tbuckley/cabot-search huggingface dataset:
BI33 A case of disseminated herpes zoster in a patient on abrocitinib
Authors: Brent Doolan, Sarah Drummond, Andrew Pink, Catherine Smith, Elaine Agius
Journal: British Journal of Dermatology (2024)

Abstract Janus kinase (JAK) inhibitors are disease-modifying agents with efficacy in treating a spectrum of burdensome dermatological conditions. Abrocitinib, which is a JAK1 selective inhibitor, has recently been approved for the treatment of moderate-to-severe atopic dermatitis in adults and young people. Data from randomized controlled trials and real-world analyses have shown herpes zoster to be one of the most frequent serious infections. We present a rare case of disseminated herpes zoster infection with lumbar plexopathy. A 62-year-old White woman was commenced on 200 mg of daily abrocitinib after failure of multiple systemic agents for treatment of her severe atopic dermatitis. After 12 months of treatment, she awoke with spontaneous left-sided ­lower-limb pain that was worse on ambulation. She was given a presumed diagnosis of sciatica and provided with analgesia. The following day the pain remained and she developed pruritic, ulcerated lesions on her face and chest and within her mouth, with periorbital oedema. She attended her local district hospital and was considered to have had a reaction to the analgesia and given oral corticosteroids. She was then reviewed 1 week later and was confined to a wheelchair as she was unable to bear weight on her left leg secondary to hip pain. Neurological examination revealed marked weakness to ankle plantar and dorsiflexion, and loss of sensation. Skin examination showed haemorrhagic crusted papules on the face, abdomen, back and lower limbs, with some intact vesicles on her thigh. Skin swabs confirmed varicella zoster virus infection and she was diagnosed with disseminated herpes zoster. In light of the neurological deficits, she was referred to the neurological team. A lumbosacral magnetic resonance imaging scan showed oedema, thickening and contrast enhancement of the left L4, L5 and S1 nerve roots, in keeping with lumbar plexopathy. She was commenced on high-dose intravenous antiviral therapy, with ongoing, significant neurological impairment to her left leg. Potential risk factors for treatment-emergent herpes zoster have been noted to include abrocitinib dose, baseline age, past history of herpes zoster and absolute lymphocyte count prior to infection. For patients with atopic dermatitis who have achieved acceptable control of their disease, abrocitinib dose reduction should be considered. Patients should be counselled on these serious infections, have their risk factors assessed and have the shingles vaccination recommended for those at risk, prior to commencing treatment.
Teledermatology &amp; Digital Dermatology SymposiumOral presentationsBT01 Developing a national artificial intelligence-assisted skin cancer pathway
Authors: Colin Morton, Gillian X M Chin, Jacob Carse, Stephen McKenna, Rubeta Matin, Colin Fleming
Journal: British Journal of Dermatology (2024)

Abstract The AI Skin Cancer Consortium seeks to progress integration of artificial intelligence (AI) into the skin cancer referral pathway to promote rapid diagnosis of skin cancer and reassurance with benign lesions. In contrast to other fields of medicine, such as radiology, dermatology has lacked standardization in data acquisition, which is required for high-quality, reproducible and interoperable AI algorithm performance. Beginning in 2021, the consortium has made substantial progress towards defining a national pathway, technology architecture and data flows. We describe a standardized approach to acquisition of macroscopic and dermoscopic images, and technical and clinical metadata in a DICOM (Digital Imaging and Communications in Medicine) format, currently acquired in outpatient imaging centres and in general practice. In order to develop a transparent competitive environment for testing of this standardized National Health Service (NHS) pipeline, the consortium created a Small Business Research Initiative funded via a government agency. Three companies were awarded funding for this two-phase programme, from 15 applicants. These industry partners tested the pipeline within a trusted research environment (TRE), using real-world data. All industry partners were able to evaluate skin lesion images in combination with interoperable clinical metadata and run existing algorithms in the TRE. We report progress on this competition and also on the process of creating a national database, to permit competitive testing performance of different algorithms with specific clinical use cases. To assess the cost-effectiveness of introducing AI into the skin cancer pathway, we have also collaborated with the York Health Economics Consortium to produce a model to permit estimation of the impact of an AI triage tool to assist clinician triage. The recent vision statement from the British Association of Dermatologists encourages AI solutions intended to address a clinical unmet need and that integrates into patient pathways to enhance the service provided by healthcare professionals [https://www.bad.org.uk/clinical-services/artificial-intelligence/vision-statement-on-artificial-intelligence-ai-interventions/ (last accessed 19 March 2024)]. If the UK is to be at the forefront of skin AI, then it is imperative that the market is stimulated through use of meticulously standardized interoperable data standards with platforms that allow for transparent testing of multiple algorithms. We have successfully introduced a pipeline for safely generating standardized, high-quality images that are suitable for AI, identifying where we can achieve the greatest potential value for introducing AI into the NHS skin cancer referral pathway.
SG12 ‘There’s something fishy going on’: a case of trimethylaminuria
Authors: Claire Quigley, Clodagh Loftus, Julianne Clowry, Alan D Irvine
Journal: British Journal of Dermatology (2024)

Abstract Trimethylaminuria (TMAU) is a rare metabolic disorder resulting in the accumulation of trimethylamine (TMA), which is a foul-smelling metabolite that is excreted in bodily fluids and exudes a characteristic odour of rotting fish. Although the condition is not life-threatening, the psychological and social consequence can be devastating. Herein, we present the case of a 35-year-old woman with a diagnosis of TMAU. This case outlines the methods by which a diagnosis of TMAU can be made, while also magnifying the negative psychosocial impact of this rare diagnosis. It also reflects real-world experience with the currently available therapeutic options. TMA is produced in the gastrointestinal tract from dietary precursors such as choline (present in eggs, liver and poultry), trimethylamine N-oxide (TMAO; found in marine fish) and carnitine (found in meat). Primary trimethylaminuria is due to a mutation in the FMO3 gene, leading to the inability to oxidize this amine to the nonodorous metabolite (TMAO) (Antoñanzas J, Querol-Cisneros E, Alkorta-Aranburu G et al. Primary trimethylaminuria syndrome: more than an unpleasant odor. Int J Dermatol 2023; 62: e176–8). At present, over 40 variants in FMO3 associated with TMAU have been identified. Secondary or acquired TMAU is the result of a combination of factors including increased consumption of dietary precursors, gut dysbiosis, hepatic impairment and hormonal fluctuations resulting in an accumulation of TMA. Treatment regimens involve limiting precursors intake, using acidic soaps to reduce the volatility of excreted TMA, targeting gut microbiota, and the use of oral sequestering agents (Schmidt AC, Leroux JC. Treatments of trimethylaminuria: where we are and where we might be heading. Drug Discov Today 2020; 25: 1710–17). However, current treatment options have had limited therapeutic effect. Referral to metabolic specialists for correct nutritional support and referral to psychiatry is paramount for these patients. As evident from our patient’s viewpoint, this diagnosis can have a lifelong impact on social engagement and psychological health.
H19 Not only a finder of ‘solutions’: Max Jessner, Holocaust survivor and discoverer of Jessner–Kanof lymphocytic infiltrate
Authors: Lucy McAllister, Siwaporn Hiranput, Paul Devakar Yesudian
Journal: British Journal of Dermatology (2024)

Abstract Max Jessner’s name is renowned for his codiscovery of Jessner–Kanof disease and his eponymous peel. However, unknown to many, Jessner faced many uncertainties in his lifetime and lived in a frequent state of movement. Max Jessner read medicine at the universities of Munich and Königsberg (now Kaliningrad). After graduation, he trained in dermatology clinics under Albert Neisser in Breslau (now Wroclaw) before moving to Bern, Switzerland to become assistant to Joseph Jadassohn from 1912 to 1914. Like his father, dermatologist Samuel Jessner, Max Jessner initially developed his specialism in the studies of syphilis, namely through an expedition to Buryat-Mongolia, to study the effect of salvarsan, an antisyphilitic agent. On his return in 1920, he moved to the University of Breslau, where he continued to work alongside Jadassohn as head of the dermatology department. Due to growing anti-Semitism in Europe, Jessner’s resignation was forced just 4 years later. He was permitted to emigrate to Switzerland but ultimately evaded persecution by leaving Europe and continuing a career in New York, like many other European dermatologists of Jewish descent facing oppression during the Third Reich. In the USA, Jessner lived in a tight-knit community socializing with other dermatologists including Hans Biberstein. Arguably Jessner’s greatest accomplishment was achieved in 1953 while working at the New York Skin and Cancer unit, with the description of Jessner–Kanof lymphocytic infiltrate, a photosensitive lymphocytic disorder now believed to be on the same disease spectrum as lupus tumidus. In the same decade, Jessner published his seminal paper on his self-named solution, an augmented formula of a well-known peel containing lactic acid, salicylic acid and resorcinol. The modified form is a tolerable and effective agent for hyperkeratotic disorders and remains popular in the treatment of acne scarring, pigmentation and rhytides. Max Jessner was born on 2 November 1887, in Slupsk, Poland. In 1971 he returned to Europe, where he spent much of his retirement. Jessner died in Switzerland at age 91. Max Jessner was survived by his wife Marianne, and children Peter and Sabine Jessner. His only sibling, Fritz Jessner, was a theatre director in Boston. Jessner’s esteemed career, his contribution to the field of dermatology and his resilience to continue in his profession despite many major obstacles will be remembered for years to come.
H07 Skin, science and suffrage: the trailblazing history of Agnes Blackadder
Authors: Maya Dyson
Journal: British Journal of Dermatology (2024)

Abstract Agnes Blackadder, born in Dundee on 4 December 1875, is widely credited as the first female consultant dermatologist in Britain. In 1895 she graduated from St Andrews University, the first woman to do so, with a Master of Arts. Following this she matriculated at Queen Margaret College in Glasgow, going on to obtain her medical degree in 1901. She was known to be a particularly voracious learner, taking multiple subjects simultaneously during her time at St Andrews, resulting in her graduating prematurely. Furthermore, during her medical education she obtained prizes across multiple fields, such as surgery, midwifery and ophthalmology. In 1907 Blackadder moved to London, where she was appointed as a consultant dermatologist at St John’s Hospital for Skin Diseases. Not only is she considered to be the first female consultant dermatologist in Britain, but she was among the first female physicians to be appointed as a consultant in a hospital serving both male and female patients. Her very presence within the medical community was, at the time, considered to be radical. Moreover, her interest in dermatology, radiology and electrotherapeutics diverged from those considered to be more acceptable for female physicians, namely paediatrics and women’s health. Central to Blackadder’s life was her advocacy for gender equality, frequently highlighting the persistent gender disparities in the fields of both medicine and academia. In 1912 she worked as part of the medical team who assessed the impact of force feeding of imprisoned suffragettes participating in hunger strikes. She published her findings, describing this practice as ‘severe physical and mental torture’, and strongly advised against its use. During World War I she served at Royaumont Hospital in France, working as a radiographer. Her research interests continued to be both progressive and wide ranging; she was among the first to identify the radiographic appearances of gas gangrene, and used this to help improve diagnostic accuracy. She observed the impact of music on health and documented its therapeutic implications. She published Music, Health and Character soon after her return to London, and this resulted in the formation of the Council for Music in Hospitals. The exceptional career of Blackadder spanned over 50 years and she continued to practise medicine into her eighth decade before she passed away in 1964, aged 88. Her legacy has left an indelible mark on both medicine and women’s rights. She succeeded in creating space for women in the fields of dermatology and academia, paving the way for subsequent generations to pursue their aspirations.
GD06 An observational study of the impact of the Ukraine war in our dermatology department
Authors: Sherok Hegazy, Berbie Byrne, Mary Laing
Journal: British Journal of Dermatology (2024)

Abstract We aimed to assess the cohort of patients attending our dermatology department who have been displaced by the war in Ukraine, to evaluate the impact of the conflict on the continuity of medical care, and to shed light on the challenges faced by political refugees in an unfamiliar medical system. Consenting Ukrainian refugees attending our department over a 3-month period answered questions regarding their displacement, medical history, and reason for referral to the dermatology service. We assessed the impact of their care on our department including translators, treatment plans and further follow-up appointments. We also present a single patient’s story, highlighting the devastating impact political conflict can have on patient care. Seventeen patients participated in the study. Most patients (82%) arrived in Ireland over 1 year ago. Thirteen of the presenting complaints (76%) occurred prior to displacement. Six patients were referred for assessment of a rash and 11 with lesions. Working diagnoses included benign naevi (35%), skin cancers (29%) and inflammatory dermatoses including eczema, psoriasis and tinea (35%). Four patients had translators booked, while the remainder communicated through family members or an online translator service. In total, seven patients required excisions, two required systemic treatment and one required biologic treatment. The remaining 10 patients were discharged from dermatology. We also present a single patient’s story. The patient was a 46-year-old woman referred to dermatology with psoriasis for which she was previously on maintenance treatment with methotrexate in Ukraine. She incidentally had a lesion recently excised in Ukraine, from which she never got the results due to the war. Following her displacement she subsequently developed pain and swelling around her surgical site. Investigation revealed what was likely metastatic melanoma. Political conflict can lead to fractured patient care, catastrophic outcomes and increased pressure on thinly stretched healthcare resources. Our hospital’s immediate catchment area has accommodated just under 10 000 Ukrainian refugees to date and we have seen some of the deleterious effects this conflict has had on patient care as a consequence. Nevertheless, we must continue supporting political refugees to the best of our ability, keeping in mind the impact of displacement on their care.
BI36 An infiltrative subcutaneous mass presenting as the first sign of relapse in a patient with T prolymphocytic leukaemia
Authors: Li Jie Helena Yoo, Nicola Kearney, John Quinn, Siona Ni Raghallaigh
Journal: British Journal of Dermatology (2024)

Abstract T prolymphocytic leukaemia (TPLL) is a rare form of post-thymic T-cell neoplasm, often involving the peripheral blood, bone marrow and spleen. Cutaneous involvement can be found in 25–35% of patients (Mallet RB, Matutes E, Catovsky D et al. Cutaneous infiltration in T-cell prolymphocytic leukaemia. Br J Dermatol 1995; 132: 263–6). Cutaneous features are not well recognized in dermatological literature and have been reported only in a limited number of case series (Herling M, Valbuena JR, Jones D, Medeiros LJ. Skin involvement in T-cell prolymphocytic leukemia. J Am Acad Dermatol 2007; 57: 533–4). There is a predilection towards the face and trunk, and reported morphologies include oedema, macules, papules, infiltrative erythema, nodules and erythroderma. A 76-year-old woman was admitted with a 6-week history of a nontender, indurated rash on her left upper arm, feeling generally unwell with vomiting and diarrhoea. Prior to admission, she was treated with flucloxacillin, doxycycline and co-amoxiclav with presumed cellulitis, but with no relief. On examination, a well-demarcated indurated plaque with central clearing and expanding erythema resembling erythema migrans was noted on her left upper arm. A symmetrical petechial rash and erythematous plaques on her legs were also present. The patient had been diagnosed with TPLL 18 months previously and had completed six cycles of alemtuzumab with disease remission. Blood investigations on this admission revealed a haemoglobin of 10.5 g dL−1, lymphocytosis of 11.20 × 109 L−1, acute kidney injury with creatinine 160 µmol L−1, elevated lactate dehydrogenase 546 IU L−1 and C-reactive protein 15 mg L−1. Her blood cultures were negative. Blood film revealed atypical lymphocytosis consistent with relapse of TPLL. Given the induration associated with the left-upper-arm lesion, an ultrasound and magnetic resonance imaging were performed, which revealed a 5 × 3 × 7-cm mass infiltrating her triceps brachialis. Core biopsy showed atypical lymphocytic infiltration in the dermis and grenz zone with positive CD3, CD4, CD5 and CD7, consistent with TPLL infiltration of the skin. Skin biopsy from her lower limb also showed cutaneous TPLL infiltration. Computed tomography of the thorax, abdomen and pelvis revealed diffuse lymphadenopathy and splenomegaly. Bendamustine was started for relapsed TPLL with significant reduction in the size of her left-upper-arm mass. This case highlights the various morphologies of cutaneous eruption that can present in a patient with TPLL. To our knowledge, this is the second case reported in the literature in a patient with TPLL presenting with a subcutaneous mass. Cutaneous features of TPLL may herald disease relapse with an ensuing aggressive clinical course. A high index of suspicion and low threshold for biopsy are needed, as extranodal involvement itself meets the criteria for active TPLL warranting treatment.
BT11 Artificial intelligence and ethnically diverse skin: potential, pitfalls and a model for reducing risk
Authors: Lucas Lamche, Jessie Felton
Journal: British Journal of Dermatology (2024)

Abstract There is increasing demand for artificial intelligence (AI) tools to manage skin cancer; however, there is minimal diversity in images used for AI training and validation (Wen D, Khan SM, Xu AJ et al. Characteristics of publicly available skin cancer image datasets: a systematic review. Lancet Digit Health 2022; 4: e64–74). Limited validation in ethnically diverse skin, in tandem with no human ‘sense check’ on photographic input and analysis by AI, increases the risk of misdiagnosis of skin cancers. We assessed AI bias and developed a cost-effective protocol to increase diagnostic accuracy in patients with ethnically diverse skin. A dermatology nurse collected clinical history and used videodermoscopy to capture optimized macro and dermoscopic images of lesions. Data were from consented patients with self-identified ethnically diverse skin, being assessed via the 2-week-wait skin cancer teledermatology pathway over 7 months. This was combined with clinical history. Histological diagnosis (where available) and consultant diagnosis were recorded for each lesion, used as gold standard to compare Moleanalyzer pro AI assessments of lesions. This ‘real-time AI’ is run at the bedside and clearly demarcates the lesion being analysed. We analysed 69 lesions from 64 patients (45 female, 19 male) with an age range of 18–81 years (mean 49.9). The AI malignancy threshold (MT) is 0–1 (1 being highest risk of malignancy). With MT on the Moleanalyzer pro AI at &amp;gt; 0.2, clinical–AI concordance was 75.4%, while AI sensitivity and specificity were 83.3% and 74.6%, respectively. Published results for Moleanalyzer pro AI in people with Fitzpatrick type II and III skin at MT 0.5 and above show sensitivity 81.6% and specificity 88.9%. In some cases in our study, AI picked out the incorrect darker area and not the index lesion in ethnically diverse skin. In addition, only rare subtypes of skin cancers were found in our patient population. We found that when using dermatological AI diagnostic tools, a nurse-led photography protocol is optimal. Incorporating clinical history alongside ‘real-time AI’ at the bedside, and a human ‘sense check’ on AI diagnosis, reduces risk. When using AI in an ethnically diverse population, a reduced MT must be considered to achieve a level of accuracy comparable with published data. With an effective protocol, AI can provide extensive savings and reduced waiting times. Each diagnostic AI tool developed for skin cancer should be validated with ethnically diverse skin images to reduce health inequality and potential harm to patients. We propose this is introduced into formal quality standards for AI used in skin cancer diagnosis.
BI31 Pembrolizumab-induced scleroderma in a patient with nonsmall cell lung cancer
Authors: Anamika Kunnumpurath, Vesna Gjorgjievska-Marsh
Journal: British Journal of Dermatology (2024)

Abstract We present the case of a 59-year-old woman with locally advanced metastatic adenocarcinoma of the lung, who developed skin tightening and thickening following a course of treatment with pembrolizumab. She was commenced on pembrolizumab in September 2021, and in July 2023 she developed the skin changes in the neck, shoulders, stomach and thighs with associated pain, as well as areas of colour change and restriction of movement. Clinical presentation combined with subsequent histopathological confirmation led to a diagnosis of scleroderma. Following a failed trial of high-dose prednisolone, methotrexate was started with beneficial effect. This case highlights that scleroderma is a rare skin-related adverse event that can occur with immune checkpoint inhibitors.