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Pellagra case

History: A 14 yr female presented to ED with 6 weeks h/o well-defined darkening and thickening of the hands, feet, ankles, neck, and the upper trunk region including upper chest and back. She had similar lesions but milder form on lips and periorbital region. The affected area of the skin was said to get exacerbated after exposure or re-exposure to sunlight. She also complaint of recurrent episodes of passage of loose watery stools. What’s the diagnosis?

Pellagra is a disease caused by a lack of vitamin niacin (vitamin B3).

Symptoms include inflamed skin, diarrhea, dementia, and sores in the mouth. Areas of the skin exposed to either sunlight or friction are typically affected first. Over time affected skin may become darker, stiffen, peel, or bleed.

There are two main types of pellagra, primary and secondary.

Primary pellagra is due to a diet that does not contain enough niacin and tryptophan.

Secondary pellagra is due to a poor ability to use niacin within the diet. This can occur as a result of alcoholism, long-term diarrhea, carcinoid syndrome, Hartnup disease, and a number of medications such as isoniazid. Diagnosis is typically based on symptoms and may be assisted by urine testing.

Treatment is with either niacin or nicotinamide supplementation. Improvements typically begin within a couple of days. General improvements in diet.

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Vitamin D supplementation did not decrease the risk of cancer or CVD

Vitamin D supplementation did not appear to influence the incidence of cancer or major cardiovascular disease (CVD) events in older adults who largely already had adequate vitamin D levels, according to a new randomized controlled study. In the cohort of nearly 2500 healthy individuals, the researchers found no differences in cancer or CVD incidence over 5 years between the groups randomly assigned to vitamin D supplementation and to placebo.

Source: The American Journal of Clinical Nutrition

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Putty kidney case

History: A 46-year-old woman presented with symptoms of urgency, frequency and urge-incontinence for 2 years with h/o of fever. Her urine was acidic with few pus cells, but sterile on culture. Other laboratory tests were normal. Ultrasonography suggested hydronephrotic right kidney with internal echoes. X-ray KUB show multiple lobulated calcifications in the right renal region conglomerated into the shape of the kidney.

Extensive parenchymal calcification in a non functioning kidney forming its cast is called a ‘putty kidney’ which is a characteristic of end-stage renal TB.

Symptoms: Persistent cystitis, unresponsive to antibiotics, ↑urinary frequency, dysuria, loin discomfort, malaise, fever, weight loss, ulcer.

Diagnosis: USG, Xray KUB, CECT scan

Treatment: ATT

Image by: BMJ

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FDA approves Cabotegravir ER Injectable for HIV PrEP

The FDA issued approval for extended-release injectable cabotegravir (Apretude, CAB-LA) for use in at-risk adults and adolescents weighing at least 35 kilograms (77 pounds) for pre-exposure prophylaxis (PrEP) to reduce the risk of sexually acquired HIV.

The priority review approval was based on phase 2b-3 clinical trial data submitted to the agency this past August, after one of the studies was stopped early because of encouraging efficacy results of the first pre-planned interim endpoint analysis.

Apretude is given first as two initiation injections administered one month apart, and then every two months thereafter. Patients can either start their treatment with Apretude or take oral cabotegravir (Vocabria) for four weeks to assess how well they tolerate the drug.

Source: FDA.gov

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Tinea Barbae case

History: A 45-year-old farmer came to dermatology OPD with C/O nonitchy red lumpy areas, pustules, and crusting around the hairs that can be pulled out easily. What’s the diagnosis?

Tinea barbae is a superficial dermatophyte fungal infection that is limited to the bearded areas of the face and neck. The most common causes are Trichophyton mentagrophytes and T. verrucosum.

Signs and symptoms

Pimple or blister
Swelling and redness around infected area
Red and lumpy skin
Crusting around hairs in infected areas and effortless pulling of hair.

Diagnosis:

Direct microscopic examination
Culture on Sabouraud agar

Treatment: Antifungals

Topical antifungals
Itraconazole can be recommended as one-pulse therapy at a dosage of 400 mg/d divided into 2 doses for 1 week.

Image by DermNet NZ

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FDA approves Efgartigimod for Myasthenia Gravis

The US FDA has approved efgartigimod (Brand name: Vygart) a first-in-class, targeted therapy for adults with generalized myasthenia gravis (gMG) who test positive for the antiacetylcholine receptor (AChR) antibody.

Efgartigimod is an antibody fragment designed to reduce pathogenic IgG antibodies and block the IgG recycling process in patients with gMG. The novel agent binds to the neonatal Fc receptor (FcRn), which is widely expressed throughout the body and plays a central role in rescuing IgG antibodies from degradation. Blocking FcRn reduces IgG antibody levels.

The most common side effects associated with the use of Vyvgart include respiratory tract infections, headache, and urinary tract infections. As Vyvgart causes a reduction in IgG levels, the risk of infections may increase. Hypersensitivity reactions such as eyelid swelling, shortness of breath, and rash have occurred. If a hypersensitivity reaction occurs, discontinue the infusion and institute appropriate therapy.

Source: FDA

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Abrocitinib approved for Atopic Dermatitis in Europe

The oral Janus kinase 1 inhibitor abrocitinib has been approved in Europe for the treatment of moderate to severe atopic dermatitis (AD) in adults, who are candidates for systemic therapy. Approval by the European Commission was based on the results of studies that include four phase 3 clinical trials (JADE MONO-1, JADE-MONO-2, JADE COMPARE, JADE REGIMEN) and an ongoing open-label extension study (JADE EXTEND) in over 2,800 patients.

Source: Mdedge

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FDA approves PreHevbrio: The first 3-antigen HBV vaccine for adults

PreHevbrio [Hepatitis B Vaccine (Recombinant)]: contains the S, pre-S2, and pre-S1 HBV surface antigens, and is the only approved 3-antigen HBV vaccine for adults in the U.S.A.

INDICATIONS AND USAGE: PREHEVBRIO is indicated for prevention of infection caused by all known subtypes of hepatitis B virus. PREHEVBRIO is approved for use in adults 18 years of age and older.

DOSAGE AND ADMINISTRATION :For intramuscular injection. Administer a series of three doses (1.0 mL each) of PREHEVBRIO on a 0-, 1 and 6-month schedule.

CONTRAINDICATIONS: Severe allergic reaction (e.g., anaphylaxis) after a previous dose of any hepatitis B vaccine or to any component of PREHEVBRIO.

ADVERSE REACTIONS: Injection site pain, tenderness, headache (most common), fatigue and myalgia.

Source: FDA

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New AKI risk score for PCI patients passes validation

A pair of updated scoring models for estimating a patient’s risk for contrast-associated acute kidney injury during and immediately after percutaneous coronary intervention (PCI) worked better than a widely used prior version in initial validation testing using data collected at a single US tertiary-care hospital. One of the two new algorithms, which both predict a patient’s risk for developing acute kidney injury (AKI) as a result of receiving iodinated contrast media within 48 hours of a PCI, relies on eight easily available variables taken from a patient’s medical record just prior to undergoing PCI: age, type of coronary disease (ranging from asymptomatic or stable angina to ST-segment elevation MI), estimated glomerular filtration rate, left ventricular ejection fraction, diabetes, hemoglobin, basal glucose, and heart failure. This risk score accounted for 72% (a C-statistic of 0.72) of the observed AKI episodes during the derivation phase, which used data from 14,616 consecutive Mount Sinai patients who underwent PCI during January 2012–December 2017.

Source: Medscape

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FDA expands Pembrolizumab approval for Advanced Melanoma

The US Food and Drug Administration has approved pembrolizumab (Keytruda) for the adjuvant treatment of stage IIB and IIC melanoma after complete resection in adults and children over age 12 years. The FDA also extended the approval to those with stage III disease. The FDA approval on December 3 was based on the first interim findings from the randomized, placebo-controlled KEYNOTE-716 trial, which evaluated patients with stage IIB and IIC disease.

Source: Medscape