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Σάββατο, 15 Δεκεμβρίου 2018

Vitamin D Supplements Don’t Reduce Cancer Incidence

12/13/2018

In the largest-ever randomized trial testing vitamin D for cancer prevention, the supplement did not lower the risk of developing cancer. The Vitamin D and Omega-3 Trial (VITAL) includes a nationally representative sample of nearly 26,000 participants.

Indian Journal of Nephrology (Indian J Nephrol)

ORIGINAL ARTICLES 

Epidemiology and outcomes of acute kidney injury in critically ill: Experience from a tertiary care center Highly accessed articlep. 413
PS Priyamvada, R Jayasurya, Vijay Shankar, S Parameswaran
DOI:10.4103/ijn.IJN_191_17  
There is only limited information on the epidemiology and outcomes of acute kidney injury (AKI) in critically ill patients from low- and middle-income countries. This study aims to identify the etiology, short-term outcomes, and determinants of mortality in patients with AKI admitted to multiple medical and surgical Intensive Care Units (ICU's) in a tertiary care center. The study also aims to compare the clinical characteristics and outcomes of community-acquired AKI (CAAKI) and hospital-acquired AKI (HAAKI). A prospective, observational study was done from June 2013 to October 2015. All patients over 18 years with AKI admitted in various medical and surgical ICU's seeking nephrology referral were included. AKI was defined according to KDIGO criteria. The follow-up period was 30 days. A total of 236 patients were recruited from five medical and nine surgical ICU's. Majority (73.3%) were males. About 53.38% patients had CAAKI, whereas 46.61% had HAAKI. The predominant etiologies for AKI were sepsis (22.4%), trauma due to road traffic accidents (21.18%), acute abdomen (perforation, acute pancreatitis, bowel gangrene, intestinal obstruction and cholangitis) (18.64%), and cardiac diseases (10.59%). Sepsis and acute abdomen were the most common causes of CAAKI, whereas trauma and cardiac causes were the predominant causes of HAAKI (P < 0.05). Patients with HAAKI were younger, admitted in surgical units, had lower SOFA scores, lower serum creatinine, lesser need for dialysis, longer hospital stay, and earlier stages of AKI compared to patients with CAAKI (P < 0.05). The 30-day mortality was 52.54%. The mortality was not different between CAAKI and HAAKI (56.3% vs. 48.18%; relative risk = 0.86: 95% confidence interval 0.67–1.1). The mortality was similar across different stages of AKI.
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Skin microcirculatory changes in relation to arteriovenous fistula maturationp. 421
Siew Cheng Chai, Wan Azman Wan Sulaiman, Arman Zaharil Mat Saad, Aida Hanum Rasool, Amran Ahmed Shokri
DOI:10.4103/ijn.IJN_402_17  
Maturation of arteriovenous fistula (AVF) involves complex vascular remodeling. In this study, we evaluated the changes of skin microvascular perfusion over the extremity with AVF maturation using the laser Doppler fluximetry (LDF). A total of 45 patients with chronic kidney disease, Stages IV–V, were included; they had undergone AVF creation from July 2014 to June 2016 at our institute. The measurement of skin microvascular perfusion was accomplished proximal and distal to the fistula anastomosis site: pre- and post-operative day 1, week 2, week 6, and week 12. Thirty-two patients with mean age of 55.6 had achieved AVF maturation. There were 40.6% radial-based and 59.4% brachial-based AVF. There was a 32.8% reduction of mean skin perfusion distal to the fistula by day 1 compared to the baseline perfusion; however, perfusion increased 47% by week 2 compared to day 1 and no dramatic change was subsequently noted. There was an increase of mean skin perfusion, proximal to fistula anastomosis, over 12 weeks with 35.8% at day 1 from the baseline. However, the changes of the mean skin perfusion were not statistically significant. There was no significant relation of skin perfusion changes with the type of fistula, diabetes mellitus, hypertension, and hyperlipidemia. LDF successfully detected the subclinical change of skin microvascular perfusion in relation to AVF creation. Reduction of skin perfusion distal to the fistula suggests that in patients with existing perfusion inadequacy of extremities, they may experience ischemic symptoms as early as day 1 postoperation, and require close monitoring for distal limb ischemic-related complications.
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Urinary neutrophil gelatinase-associated lipocalin and urinary soluble CXCL16 as biomarkers of activity in pediatric lupus nephritisp. 427
MA El-Gamasy, W El-Naghy
DOI:10.4103/ijn.IJN_265_17  
One of the challenges of treating patients with lupus nephritis (LN) is to assess disease activity. The aim of this study was to measure the urinary neutrophil gelatinase-associated lipocalin (uNGAL) and urinary soluble chemokine (C-X-C motif) ligand 16 (CXCL16) levels in children and adolescents with systemic lupus erythematosus (SLE) and investigate whether they are elevated in active LN. This study was conducted on 80 patients diagnosed as SLE by the Systemic Lupus International Collaborating Clinics criteria and 60 apparently healthy individuals as controls. Global and renal disease activities were evaluated by Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and renal SLEDAI, respectively. uNGAL and urinary CXCL16 were measured for all participants by ELISA. Renal biopsy was done for all cases at initial diagnosis and was graded using ISN/RPS classification. uNGAL and CXCL16 were higher in patients than in the controls (8.9 ± 3.56 ng/dl and 1067 ± 367 ug/L vs. 2.26 ± 1.95 ng/dl and 471 ± 106 ug/L, respectively). uNGAL had higher sensitivity and specificity than urinary CXCL16 as predictor of LN (95% and 90% vs. 85% and 80%, respectively). There was significant positive correlations between uNGAL levels, 24-h urinary proteins (r = 0.732, P = 0.001), and SLEDAI (r = 0.359, P = 0.001). There was also significant positive correlations between urinary CXCL16 levels, 24-h urinary proteins (r = 0.47, P = 0.001), and SLEDAI (r = 0.17, P = 0.001). uNGAL and CXCL16 were reliable indicators of the activity of LN.
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Optimization of treatment modality in elderly end-stage renal disease population: Peritoneal dialysis versus transplantp. 433
A Kaul, MR Behera, R Kishore, B Karthikeyan, DS Bhadauria, P Mishra, N Prasad, A Gupta, RK Sharma
DOI:10.4103/ijn.IJN_305_17  
Despite kidney transplantation (KT) being considered as the best treatment modality for end-stage renal disease (ESRD), patient and graft survival in the elderly population is poorer than younger individuals. Many authors argue that prolonged life expectancy outweighs the risk of remaining on dialysis, but few studies had compared the treatment modalities, especially with peritoneal dialysis (PD). A retrospective study was conducted at a tertiary care institute to compare outcome of elderly ESRD patients, who received KT with those continued on PD; and to evaluate the predictors of patient survival. Patient survival at 1 year was (76.2% vs. 91.1%); 5 years (53.7% vs. 21.8%); and 10 years (35.6% vs. 0.00%) among KT and PD population, respectively. Infection was the most common cause of death among KT group (35 [41.2%] vs. 34 [28.2%]) while cardiovascular mortality in PD group (55 [46.2%] vs. 7 [8.2%]). Technique survival at 1, 5, and 10 years in PD group was 92.8%, 58.5%, and 0%, respectively. Similarly, graft survival at 1, 5, and 10 years in KT group was 98.7%, 90.2%, and 90.2%, respectively. Multivariate analysis showed body mass index (BMI) (hazard ratio [HR] 0.88, 95% confidence interval [CI] 0.82–0.93, p < 0.001), and albumin (HR 0.55, 95% CI 0.37–0.80, p = 0.002) were significant predictors of survival. In the 1st year, patient survival was better in PD than KT, but after adjustment for BMI and albumin, both short-term and long-term survival in elderly KT group was better than that of PD. Hence, elderly ESRD patients should not be barred from KT just because of age.
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Role of blood oxygen level-dependent MRI in differentiation of acute renal allograft dysfunctionp. 441
Hira Lal, Ezaz Mohamed, Neelam Soni, Priyank Yadav, Manoj Jain, Dharmendra Bhadauria, Anupma Kaul, Narayan Prasad, Amit Gupta, RK Sharma
DOI:10.4103/ijn.IJN_43_18  
Early graft dysfunction after renal transplantation manifests as acute rejection (AR) or acute tubular necrosis (ATN). Blood oxygen level-dependent (BOLD) magnetic resonance (MR) imaging is a noninvasive method of assessing tissue oxygenation, which may be useful for predicting acute allograft dysfunction. This was a prospective study involving 40 patients scheduled for renal transplantation from August 2012 to August 2014. In addition, 15 healthy donors were also enrolled in this study. All recipients underwent BOLD MR imaging (MRI) and R2* mapping 10–20 days after transplant, and additionally within 48 h of biopsy if there was any evidence of graft dysfunction. The healthy donors underwent BOLD MRI 1–2 days before surgery. The biopsies were grouped into AR, ATN, and no evidence of AR or ATN. The mean medullary R2*, cortical R2*, corticomedullary gradient, and medullary: cortical R2* ratio were compared between groups using one-way analysis of variance. Spearman's correlation and multinomial linear regression were applied to determine the influence factors of R2* value. Overall, nine patients had graft dysfunction. Six were reported as AR, two as ATN, and one as no evidence of ATN or rejection. The mean medullary and cortical R2* were significantly higher in ATN group compared with AR and normal group, whereas the mean medullary and cortical R2* of AR group were significantly lower than normal group. The corticomedullary gradient of AR group was significantly lower compared with ATN and normal group. Medullary R2*:cortical R2* ratio was significantly lower in AR group compared with normal group. No significant difference was noted between the 15 donors and patients with normal graft function. R2* values on BOLD MRI are significantly decreased in AR allografts and increased in an early stage of ATN allografts, suggesting that BOLD MRI can become a valuable tool for discriminating between AR and ATN.
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Prevalence and clinical correlates of white coat effect in patients with chronic kidney disease and the role of automated blood pressure device in its assessmentp. 448
Srinivas Shenoy, Shankar Prasad Nagaraju, Nileshwar R Rau, Ravindra A Prabhu, Uday Venkat Mateti, Dharshan Rangaswamy, Indu R Rao, Karan Saraf
DOI:10.4103/ijn.IJN_418_17  
Context: Hypertension in chronic kidney disease (CKD) is an important modifiable cardiovascular risk factor. Patients with CKD can have clinically significant white coat effect (WCE), making routine clinic blood pressure (BP) measurements an unreliable indicator of actual BP control. Automated BP monitoring is useful in identifying WCE. The utility of automated BP monitoring has seldom been part of clinical practice in developing countries. Aim: The goal of this study was to estimate the prevalence and determinants of WCE in adult patients with CKD in an outpatient setting using an automated BP device. Materials and Method: In this prospective observational study, patients with CKD attending the nephrology clinic over a period of 6 months (January 2016 to July 2016), who were suspected to have WCE by the treating physician, were assigned to measurement of BP by both the standardized manual BP recording by a single nephrologist and with automated machine as per a defined protocol. Clinical, demographic characters that would influence outcomes were also studied. Results: Among 118 patients with CKD with suspected WCE, 57.6% showed WCE. The mean systolic and diastolic BPs were significantly lower with automated machine when compared with manual BP recordings in patients with WCE (p = 0.04). WCE was seen in all stages of CKD. Occurrence of WCE in CKD was not dependent on factors such as old age, sex, diabetes mellitus, or smoking status in our study. Conclusion:WCE is a highly prevalent and underdiagnosed entity in patients with CKD. Automated machine is a useful and time-saving tool in detection of WCE in patients with CKD attending the outpatient clinic and guide management.
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Acute pyelonephritis: A single-center experiencep. 454
L Umesha, SM Shivaprasad, EN Rajiv, MM Satish Kumar, V Leelavathy, CG Sreedhara, MR Niranjan
DOI:10.4103/ijn.IJN_219_16  
Acute pyelonephritis (APN), although a common clinical entity, still not much is known about the clinical profile in the Indian scenario. We prospectively collected clinical, biochemical, and radiological data of patients hospitalized with a diagnosis of APN from March 2014 to June 2016. A total of 296 cases were included in the study. Mean age was 53.85 ± 9.78 years. Male to females ratio was 1.93:1. Among the risk factors recognized for complicated pyelonephritis (PN), diabetes mellitus (DM) (54.4%) was the most common factor followed by renal calculi (14.4%), benign prostatic hyperplasia (6.7%), immunocompromised state (3.3%), stricture urethra and meatal stenosis (3.3%), and neurogenic bladder (2%). Urinary culture was negative in 153 (51.7%) and positive in 143 patient (48.3%). Most common organism isolated was Escherichia coli (29.7%), followed by Klebsiella pneumoniae (5.4%), pseudomonas (5.4%), Enterococcus (4.4%), and Proteus in 10 (3.4%). Serum creatinine of more than 1.5 mg/dl at admission was seen in 96.3% patients; 40% of them had underlying chronic kidney disease with DM being the most common. Multiorgan dysfunction either at admission or during the course in hospital stay was seen in 31.8% patients. Twelve (2%) had emphysematous PN. Six patients had Class II, 4 had Class III, 1 with Class I, and another with Class IV. A total of 18 deaths were noted (6.1%). Hemoglobin <10 g/dl, serum creatinine at admission >1.5 mg/dl, HbA1c% >10%, and immunosuppression had statistically significant association with the development of multiorgan dysfunction on univariate analysis, but on multivariate analysis, only hemoglobin, HbA1c%, and immunosuppression reached statistical significance. Even with attributable risk of mortality, only hemoglobin, HbA1c%, and immunosuppression reached statistical significance on multivariate analysis. HbA1c% adds to the predictive parameters to recognize at-risk patients to intensify the treatment and avoid complications.
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Hepatitis C virus-associated membranoproliferative glomerulonephritis treated with directly acting antiviral therapyp. 462
S Nayak, A Kataria, MK Sharma, A Rastogi, E Gupta, A Singh, SC Tiwari
DOI:10.4103/ijn.IJN_235_17  
Hepatitis C virus (HCV) infection has been shown to affect kidneys with various histopathological pattern on the kidney biopsy. These commonly include a membranoproliferative glomerulonephritis (MPGN) pattern with mixed cryoglobulinemia (CG), thrombotic microangiopathy, membranous nephropathy, and vasculitis affecting medium and small vessels of the kidneys causing polyarteritis nodosa. It has been rarely associated with MPGN without detectable CG. We present one such patient who presented to us with HCV-associated MPGN without detectable CG, who recovered completely with directly acting antiviral therapy without any immunosuppression.
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Systemic lupus erythematosus with linear IgA bullous dermatosis and renal vascular lesions: An extremely rare associationp. 465
R Malipatel, V Gnanapriya, A Manocha, YK Inchara
DOI:10.4103/ijn.IJN_200_17  
We report a rare case of systemic lupus erythematosus presenting initially with cutaneous manifestations of linear IgA bullous dermatosis. Later the patient developed renal abnormalities due to thrombotic microangiopathy and lupus nephritis with inflammatory necrotizing vasculitis. Paucity of immune deposits was observed on Immunofluorescence. This association of SLE with these cutaneous and renal lesions is rarely reported in the literature.
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Xanthogranulomatous pyelonephritis: Intrahepatic and intrathoracic extensionp. 468
U Anandh, N Birajdar, R Kumar, S Babu
DOI:10.4103/ijn.IJN_213_17  
A 32-year-old female presented to us with worsening cough and expectoration, low-grade fever, and malaise for 3 months. She gave a history of pregnancy loss secondary to urinary tract infection (UTI) a year back. At that time, she was told to have an obstructive right renal calculus. She also had a history of recurrent UTI in the past 1 year. She had no other comorbidities. Her clinical evaluation revealed an enlarged right kidney and reduced air entry in the right hemithorax. Radiological investigations revealed a large right kidney invading into the inferior surface of the right lobe of the liver and the right pleural space. A clinical diagnosis of xanthogranulomatous pyelonephritis was made, and she was advised nephrectomy. Intraoperatively, the right kidney was found to invade both the right lobe of the liver and the right pleural cavity through a right diaphragmatic defect. Histopathology of the kidney revealed the presence of foamy histiocytes suggestive of xanthogranulomatous pyelonephritis. Invasive xanthogranulomatous pyelonephritis is known, however, invasion into the extra-abdominal structures has not been reported in the literature. Our case is a rare manifestation of a rare clinical entity – xanthogranulomatous pyelonephritis.
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Crystalline nephropathy in renal transplant: A series of 4 casesp. 472
K Mnif, S Yaich, M Mars, K Kammoun, F Fendri, K Charfeddine, F Jarraya, T Boudawara, J Hachicha
DOI:10.4103/ijn.IJN_76_17  
Crystals are particles of endogenous inorganic or organic composition that can trigger kidney injury when deposited or formed inside the kidney. The most common forms of crystalline nephropathies (CNs) are nephrocalcinosis and oxalate nephropathy. The causes of early allograft dysfunction are changing constantly, and recently calcium oxalate (CaOx) crystal deposition has been added to this list. CaOx deposition in renal allograft is important and probably under-recognized cause of delayed graft function that requires adequate awareness with early intervention to improve the allograft outcome. Here, we describe four cases of irreversible renal graft injury due to CNs.
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Allopurinol-induced drug reactions with eosinophilia and systemic symptoms syndrome with interstitial nephritisp. 477
T Aatif, J Fatihi, H El Annaz, O Qamouss
DOI:10.4103/ijn.IJN_166_17  
Allopurinol-induced drug reactions with eosinophilia and systemic symptoms (DRESS) is a severe illness related to hypersensitivity syndrome characterized by fever, skin rash, lymph node enlargement, hematological abnormalities, especially eosinophilia and atypical lymphocytosis, and single or multiple organ involvement. The syndrome is difficult to diagnose in view of its clinical heterogeneity and long latency period within 8 weeks after start treatment. We report a case of DRESS syndrome in a 64-year-old man, induced by allopurinol treatment for asymptomatic hyperuricemia, started 8 weeks earlier but stopped only 3 days after because of the onset of rash. The diagnosis was retained due to combining of interstitial nephritis with the clinical findings of fever, skin rash, cervical lymphadenopathy, eosinophilia, and reactivation of human herpesviruses specifically HHV-6. The glucocorticoids were started to relieve hypersensitivity. Five days later, the patient became afebrile, and the rash improved significantly. However, interstitial nephritis with renal function impairment progressed to severe azotemia, and even anuria requiring hemodialysis. Allopurinol-induced DRESS syndrome is associated with significant mortality, and care must, therefore, be exercised when given this drug.
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Autosomal dominant polycystic kidney disease: Presence of hypomorphic alleles in PKD1 Genep. 482
S Pandita, D Khullar, R Saxena, IC Verma
DOI:10.4103/ijn.IJN_236_17  
Autosomal dominant polycystic kidney disease is characterized by multiple cysts in both kidneys manifesting in adult life. In general, the disorder is caused by a pathogenic variant in one allele of PKD1 or PKD2 genes, while the other allele is normal. Pathogenic variants in both the alleles are rare and have variable phenotypes, from lethal or perinatal presentation to a mild form in later adulthood, depending on the type of variant. Here, we describe a proband with two variants (p.Thr1773Ile and p.Ala1871Thr in trans) in PKD1 gene, who presented with disease at age 24 years. Both the parents and one brother had a variant in one allele, the other being wild type only and had normal ultrasound findings. Segregation studies suggest that both the variants may act as "hypomorphic" or "incompletely penetrant" alleles and acting together resulted in haploinsufficiency of protein PC1 in renal cells, leading to cystogenesis in the proband. The consequences of the presence of two hypomorphic variants have been poorly documented in literature. We reviewed the few published cases having two hypomorphic variants and the data conform to the conclusions that we reached by study of the family described. It is emphasized that to resolve the significance of suspected hypomorphic variants, segregation studies in the parents and siblings are essential.
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An unusual association of renal cell carcinoma and renal malakoplakia with focal segmental glomerulosclerosis in an elderly patientp. 485
M Vijayan, P Koshy, R Parthasarathy, M Mathew, G Abraham
DOI:10.4103/ijn.IJN_289_17  
The association of malignancy and glomerulonephritis may be missed, especially in elderly patients. Here, we report a case of eosinophilic variant of renal cell carcinoma and renal parenchymal malakoplakia discovered on renal biopsy in a patient with steroid-dependent nephrotic syndrome. The presence of malakoplakia in our biopsy was probably due to systemic steroid therapy for glomerulonephritis, presence of concomitant asymptomatic urinary tract infection, and/or history of diabetes mellitus. The patient had remission of proteinuria following laparoscopic removal of the tumor, indicating probable remission of glomerulonephritis.
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Kidney transplantation from a hepatitis C virus-positive donor to a hepatitis C virus-negative recipient Highly accessed articlep. 488
M Kamalkiran, V Ravikiran, C Shashidhar, K. V. R Prasad, V Yeldandi
DOI:10.4103/ijn.IJN_267_17  
Kidney transplantation from a hepatitis C virus (HCV)-positive donor to an HCV-negative recipient till recently has been a contraindication. In view of the excellent sustained virological response (SVR) rates with directly acting antiviral agents, HCV-positive donors are being considered for the HCV-negative recipients in a few centers. We report the successful transplantation of an HCV-negative recipient transplanted with an HCV-positive donor kidney. Donor was treated with sofosbuvir and ribavirin for 12 weeks. At 10th and 16th weeks of starting treatment, her HCV-RNA PCR was negative. Three weeks later, transplantation was performed with basiliximab induction and triple immunosuppression with tacrolimus, mycophenolate, and prednisolone. The recipient was administered sofosbuvir and ribavirin for 12 weeks. He attained good graft function with a stable creatinine. His serial alanine transaminases were normal on 3rd, 6th, and 12th months, respectively. Six months posttransplant his anti-HCV antibody, and HCV-RNA PCR were negative.
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LETTERS TO EDITORTop

Cystinuria in a 13-Month-Old girl with absence of mutations in the SLC3A1 and SLC7A9 genesp. 490
MD Al-Mendalawi
DOI:10.4103/ijn.IJN_46_18  
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Improving crossmatch techniques and graft outcomesp. 491
L Vincent
DOI:10.4103/ijn.IJN_362_17  
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Estimated glomerular filtration rate using creatinine-based chronic kidney disease epidemiology collaboration equationp. 492
AA Rani, V Viswanathan
DOI:10.4103/ijn.IJN_439_17  
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Indian Journal of Paediatric Dermatology (Indian J Paediatr Dermatol)

CME ARTICLE 

Atopic dermatitis: Update on comorbidities and therapeutic advances Highly accessed articlep. 1
Katie Kim, Caitlin Crimp, Robert Sidbury
DOI:10.4103/ijpd.IJPD_92_18  
Atopic dermatitis (AD) is a chronic inflammatory disorder that primarily affects the skin. Recent literature has expanded our knowledge of associated comorbidities. In this review, we will discuss sleep loss, attention deficit hyperactivity disorder, obesity, and anemia as they relate to AD. We will also review two recently approved medications and how they fit into the therapeutic ladder.
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REVIEW ARTICLESTop

Evolution of pediatric dermatology in India: A medico-historical overviewp. 5
Amiya Kumar Mukhopadhyay
DOI:10.4103/ijpd.IJPD_46_18  
Pediatric dermatology is a newly emerging branch of dermatology dealing with pediatric dermatoses. It was "officially" born in 1972 when the first International Symposium of Pediatric Dermatology was held in Mexico City. Historically, in India, a well-established branch of medicine, Kaumarabhritya (pediatrics) exists since ancient times. The Unani and the Western system were introduced in the country in later days and enriched the medical system of the country. They served pediatric patients with their own methods. The activity to establish modern pediatric dermatology began in recent years. In the year 1996, the Indian Society for Pediatric Dermatology was formed to establish a platform for the further advancement of the subject. The Indian Journal of Pediatric Dermatology has served the purpose of publishing modern research on pediatric dermatology in India and abroad since 1998. The present article is a review of history and evolution of pediatric dermatology in India since ancient time.
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Leprosy in childrenp. 12
Tarun Narang, Bhushan Kumar
DOI:10.4103/ijpd.IJPD_108_18  
Children are believed to be the most vulnerable group to infection with Mycobacterium leprae due to their immature or nascent immunity and exposure to intrafamilial contacts. The child proportion among newly detected cases of leprosy is a strong indicator of continued transmission of the disease and one of the main targets of the current World Health Organization strategy is "to reduce transmission of the disease and reduction of grade-2 disability among new child cases." Despite an effective treatment and global achievement of leprosy elimination, the childhood leprosy proportion has not improved significantly. Leprosy in children does not just affect a child's health like other diseases; they can be stigmatized, bullied, and shunned for their lives. Hence, effective planning to bring down the incidence of leprosy and its complications in children should become a top priority. Regular school surveys and annual contact surveys for early detection of cases is therefore an important tool in achieving the goal of elimination of leprosy. In addition to continuing to administer multidrug therapy to patients, new preventive approaches need to be considered to break the chain of transmission and reach zero disease status.
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ORIGINAL ARTICLESTop

Association of early-onset androgenetic alopecia with metabolic syndrome: A case–control study on 46 patients in a tertiary care hospital in South Indiap. 25
K C Dharam Kumar, Yadalla Hari Kishan Kumar, Vivekananda Neladimmanahally
DOI:10.4103/ijpd.IJPD_127_17  
Background: Androgenetic alopecia (AGA) has a significant psychosocial impact on the patient, especially early-onset AGA patients. The severity and prevalence increase with age in all races worldwide. "Metabolic syndrome" (MetS) is a combination of risk factors of cardiovascular and diabetes-related parameters. Aim of the Study: The aim of the study is to study the association of early-onset AGA with MetS. Materials and Methods:A case–control study was done in a tertiary care hospital, Bengaluru, from December 2015 to November 2016 with 46 cases and controls in the age group of 20–30 years. The Norwood–Hamilton classification was used to grade the AGA patients. Diagnosis of MetS was done based on the national cholesterol education program adult treatment Panel III. Independent t-test will be used as a test of significance. Categorical data were assessed using Chi-square test of significance. Value of P < 0.05 was considered to be statistically significant. Results:MetS was seen in 39.13% of cases and 4.35% of controls (P < 0.001) which was statistically significant. The mean systolic blood pressure (P = 0.017 and P < 0.05) was statistically significant when compared to healthy controls. However, no statistically significant values were seen in the mean values of other parameters. Conclusion: A higher prevalence of MetS was seen in early-onset AGA. Early screening for MetS is important in patients with early-onset AGA to minimize the complications in the future.
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Adapalene in the management of warts in pediatric populationp. 29
Mrinal Gupta
DOI:10.4103/ijpd.IJPD_76_18  
Introduction: Warts are a common skin infection caused by human papillomavirus. Although any age group can be affected, plane warts and verruca vulgaris occur mostly in children and young adults. A large number of treatment modalities are available which include electrodessication, cryotherapy, topical imiquimod, tretinoin, and phenol application but most of these are not well tolerated by children owing to irritation or painful nature. Adapalene is a retinoid derivative with lesser irritant potential than tretinoin which has been tried in the management of warts. Aims: We carried out this study to assess the safety and efficacy of adapalene in the management of warts in the pediatric population. Materials and Methods: It was a prospective study carried out over a period of one and a ½ year where 50 patients in the age group of 3–18 years with different types of warts were included. After taking an informed consent from the attendants/parents of the patients, they were treated with topical bedtime application of adapalene 0.1% gel and were followed up every month for 3 months to assess the response. Exclusion criteria were extensive lesions, lesions on genitalia, eyelid involvement, secondary infection, or patients on any immunosuppressive therapies. Results: Out of 50 patients, 44 patients (M:F 25:19) completed the study. The age of patients varied from 3 to 18 years with a mean age of 11.3 ± 4.6 years. The most common type of warts in our study were plane warts in 61.36% (n = 27), followed by verruca vulgaris in 27.27% (n = 12) and plantar warts in 11.36% (n = 5). After 3 months of therapy, complete clearance of lesions was observed in 59.09% (n = 26) patients, partial clearance in 25% (n = 11) whereas no response was seen in 15.9% (n = 7) patients. Adverse effects in the form of erythema, irritation, and dryness were observed in six patients (13.64%). Conclusions: Adapalene can be used a safe and effective treatment modality in the management of plane and common warts especially in the pediatric age group.
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Evaluation of vitamin D in pediatric alopecia areata: A case–control study of thirty patients in a tertiary care hospitalp. 32
Harsha Siddappa, Yadalla Hari Kishan Kumar, Vivekananda Neladimmanahally
DOI:10.4103/ijpd.IJPD_83_18  
Background: Alopecia areata is a common form of autoimmune, non-scarring alopecia and about one-third of cases affect people aged below 18 years. Alopecia in pediatric age group can cause psychological stress to parents and patients. Vitamin D plays a role in immune regulation and maintenance of hair cycle. Aims and Objectives: To evaluate serum vitamin D levels in pediatric alopecia areata cases. Methods: A comparative case-control study with 30 cases of pediatric alopecia areata and 30 age and sex matched healthy controls was conducted between Feb 2015 to July 2015. All subjects underwent complete evaluation and laboratory investigations including serum vitamin D was done. Results: Mean serum vitamin D level of pediatric alopecia areata cases (17.21±6.57 ng/ml) was significantly lower when compared to controls (25.03±13.84 ng/ml) (P < 0.05). Distribution of vitamin D deficiency was significantly higher in cases (73%) when compared to controls (46%) (P < 0.05). There was a significant inverse correlation between SALT scores of cases and their serum vitamin D levels (P < 0.05). Conclusions: There was decreased vitamin D levels observed in cases suggesting a possible role of vitamin D in alopecia areata and treating the deficiency may prevent the chronicity of the disease in children.
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A study of neonatal dermatoses in a tertiary care centerp. 36
Vishalakshi S Pandit, K Udaya
DOI:10.4103/ijpd.IJPD_49_18  
Background: Neonatal dermatoses by definition encompass the spectrum of cutaneous disorders that arise during the 1st 4 weeks of life. The appreciation of normal phenomena and their differentiation from the more significant cutaneous disorders of the newborn is critical for the dermatologists and pediatricians. Aims and Objectives: The aim of the study is to estimate the prevalence of various neonatal dermatoses and identify varying patterns of various physiological and pathological dermatoses. Materials and Methods: This was a hospital-based, cross-sectional study conducted during a period of 6 months. A total of 150 neonates were examined and data were collected, and results were analyzed statistically. Results: Out of 150 neonates, 147 (98%) had cutaneous lesions. Among them, 79 (52.6%) were male and rest were female. Of these, 112 (74.6%) weighed between 2.5 and 4 kg, 35 (23.3%) <2.5 kg, and 3 (2%) >4 kg. Physiological skin lesions were most common features seen in 148 (98.6%), followed by birthmarks 46 (31.3%), transient noninfectious lesions 35 (23.3%), inflammatory eruptions 13 (8.6%), and infections 7 (4.6%). Conclusions: A good knowledge of neonatal dermatoses is necessary for the treating dermatologists and pediatricians as many of cutaneous conditions are transient, appearing in the 1st few days to weeks of life, only to disappear shortly thereafter. However, their occurrence makes the parents worrisome. Proper diagnosis of the conditions helps in relieving the anxiety of parents and caregivers.
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A controlled crossover study to assess the role of dietary eliminations in reducing the severity of atopic dermatitis in childrenp. 41
Pretty Mathew, Rajiv Sridharan, Thyvalappil Anoop, Ajayakumar Sreenivasan
DOI:10.4103/ijpd.IJPD_20_18  
Background: In the pathogenesis of atopic dermatitis (AD), immune sensitization to food-derived allergens has a role. However, the evidence of allergen sensitization is not a proof of clinically relevant allergy and it has to be confirmed by food challenges so that unnecessary food restrictions in growing children can be avoided. Aims and Objectives: This study was conducted to assess the clinical severity of AD in children after certain dietary modifications and to correlate absolute eosinophil count (AEC) with dietary modification. Materials and Methods: A total of thirty AD children were enrolled randomly into a trial period of egg and cow's milk exclusion diet or control period of egg and cow's milk inclusion diet of 3 weeks. At the end of 3 weeks, patients resumed their normal diet to minimize any carryover effect for next 3 weeks. In the last 3 weeks, the trial and the control groups were crossed over. Patients were assessed at baseline and at the end of each 3-week period using SCORing AD (SCORAD) index and AEC. The data were analyzed using paired t-test. Results: The mean SCORAD at the end of control and trial period was 18.3 and 14.3, respectively, with a mean difference of 3.4, which is statistically not significant (P = 0.165). The mean AEC at the end of control and trial period was 836.5 and 799.6, respectively, the reduction being statistically not significant. Conclusion: Our study could not confirm the beneficial effects of an allergen avoidance diet in AD. We propose that dietary elimination advices should be given only to patients with a definite history of food-induced exacerbations of the disease.
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Dermoscopic study of scabies in childrenp. 46
Shilpitha Srinivas, Kallappa C Herakal, Srinivasa Krishnamurthy Murthy, Shwetha Suryanarayan
DOI:10.4103/ijpd.IJPD_25_18  
Background: Dermoscopy is a technique involving the rapid and magnified observation of the skin. Infection with Sarcoptes scabiei in children usually presents with pruritus. Primary scabetic lesions consist of small, erythematous papules, and burrows. The definitive diagnosis of scabies is by visualizing the mites, eggs, or feces under the microscope. Aims and Objectives: The aim of the study was to compare the diagnosis of scabies in children with naked eye examination and a dermoscope. The objective was to find out if there was a significant difference between the two methods of diagnosis of scabies. Subjects and Methods: A cross-sectional study was done. Fifty children aged between 1–15 years with symptoms clinically suspicious of scabies from May 15, 2016 to May 14, 2017 were taken. Thirty were male and 20 were female. After taking history, the lesions were examined clinically and with Dermalite DL4 and photographs were taken. A triangular structure with a furrowing burrow was considered to indicate the presence of a mite. Results: Among 50 children, 37 children had clinical features of scabies: the presence of burrows and scabetic nodules. Among 50, 45 children had dermoscopic features of scabies: the presence of the delta glider sign. The data were analyzed using Z- test using MS Excel 2010. There was a significant difference (P < 0.03) on comparing the number of children diagnosed with scabies with naked eye and dermoscopic examination. Conclusion: A handheld dermoscope can be a useful tool to rapidly and non invasively diagnose scabies with high sensitivity compared to Clinical Examination.
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Clinicoepidemiological study of dermatophyte infections in pediatric age group at a tertiary hospital in Karnatakap. 52
Sneha Gandhi, Suma Patil, Somnath Patil, Ambresh Badad
DOI:10.4103/ijpd.IJPD_35_18  
Background: The incidence of fungal infections is increasing at an alarming rate, presenting an enormous challenge to healthcare professionals. Apart from the resistance of the causative organisms, there are many modifiable environmental factors contributing to this sudden pandemic. The prevalence of the disease and the associated environmental factors need to be evaluated further. Aims and Objectives: The aim of this study was to ascertain the epidemiological features of dermatophyte infection in children such as its incidence, clinical presentation, knowledge regarding over-the-counter drugs, compliance to therapy, and steroid abuse among others. Subjects and Methods: All children with dermatophytic infections up to the age group of 18 years were studied for the pattern of infection and various environmental associations. Results: The prevalence rate of pediatric dermatophyte infection was found to be 19% and was mostly seen in the age group of 10–14 years, with a male-to-female ratio of 1.27:1. About 72% of patients belonged to a rural background, and 64% were from a low socioeconomic background. Among the environmental factors, 83% of patients reported contact history with an affected family member, 55% reported joint family setup, and 81% of patients were found to maintain poor personal hygiene. Tinea corporis was the most common clinical variant of dermatophyte infection (45%). Nearly 58% of patients had been treated by unqualified personnel before visiting our hospital, and 51% had applied steroids. Out of 17% patients who had been prescribed anti-fungals only 8% received accurate dose and duration related treatment; while none of them completed their prescribed course before visiting our hospital. Conclusions: This study attempts to highlight the clinicoepidemiological features of dermatophytic infections and the various social and environmental factors associated with it.
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Rapidly involuting congenital hemangioma with complete resolution In Uterop. 57
Sabitha Lakshminarayanan
DOI:10.4103/ijpd.IJPD_122_17  
There are three types of congenital hemangioma - rapidly involuting congenital hemangioma (RICH), partially involuting congenital hemangioma, and noninvoluting congenital hemangioma. We report a case of RICH on the back of a 4-month-old Caucasian male infant, based on ultrasound and magnetic resonance imaging findings in the antenatal period, skin changes at birth, and a normal ultrasound after birth. He was born with an atrophic plaque at the site of the vascular swelling depicted on the scans, suggesting the complete involution of the lesion in the antenatal period.
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Zosteriform idiopathic atrophoderma of Pasini and Pierini Highly accessed articlep. 60
Tasleem Arif
DOI:10.4103/ijpd.IJPD_85_18  
Idiopathic atrophoderma of Pasini and Pierini (IAPP) is a rare disease of unknown etiology characterized by well-defined atrophic plaques with a "cliff-drop" border that show no signs of inflammation, sclerosis, and induration. The trunk is most commonly affected site. It usually affects the body in a bilaterally symmetrical distribution, although asymmetric involvement has also been reported. Very few cases occurring in a zosteriform distribution have been reported. In this article, the author reports a rare case of IAPP in an 18-year-old male where the lesions are distributed in a zosteriform distribution on the trunk.
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Hyaline fibromatoses syndrome: A rare entityp. 64
Resham Vasani, Deepak Parikh
DOI:10.4103/ijpd.IJPD_31_18  
Hyaline fibromatoses syndrome is a rare autosomal recessive disorder with very few cases reported from India till date. It is characterized by the deposition of amorphous hyaline material in the skin, bones, and viscera. It represents a disease spectrum with infantile systemic hyalinosis as the most severe form and juvenile hyaline fibromatoses (JHF) being the mild form. These conditions characteristically present with overlapping clinical features such as nodules and/or pearly papules, gingival hyperplasia, flexion contractures of the joints, and osteolytic bone defects. Identification of this condition by the treating dermatologist is important to facilitate an early diagnosis and a multidisciplinary follow-up. We report one such case of this uncommon condition– JHF.
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Pebbled skin over axilla and umbilicusp. 68
Ankita Agrawal, Yogesh Kalyanpad
DOI:10.4103/ijpd.IJPD_58_18  
Pseudoxanthoma elasticum or Grönblad–Strandberg syndrome is characterized by progressive calcification and degeneration of the elastic fibers throughout the body. They are noted in the second or third decade and comprise flat-topped, discrete-to-confluent yellowish papules in a linear or reticular pattern over flexures, and periumbilical skin giving a "cobblestone," "plucked chicken skin," or "Moroccan leather" appearance. We report a case of 13-year-old-child with yellowish pebbled skin over axilla and umbilicus. Angioid streaks were present on ophthalmological examination. On histopathology, fragmented and curled fibers were present in the dermis giving ravelled wool appearance. Von Kossa and Verhoeff-van gieson stain fibers stains showed calcified and fragmented elastic fibers in the mid-dermis.
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Zinser–Engmann–Cole syndrome: Two case reportp. 71
Bangaru Hanumaiah, Sathish Shankar, Nanjunda Swamy B Lingaiah
DOI:10.4103/ijpd.IJPD_41_18  
We report two cases of dyskeratosis congenita. Case 1: An 11-year-old male child presented to us with severe anemia and pancytopenia resulting in cardiac failure, in addition to the classical clinical triad including skin atrophy with mottled pigmentation, nail dystrophy, and oral leukoplakia; he also had palmoplantar keratoderma, adermatoglyphia, mucosal involvement resulting in epiphora, and urethral stricture. Urethral involvement is usually a rare presentation. Case 2: A 5-year-old female child presented with mottled pigmentation, oral leukoplakia, palmoplantar keratoderma with adermatoglyphia, delayed milestones, mental retardation, repeated skin and pulmonary infections, and dental caries along with anemia. In addition, the child had meningocoele which is so far not reported. It is very important to have high index of suspicion about cutaneous markers of dyskeratosis congenita, and its early diagnosis helps to prevent life-threatening systemic complications and to give quality of life.
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Congenital triangular alopecia: Clinical and dermoscopic differentialsp. 75
Vishalakshi Viswanath, Vaibhav Kalambe, Dhananjay Sanap
DOI:10.4103/ijpd.IJPD_57_18  
Congenital triangular alopecia (CTA), also known as temporal triangular alopecia; originally described by Sabouraud in 1905; is a type of triangular, unilateral, nonprogressive, noncicatricial type of alopecia affecting mostly the temporal region of the scalp. It usually presents at birth or in early childhood, however adult cases have also been reported. Routinely confused with alopecia areata; dermoscopy helps in the diagnosis of this condition. We report a case of CTA with clinical and dermoscopic findings and discuss the differential diagnosis.
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RESIDENTS CORNERTop

Meyerson phenomenonp. 78
Resham Vasani
DOI:10.4103/ijpd.IJPD_144_18  
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REVIEW OF CURRENT LITERATURETop

Hot topics in pediatric dermatologyp. 81
Rajsmita Bhattacharjee, Rahul Mahajan
DOI:10.4103/ijpd.IJPD_143_18  
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LETTERS TO EDITORTop

Lichenoid eruption of genital region following chloroquine therapy: Uncommon presentationp. 86
Sudha Rani Chintagunta
DOI:10.4103/ijpd.IJPD_45_18  
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Segmental infantile hemangioma mimicking michelin tire baby syndromep. 87
Isha Gupta, Kamal Aggarwal
DOI:10.4103/ijpd.IJPD_50_18  
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Late-onset capillary hemangioma: A rare occurrencep. 89
Shilpa Garg, Priyanka Borde Bisht, Seema Rao
DOI:10.4103/ijpd.IJPD_66_18  
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A case of congenital hemangioma treated with topical timololp. 91
Kavish Chouhan, Rahulkrishna S Kota, Amrendra Kumar, Jyoti Gupta
DOI:10.4103/ijpd.IJPD_131_17  
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