This month’s news from across the specialty
What’s hot
October 1, 2022
In this monthly column, members of the DermWorld Editorial Advisory Workgroup identify exciting news from across the specialty.
With growing media hype, “rule-out monkeypox” consults with dermatologists are increasing. So, as a dermatologist, what do you need to know about monkeypox? In a June Dialogues in Dermatology episode, Dr. Esther Freeman, an infectious disease in dermatology expert and member of the AAD Monkeypox Taskforce, provides us with tips on what we should know.
What is the background history? Monkeypox has been around for a relatively long time, dating back to at least 1958. Its name derived from the fact that it was first discovered in monkeys, but it affects many different mammals. In humans, it has historically been seen mostly in sub-Saharan Africa. Currently, the most outbreaks are occurring in the U.K. and Spain with relatively few cases in the United States. There are two distinct clades of monkeypox, and the one that is primarily circulating now has a low case fatality rate.
How do patients first present? It has a long incubation period, on average 7-14 days, at which time you get a fever (and possible lymphadenopathy), and then several days later you can start to develop the rash. The rash is characteristic — it classically starts with macules, then progresses to papules, then to vesicles, then finally to pustules with eventual crusting over of the lesions.
How is it spread? The most frequent is probably direct contact with the lesions or possibly through infected body fluids, and usually in close, intimate situations.
How do you diagnose monkeypox if you are very suspicious? You should be able to swab the base of a lesion for PCR similar to how you would in a case of HSV.
Keep reading
Check out the Academy’s resources on monkeypox.
Merkel cell carcinoma is an uncommon cutaneous malignancy with an increasing incidence in recent years. This is an aggressive cutaneous tumor with an overall survival rate in the range of 50-60%. The cell of origin remains under investigation; both Merkel cell polyomavirus and ultraviolet irradiation are felt to be risk factors in the pathogenesis of this tumor. Information about prognostic factors is limited because large-scale studies are lacking in this uncommon tumor. In a recent investigation published in JAAD, 4,023 patients with Merkel cell carcinoma from the National Cancer Database were studied. The authors found that the presence of lymphovascular invasion on the primary tumor was associated with a poor survival in a stage-independent manner. Additionally, utilization of adjuvant radiation therapy in these patients was associated with improved survival. The study suggests that lymphovascular invasion may be important prognostic information and should be included in dermatopathology reports of Merkel cell carcinoma.
At a teaching conference, a hospitalized patient was presented who had received vancomycin. The histopathology showed a subepidermal bulla with neutrophils and the direct immunofluorescence (DIF) showed linear IgA along the basement membrane zone. Since bullous pemphigoid was in the clinical differential diagnosis, the dermatologist also ordered an enzyme-linked immunosorbent assay (ELISA) for BP180-NC16A, which was negative at < 9 U/mL, and an ELISA for BP230, which was positive at 17 U/mL with these reference ranges: BP180: <9.0 U/mL (negative), > or = 9 U/mL (positive); BP230: <9.0 U/mL (negative), > or = 9 U/mL (positive).
Due to the positive DIF of linear IgA along the basement membrane zone and the positive ELISA for BP230, the patient was diagnosed with both linear IgA bullous dermatosis (LABD) and bullous pemphigoid (BP) and was started on prednisone. Question: Does the patient really have both LABD and BP?
In a recent retrospective study of 54 LABD patients, the authors found that BP autoantibodies can be found in a significant portion of patients with LABD (Acta Derm Venereol. 2020.(4)100). IgA reactivity to BP180-NC16A by ELISA was found in 32% and to BP230 in 26%. In another study, the authors found that low-level BP autoantibodies can be found in patients who do not have BP and the results of BP ELISA should be interpreted in conjunction with clinical findings and immunopathologic test results (J Am Acad Dermatol. 2019; 80(3): 774-5). Answer: The patient has LABD, not both LABD and BP.
More What’s Hot!
Check out more What’s Hot columns from the DermWorld Editorial Advisory Workgroup at the DermWorld homepage.
The first case of monkeypox in the United States was identified on May 17, 2022, with more than 7,500 identified since then as of August 2022. Tens of thousands more have been identified globally in non-endemic areas. On Aug. 4, 2022, the U.S. government declared monkeypox a public health emergency.
The monkeypox epidemiology — but fortunately not its mortality — closely parallels the early HIV epidemic. A CDC study of nearly 3,000 persons with monkeypox diagnosed between May and July 2022 demonstrates those parallels. The study also investigated clinical characteristics. Among persons for whom data were available, 99% were men, and 94% reported same-sex sexual or close intimate contact within three weeks of symptom onset. Those data reinforce the importance of eliciting a sexual history, including gender(s) of sex partner(s), when a differential diagnosis includes monkeypox or other infections (such as syphilis) that disproportionately affect men who have sex with men.
Moreover, the study showed that racial and ethnic minority groups were over-represented; 41% were non-Hispanic whites, 28% Hispanics, 26% non-Hispanic Blacks, and 5% Asians. According to U.S. Census data, as of July 2021, the U.S. population in each of those groups was 76%, 19%, 14%, and 6%, respectively.
As the U.S. government struggles — as with COVID-19 and HIV — to mitigate the monkeypox epidemic, dermatologists should be aware of monkeypox epidemiology to facilitate prompt diagnosis and, if needed, treatment of the infection.
