referred to the 'Hand and Plastic Injuries Clinic' by his general practitioner and diagnosed with a chronic traumatic-induced nail-bed injury. As his symptoms did not improve, he was referred to the 2-week wait Skin Cancer Clinic. The left thumb nail-bed was excised as a nail unit down to bone, and the diagnosis of melanoma was rendered. Left axillary lymphadenopathy was confirmed as metastatic melanoma. He underwent amputation of his left thumb at the interproximal phalangeal joint, and a left axillary node dissection was performed. No residual melanoma was identified in his thumb. Microscopically, his left axillary dissection confirmed 9 out of 36 positive nodes for metastatic melanoma with extracapsular spread. He was staged at IIIC disease. This case report demonstrates missed opportunities to diagnose subungual melanoma and acts as a cautionary tale in considering this pathology in the differential diagnosis of nail-bed lesions with prompt referral for further investigation.

Myrnie Gifford

She began to conduct skin tests on all patients suffering from valley fever; and found that whilst some were symptomless, they were all positive for coccidioidomycosis. Gifford was the first person to recognise that desert fever and valley fever were caused by the coccidioides fungus. This work received national recognition. She was the first to demonstrate that valley fever were the primary stages of the coccidioidomycosis infection. In 1938, Gifford joined E. C. Dickson to explain that the infection resembles primary tuberculosis and a full clinical recovery is possible. She continued to work on coccidioidomycosis and found that it occurred more often in men than in women and people of ethnic minorities. Over 80% of the patients who died had been engaged in agriculture or work where dust could have been involved.

<i>Mycobacterium chelonae</i> cutaneous infection: An opportunistic disease in an immunosuppressed patient with myasthenia gravis.

<iMycobacterium chelonae</i can cause chronic skin, soft-tissue or bone infections. and is often associated with the immunocompromised state.We describe a case of a 58-year-old male patient with myasthenia gravis, chronically immunosuppressed, with a four month progression of growing erythematous, nodular and hard cutaneous lesions in the left forearm, leg and foot. He was receiving immunoglobulin every four weeks (2 g/kg) and prednisolone 25 mg/day and had an important previous history of several opportunistic infections while he was receiving corticosteroids. Histopathological examination of a biopsy showed acid-fast bacilli and tissue culture identified a <iMycobacterium</i spp. within seven days of incubation, with <iMycobacterium chelonae</i being identified by polymerase chain reaction assay. Antimicrobial susceptibility testing was performed showing no resistance and the patient was successfully treated during four months with ciprofloxacin, clarithromycin and trimethoprim-sulfamethoxazole with regression of the lesions, leaving some hyperpigmentation scars and without unbalancing his neurological disease. Patients with myasthenia gravis should be closely monitored because first line treatments for <iM. chelonae</i infection may be associated with myasthenic crisis.

Tinea Barbae -- History and Physical

The classic inflammatory form of tinea barbae develops a characteristic lesion called kerion. Kerion is an erythematous, boggy, tender, often sterile, weeping nodule or plaque with pustules and draining sinuses. [6] [7] Hair in these areas appears lusterless, brittle, and is easily plucked. Kerion can be solitary or multiple but is usually unilateral. [6] [7] Patients with inflammatory tinea barbae may have constitutional symptoms like fever and malaise. [6] Kerion is a coalesced sterile pustule, but occasionally they can get superinfected with cutaneous bacteria and develop regional lymphadenopathy. [7]

A Rare Manifestation of Tuberculosis in a Renal Transplant Patient: A Case Report.

Cutaneous lesions in the presence of fever in patients undergoing immunosuppressive therapy are a diagnostic challenge and may represent manifestations of multiple diseases, such as fungal infections, nocardiosis, lymphoproliferative diseases, zoonosis, and tuberculosis. The authors report a case of a 66-year-old white man with chronic kidney disease since 2014 (chronic pyelonephritis) who had a renal transplant in the previous 6 months. Induction therapy was performed with thymoglobulin, and his current immunosuppression scheme included tacrolimus, mycophenolate mofetil, and prednisolone. The patient had no history of pulmonary tuberculosis. The patient presented with 2 cutaneous lesions, localized on the back and abdomen, that appeared to be firm, painful, subcutaneous, erythematous nodules with an approximately 5 cm diameter overlying an infected focus and purulent material inside. The patient also had a fever and fatigue. Blood analysis showed pancytopenia with an elevation of inflammatory markers and graft dysfunction. Tissue cultures and skin biopsy with histological analysis were performed. Histopathology of the lesion showed a nonspecific inflammatory infiltrate without granulomas, and acid-fast bacillus staining was negative. Nevertheless, serum QuantiFERON testing was positive. But polymerase chain reaction finally confirmed the presence of Mycobacterium tuberculosis, which confirmed the diagnosis of cutaneous tuberculosis. A chest computed tomography scan showed a lung pattern of miliary tuberculosis. The patient was treated with multidrug tuberculosis therapy, resulting in lesion clearance after 3 weeks. Tuberculosis is a serious infection, especially in high-risk patients, such as those in an immunocompromised state. The incidence of cutaneous tuberculosis is rare, but it should be considered in patients presenting with atypical skin lesions suggestive of an underlying infectious etiology.

Erythrasma -- Introduction

Erythrasma is a common skin disorder caused by bacteria. It was first described in 1859 by Burchardt, who thought the etiology was fungal. In 1862, Burchardt's teacher, Von Barensprung coined the term erythrasma and named the bacteria Microsporum minutissimum . Today, erythrasma is known to be caused by Corynebacterium minutissimum, which is a gram-positive, catalase-positive, non-spore-forming organism. Erythrasma usually causes infection of the intertriginous parts of the body and causes itching, scaling, and erythema. It is often asymptomatic. [1] [2]