Ulcerative lichen planus (ULP)(also called erosive) is a rare variant of lichen planus. Similar to classic lichen planus, the cause of ULP is largely unknown. Ulcerative lichen planus typically involves the oral mucosa or genitalia but rarely may present as ulcerations on the palms and soles. Clinical presentation usually involves a history of chronic ulcers that often have been previously misdiagnosed and resistant to treatment. Ulcerations on the plantar surfaces frequently cause severe pain and disability. Few cases have been reported and successful treatment is rare.

Case Report

A 56-year-old man was referred by podiatry to the dermatology clinic for evaluation of painful ulcerations involving the dorsal and plantar surfaces of the right great toe as well as the second to third digits. The ulcers had been ongoing for 8 years, treated mostly with local wound care without clinical improvement. His medical and family history was considered noncontributory as a possible etiology of the ulcers; however, he had been taking ibuprofen intermittently for years for general aches and pains, which raised the suspicion of a drug-induced etiology. Laboratory evaluation revealed positive hepatitis B serology but was otherwise unremarkable, including normal liver function tests and negative wound cultures.

Physical examination revealed a beefy red, glazed ulceration involving the entire right great toe with extension onto the second and third toes. There was considerable scarring with syndactyly of the second and third toes and complete toenail loss of the right foot (Figure 1). On the insteps of the bilateral soles were a few scattered, pale, atrophic, violaceous papules with overlying thin lacy white streaks that were reflective of Wickham striae. Early dorsal pterygium formation also was noted on the bilateral third fingernails. Oral mucosal examination revealed lacy white plaques on the bilateral buccal mucosa with a large ulcer of the left lateral tongue (Figure 2). No genital or scalp lesions were present.

Histologic examination of a papule on the instep of the right sole demonstrated a dense lichenoid lymphocytic infiltrate in the papillary dermis with basal vacuolar degeneration and early focal Max-Joseph space formation. Additionally, there was epidermal atrophy with mild hypergranulosis and scattered necrotic keratinocytes (Figure 3). A similar histologic picture was noted on a biopsy of the buccal mucosa overlying the right molar, albeit with epithelial acanthosis rather than atrophy.

Based on initial clinical suspicion for ULP, we suggested that our patient discontinue ibuprofen and started him on a regimen of oral prednisone 40 mg once daily and clobetasol ointment 0.05% applied twice daily to the plantar ulceration, both for 2 weeks. Dramatic improvement was noted after only 2 weeks of treatment. This regimen was then switched to oral doxycycline 100 mg twice daily combined with tacrolimus ointment 0.1% applied twice daily to the plantar ulceration to avoid side effects of prolonged steroid use. Topical therapies were not used for the mucosal lesions. At 4-week follow-up, the patient continued to demonstrate notable clinical response with a greater than 70% physician-assessed improvement in ulcer severity (Figure 4) and near-complete resolution of the oral mucosal lesions. Our patient also reported almost complete resolution of pain. By 4-month follow-up, complete reepithelialization and resolution of the ulcers was noted (Figure 5). This improvement was sustained at additional follow-up 1 year after the initial presentation.

Comment

Ulcerative (or erosive) lichen planus is a rare form of lichen planus. Ulcerative lichen planus most commonly presents as erosive lesions of the oral and genital mucosae but rarely can involve other sites. The palms and soles are the most common sites of cutaneous involvement, with lesions frequently characterized by severe pain and limited mobility.²

We conducted a review of the Ovid MEDLINE database using the search terms ulcerative lichen planus and erosive lichen planus for articles from the last 30 years, focusing specifically on articles that reported cases of cutaneous involvement of ULP and successful therapeutic modalities. The Table provides a detailed summary of the cases from 1985 to present, representing a spectrum of clinical manifestations and successful treatments of ULP.^1-13

Hepatitis C is a comorbidity commonly associated with classic lichen planus, while hepatitis B immunization has a well-described association with classic and oral ULP.^12,14 Although hepatitis C was negative in our patient, we did find a chronic inactive carrier state for hepatitis B infection. Al-Khenaizan and Al-Mubarak¹² reported the only other known case of ULP of the sole associated with positive serology for hepatitis B surface antigen.

Ulcerative lichen planus of the soles can be difficult to diagnose, especially when it is an isolated finding. It should be differentiated from localized bullous pemphigoid, epidermolysis bullosa acquisita, ulcerative lupus erythematosus, and dermatitis artefacta.¹³ The characteristic associated clinical features of plantar ULP in our patient and lack of diagnostic immunofluorescence helped us to rule out these alternative diagnoses.⁴ Long-standing ulcerations of ULP also pose an increased risk for neoplastic transformation. Eisen¹⁵ noted a 0.4% to 5% frequency of malignant transformation into squamous cell carcinoma in those with oral ULP. Therefore, it is important to monitor previously ulcerated lesions long-term for such development.

Plantar ULP is difficult to treat and often is unresponsive to systemic and local treatment. Historically, surgical grafting of the affected areas was the treatment of choice, as reported by Patrone et al.⁶ Goucha et al¹³ reported complete healing of ulcerations within 3 weeks of starting oral prednisone 1 mg/kg once daily followed by a maintenance dosage of 5 mg once daily. Tacrolimus is a macrolide immunosuppressant that inhibits T-cell activation by forming a complex with FK506 binding protein in the cytoplasm of T cells that binds and inhibits calcineurin dephosphorylation of nuclear factor of activated T cells.¹² Al-Khenaizan and Al-Mubarak¹² reported resolution of plantar ULP ulcerations after 4 weeks of treatment with topical tacrolimus. Eisman and Orteu⁷ also achieved complete healing of ulcerations of plantar ULP using tacrolimus ointment 0.1%.

In our patient, doxycycline also was started at the time of initiating the topical tacrolimus. We chose this treatment to take advantage of its systemic anti-inflammatory, antiangiogenic, and antibacterial properties. Our case represents rapid and successful treatment of plantar ULP utilizing this specific combination of oral doxycycline and topical tacrolimus.

Conclusion

Ulcerative lichen planus is an uncommon variant of lichen planus, with cutaneous involvement only rarely reported in the literature. Physicians should be aware of this entity and should consider it in the differential diagnosis in patients presenting with chronic ulcers on the soles, especially when lesions have been unresponsive to appropriate wound care and antibiotic treatment or when cultures have been persistently negative for microbial growth. The possibility of drug-induced lichen planus also should not be overlooked, and one should consider discontinuation of all nonessential medications that could be potential culprits. In our patient ibuprofen was discontinued, but we can only speculate that it was contributory to his healing and only time will tell if resumption of this nonsteroidal anti-inflammatory drug causes a relapse in symptoms.

In our patient, a combination of systemic and topical steroids, topical tacrolimus, and oral doxycycline successfully treated his plantar ULP. Our findings provide further support for the use of topical tacrolimus as a steroid-sparing anti-inflammatory agent for the treatment of plantar ULP. We also introduce the combination of topical tacrolimus and oral doxycycline as a novel therapeutic combination and relatively safer alternative to conventional immunosuppressive agents for long-term systemic anti-inflammatory effects.

Ulcerative lichen planus (ULP)(also called erosive) is a rare variant of lichen planus. Similar to classic lichen planus, the cause of ULP is largely unknown. Ulcerative lichen planus typically involves the oral mucosa or genitalia but rarely may present as ulcerations on the palms and soles. Clinical presentation usually involves a history of chronic ulcers that often have been previously misdiagnosed and resistant to treatment. Ulcerations on the plantar surfaces frequently cause severe pain and disability. Few cases have been reported and successful treatment is rare.

Case Report

A 56-year-old man was referred by podiatry to the dermatology clinic for evaluation of painful ulcerations involving the dorsal and plantar surfaces of the right great toe as well as the second to third digits. The ulcers had been ongoing for 8 years, treated mostly with local wound care without clinical improvement. His medical and family history was considered noncontributory as a possible etiology of the ulcers; however, he had been taking ibuprofen intermittently for years for general aches and pains, which raised the suspicion of a drug-induced etiology. Laboratory evaluation revealed positive hepatitis B serology but was otherwise unremarkable, including normal liver function tests and negative wound cultures.

Physical examination revealed a beefy red, glazed ulceration involving the entire right great toe with extension onto the second and third toes. There was considerable scarring with syndactyly of the second and third toes and complete toenail loss of the right foot (Figure 1). On the insteps of the bilateral soles were a few scattered, pale, atrophic, violaceous papules with overlying thin lacy white streaks that were reflective of Wickham striae. Early dorsal pterygium formation also was noted on the bilateral third fingernails. Oral mucosal examination revealed lacy white plaques on the bilateral buccal mucosa with a large ulcer of the left lateral tongue (Figure 2). No genital or scalp lesions were present.

Histologic examination of a papule on the instep of the right sole demonstrated a dense lichenoid lymphocytic infiltrate in the papillary dermis with basal vacuolar degeneration and early focal Max-Joseph space formation. Additionally, there was epidermal atrophy with mild hypergranulosis and scattered necrotic keratinocytes (Figure 3). A similar histologic picture was noted on a biopsy of the buccal mucosa overlying the right molar, albeit with epithelial acanthosis rather than atrophy.

Based on initial clinical suspicion for ULP, we suggested that our patient discontinue ibuprofen and started him on a regimen of oral prednisone 40 mg once daily and clobetasol ointment 0.05% applied twice daily to the plantar ulceration, both for 2 weeks. Dramatic improvement was noted after only 2 weeks of treatment. This regimen was then switched to oral doxycycline 100 mg twice daily combined with tacrolimus ointment 0.1% applied twice daily to the plantar ulceration to avoid side effects of prolonged steroid use. Topical therapies were not used for the mucosal lesions. At 4-week follow-up, the patient continued to demonstrate notable clinical response with a greater than 70% physician-assessed improvement in ulcer severity (Figure 4) and near-complete resolution of the oral mucosal lesions. Our patient also reported almost complete resolution of pain. By 4-month follow-up, complete reepithelialization and resolution of the ulcers was noted (Figure 5). This improvement was sustained at additional follow-up 1 year after the initial presentation.

Comment

Ulcerative (or erosive) lichen planus is a rare form of lichen planus. Ulcerative lichen planus most commonly presents as erosive lesions of the oral and genital mucosae but rarely can involve other sites. The palms and soles are the most common sites of cutaneous involvement, with lesions frequently characterized by severe pain and limited mobility.²

We conducted a review of the Ovid MEDLINE database using the search terms ulcerative lichen planus and erosive lichen planus for articles from the last 30 years, focusing specifically on articles that reported cases of cutaneous involvement of ULP and successful therapeutic modalities. The Table provides a detailed summary of the cases from 1985 to present, representing a spectrum of clinical manifestations and successful treatments of ULP.^1-13

Hepatitis C is a comorbidity commonly associated with classic lichen planus, while hepatitis B immunization has a well-described association with classic and oral ULP.^12,14 Although hepatitis C was negative in our patient, we did find a chronic inactive carrier state for hepatitis B infection. Al-Khenaizan and Al-Mubarak¹² reported the only other known case of ULP of the sole associated with positive serology for hepatitis B surface antigen.

Ulcerative lichen planus of the soles can be difficult to diagnose, especially when it is an isolated finding. It should be differentiated from localized bullous pemphigoid, epidermolysis bullosa acquisita, ulcerative lupus erythematosus, and dermatitis artefacta.¹³ The characteristic associated clinical features of plantar ULP in our patient and lack of diagnostic immunofluorescence helped us to rule out these alternative diagnoses.⁴ Long-standing ulcerations of ULP also pose an increased risk for neoplastic transformation. Eisen¹⁵ noted a 0.4% to 5% frequency of malignant transformation into squamous cell carcinoma in those with oral ULP. Therefore, it is important to monitor previously ulcerated lesions long-term for such development.

Plantar ULP is difficult to treat and often is unresponsive to systemic and local treatment. Historically, surgical grafting of the affected areas was the treatment of choice, as reported by Patrone et al.⁶ Goucha et al¹³ reported complete healing of ulcerations within 3 weeks of starting oral prednisone 1 mg/kg once daily followed by a maintenance dosage of 5 mg once daily. Tacrolimus is a macrolide immunosuppressant that inhibits T-cell activation by forming a complex with FK506 binding protein in the cytoplasm of T cells that binds and inhibits calcineurin dephosphorylation of nuclear factor of activated T cells.¹² Al-Khenaizan and Al-Mubarak¹² reported resolution of plantar ULP ulcerations after 4 weeks of treatment with topical tacrolimus. Eisman and Orteu⁷ also achieved complete healing of ulcerations of plantar ULP using tacrolimus ointment 0.1%.

In our patient, doxycycline also was started at the time of initiating the topical tacrolimus. We chose this treatment to take advantage of its systemic anti-inflammatory, antiangiogenic, and antibacterial properties. Our case represents rapid and successful treatment of plantar ULP utilizing this specific combination of oral doxycycline and topical tacrolimus.

Conclusion

Ulcerative lichen planus is an uncommon variant of lichen planus, with cutaneous involvement only rarely reported in the literature. Physicians should be aware of this entity and should consider it in the differential diagnosis in patients presenting with chronic ulcers on the soles, especially when lesions have been unresponsive to appropriate wound care and antibiotic treatment or when cultures have been persistently negative for microbial growth. The possibility of drug-induced lichen planus also should not be overlooked, and one should consider discontinuation of all nonessential medications that could be potential culprits. In our patient ibuprofen was discontinued, but we can only speculate that it was contributory to his healing and only time will tell if resumption of this nonsteroidal anti-inflammatory drug causes a relapse in symptoms.

In our patient, a combination of systemic and topical steroids, topical tacrolimus, and oral doxycycline successfully treated his plantar ULP. Our findings provide further support for the use of topical tacrolimus as a steroid-sparing anti-inflammatory agent for the treatment of plantar ULP. We also introduce the combination of topical tacrolimus and oral doxycycline as a novel therapeutic combination and relatively safer alternative to conventional immunosuppressive agents for long-term systemic anti-inflammatory effects.

Ulcerative lichen planus (ULP)(also called erosive) is a rare variant of lichen planus. Similar to classic lichen planus, the cause of ULP is largely unknown. Ulcerative lichen planus typically involves the oral mucosa or genitalia but rarely may present as ulcerations on the palms and soles. Clinical presentation usually involves a history of chronic ulcers that often have been previously misdiagnosed and resistant to treatment. Ulcerations on the plantar surfaces frequently cause severe pain and disability. Few cases have been reported and successful treatment is rare.

Case Report

A 56-year-old man was referred by podiatry to the dermatology clinic for evaluation of painful ulcerations involving the dorsal and plantar surfaces of the right great toe as well as the second to third digits. The ulcers had been ongoing for 8 years, treated mostly with local wound care without clinical improvement. His medical and family history was considered noncontributory as a possible etiology of the ulcers; however, he had been taking ibuprofen intermittently for years for general aches and pains, which raised the suspicion of a drug-induced etiology. Laboratory evaluation revealed positive hepatitis B serology but was otherwise unremarkable, including normal liver function tests and negative wound cultures.

Physical examination revealed a beefy red, glazed ulceration involving the entire right great toe with extension onto the second and third toes. There was considerable scarring with syndactyly of the second and third toes and complete toenail loss of the right foot (Figure 1). On the insteps of the bilateral soles were a few scattered, pale, atrophic, violaceous papules with overlying thin lacy white streaks that were reflective of Wickham striae. Early dorsal pterygium formation also was noted on the bilateral third fingernails. Oral mucosal examination revealed lacy white plaques on the bilateral buccal mucosa with a large ulcer of the left lateral tongue (Figure 2). No genital or scalp lesions were present.

Histologic examination of a papule on the instep of the right sole demonstrated a dense lichenoid lymphocytic infiltrate in the papillary dermis with basal vacuolar degeneration and early focal Max-Joseph space formation. Additionally, there was epidermal atrophy with mild hypergranulosis and scattered necrotic keratinocytes (Figure 3). A similar histologic picture was noted on a biopsy of the buccal mucosa overlying the right molar, albeit with epithelial acanthosis rather than atrophy.

Based on initial clinical suspicion for ULP, we suggested that our patient discontinue ibuprofen and started him on a regimen of oral prednisone 40 mg once daily and clobetasol ointment 0.05% applied twice daily to the plantar ulceration, both for 2 weeks. Dramatic improvement was noted after only 2 weeks of treatment. This regimen was then switched to oral doxycycline 100 mg twice daily combined with tacrolimus ointment 0.1% applied twice daily to the plantar ulceration to avoid side effects of prolonged steroid use. Topical therapies were not used for the mucosal lesions. At 4-week follow-up, the patient continued to demonstrate notable clinical response with a greater than 70% physician-assessed improvement in ulcer severity (Figure 4) and near-complete resolution of the oral mucosal lesions. Our patient also reported almost complete resolution of pain. By 4-month follow-up, complete reepithelialization and resolution of the ulcers was noted (Figure 5). This improvement was sustained at additional follow-up 1 year after the initial presentation.

Comment

Ulcerative (or erosive) lichen planus is a rare form of lichen planus. Ulcerative lichen planus most commonly presents as erosive lesions of the oral and genital mucosae but rarely can involve other sites. The palms and soles are the most common sites of cutaneous involvement, with lesions frequently characterized by severe pain and limited mobility.²

We conducted a review of the Ovid MEDLINE database using the search terms ulcerative lichen planus and erosive lichen planus for articles from the last 30 years, focusing specifically on articles that reported cases of cutaneous involvement of ULP and successful therapeutic modalities. The Table provides a detailed summary of the cases from 1985 to present, representing a spectrum of clinical manifestations and successful treatments of ULP.^1-13

Hepatitis C is a comorbidity commonly associated with classic lichen planus, while hepatitis B immunization has a well-described association with classic and oral ULP.^12,14 Although hepatitis C was negative in our patient, we did find a chronic inactive carrier state for hepatitis B infection. Al-Khenaizan and Al-Mubarak¹² reported the only other known case of ULP of the sole associated with positive serology for hepatitis B surface antigen.

Ulcerative lichen planus of the soles can be difficult to diagnose, especially when it is an isolated finding. It should be differentiated from localized bullous pemphigoid, epidermolysis bullosa acquisita, ulcerative lupus erythematosus, and dermatitis artefacta.¹³ The characteristic associated clinical features of plantar ULP in our patient and lack of diagnostic immunofluorescence helped us to rule out these alternative diagnoses.⁴ Long-standing ulcerations of ULP also pose an increased risk for neoplastic transformation. Eisen¹⁵ noted a 0.4% to 5% frequency of malignant transformation into squamous cell carcinoma in those with oral ULP. Therefore, it is important to monitor previously ulcerated lesions long-term for such development.

Plantar ULP is difficult to treat and often is unresponsive to systemic and local treatment. Historically, surgical grafting of the affected areas was the treatment of choice, as reported by Patrone et al.⁶ Goucha et al¹³ reported complete healing of ulcerations within 3 weeks of starting oral prednisone 1 mg/kg once daily followed by a maintenance dosage of 5 mg once daily. Tacrolimus is a macrolide immunosuppressant that inhibits T-cell activation by forming a complex with FK506 binding protein in the cytoplasm of T cells that binds and inhibits calcineurin dephosphorylation of nuclear factor of activated T cells.¹² Al-Khenaizan and Al-Mubarak¹² reported resolution of plantar ULP ulcerations after 4 weeks of treatment with topical tacrolimus. Eisman and Orteu⁷ also achieved complete healing of ulcerations of plantar ULP using tacrolimus ointment 0.1%.

In our patient, doxycycline also was started at the time of initiating the topical tacrolimus. We chose this treatment to take advantage of its systemic anti-inflammatory, antiangiogenic, and antibacterial properties. Our case represents rapid and successful treatment of plantar ULP utilizing this specific combination of oral doxycycline and topical tacrolimus.

Conclusion

Ulcerative lichen planus is an uncommon variant of lichen planus, with cutaneous involvement only rarely reported in the literature. Physicians should be aware of this entity and should consider it in the differential diagnosis in patients presenting with chronic ulcers on the soles, especially when lesions have been unresponsive to appropriate wound care and antibiotic treatment or when cultures have been persistently negative for microbial growth. The possibility of drug-induced lichen planus also should not be overlooked, and one should consider discontinuation of all nonessential medications that could be potential culprits. In our patient ibuprofen was discontinued, but we can only speculate that it was contributory to his healing and only time will tell if resumption of this nonsteroidal anti-inflammatory drug causes a relapse in symptoms.

In our patient, a combination of systemic and topical steroids, topical tacrolimus, and oral doxycycline successfully treated his plantar ULP. Our findings provide further support for the use of topical tacrolimus as a steroid-sparing anti-inflammatory agent for the treatment of plantar ULP. We also introduce the combination of topical tacrolimus and oral doxycycline as a novel therapeutic combination and relatively safer alternative to conventional immunosuppressive agents for long-term systemic anti-inflammatory effects.

Provider attire has come under scrutiny in the more recent medical literature. Epidemiologic data have shown that lab coats, ties, and other articles of clothing are frequently contaminated with disease-causing pathogens including methicillin-resistant Staphylococcus aureus , vancomycin-resistant enterococci, Acinetobacter species, Enterobacteriaceae, Pseudomona s species, and Clostridium difficile.¹ Clothing may serve as a vector for spread of these bacteria and may contribute to hospital-acquired infections, increased cost of care, and patient morbidity. Prior to February 2015, the dermatology service line at Geisinger Medical Center in Danville, Pennsylvania, had followed a formal dress code that included white lab coats (white coats) along with long-sleeve shirts and ties/bowties for male providers and blouses, skirts, dress pants, and dresses for female providers. After a review of the recent literature on contamination rates of provider attire,² we transitioned away from formal attire to adopt fitted, embroidered, black or navy blue scrubs to be worn in the clinic (Figure). Fitted scrubs differ from traditional unisex operating room scrubs, conferring a more professional appearance.

Limited research has shown that dermatology patients may have a slight preference for formal provider attire.^2,3 In these studies, patients were shown photographs of providers in various dress (ie, professional attire, business attire, casual attire, scrubs). Patients preferred or had more confidence in the photograph of the provider in professional attire^2,3; however, it is unclear if dermatology provider attire has any measurable effect on overall patient satisfaction. Patient satisfaction relies on a myriad of factors, including both spoken and unspoken communication skills. Patient satisfaction has become an integral part of health care, and with an emphasis on value-based care, it will likely be one determining factor in how providers are reimbursed for their services.^4,5 In this study, we investigated if a change from formal attire to fitted scrubs influenced patient satisfaction using a common third-party patient satisfaction survey.

Methods

Patient Satisfaction Survey
We conducted a retrospective cohort study analyzing 10 questions from the care provider section of the Press Ganey third-party patient satisfaction survey regarding providers in our dermatology service line. Only providers with at least 12 months of survey data before (study period 1) and after (study period 2) the change in attire were included in the study. Mohs surgeons were excluded, as they already wore fitted scrubs in the clinic. Residents also were excluded, as they are rapidly developing their patient communication skills and may have a notable change in patient satisfaction over a 2-year period.

The survey data were collected, and provider names were removed and replaced with alphanumeric codes to protect anonymity while still allowing individual provider analysis. Aggregate patient comments from surveys before and after the change in attire were digitally searched using the terms scrub, coat, white, attire, and clothing for pertinent positive or negative comments.

Outcomes
We compared individual and aggregate satisfaction scores for our providers during the 12-month periods before and after the adoption of fitted scrubs. The primary outcome was statistically significant change in patient satisfaction scores before and after the institution of fitted scrubs. Secondary outcomes included summation of patient comments, both positive and negative, regarding provider attire, as recorded on satisfaction surveys.

Statistical Analysis
Overall survey scores and scores on individual survey items were summarized using mean (SD), median and interquartile range, or frequency counts and percentage, as appropriate. The overall satisfaction score and responses to individual survey items were compared using Mantel-Haenszel or Pearson χ² tests, as appropriate.

Assuming an equal number of surveys would be completed during study periods 1 and 2, an average (SD) satisfaction score of 95.4 (15), we calculated that as many as 2136 surveys would be needed to conclude satisfaction scores are the same for equivalence limits of −1.9 and 1.9 (a 1% difference). As few as 352 surveys would be needed to conclude satisfaction scores are the same for equivalence limits of −4.7 and 4.7 (a 5% difference). Sample size calculations assume 80% power and a significance level of 0.05. Comparison of responses for study periods 1 and 2 were made using the Mantel-Haenszel χ² test.

Because more than 80% of respondents selected very good for each question, the responses also were treated as dichotomous variables with a category for very good and a category for responses that were lower than very good (ie, good, fair, poor, very poor). Responses of very good versus less than very good were compared for the study periods 1 and 2 using the Pearson χ² test.

Two versions of an overall score were analyzed. The first version was for patients who responded to at least 1 of 10 survey items. If responses to all the items were very good, the patient was assigned to the category of all very good. If a patient answered any of the questions with a response less than very good, he/she was categorized as at least 1 less than very good. The second version was for patients who responded to all 10 survey items. If all 10 responses were very good, the patient was assigned to a category of all very good. If any of the 10 responses were less than very good, he/she was categorized as at least 1 less than very good. Differences between study periods for both score versions were tested using the Pearson χ² test.

Results

Data for 22 providers in the dermatology service line—13 staff dermatologists, 6 physician assistants, 1 nurse practitioner, and 2 podiatrists—were included in the study, with a total of 7702 patient satisfaction surveys completed between February 1, 2014, and January 31, 2016: 3511 were completed between February 1, 2014, and January 31, 2015 (study period 1), and 4191 were completed between February 1, 2015, and January 31, 2016 (study period 2).

Analysis of the overall distribution of possible responses for each survey item showed significant differences between study periods 1 and 2 for friendliness/courtesy of the care provider (P=.0307), explanations the care provider gave about the problem or condition (P=.0038), concern the care provider showed for questions or worries (P=.0087), care provider’s efforts to include the patient in decisions about treatment (P=.0377), and patient confidence in the care provider (P=.0156). These survey items trended toward more positive responses in study period 2. The full results are provided in eTable 1.

The analysis that looked at responses as binary (very good vs less than very good) showed a greater proportion of very good responses for friendliness/courtesy of the care provider (P=.0438), explanations the care provider gave about the problem or condition (P=.0115), concern the care provider showed for questions or worries (P=.0188), and patient confidence in the care provider (P=.0417). The full results are provided in eTable 2.

There were no significant differences in the overall satisfaction scores between the first and second study periods. The differences were statistically significant when the overall score was calculated if any questions were answered (P=.5177) and when the overall score was calculated if all 10 questions were answered (P=.9959). For patients who responded to all survey items, 75.3% selected all very good responses for both the first and second study periods.

Review of the surveys for comments from both study periods revealed only a single patient comment pertaining to attire. The comment, which was submitted during study period 2, was considered positive, referring to the fitted scrubs as neat and professional. No negative comments were found during either period.

Comment

In this study, we did not find that a change from formal attire to fitted scrubs had a measurable negative impact on patient satisfaction scores. Conversely, we found a small but statistically significant improvement on several survey items after the change to fitted scrubs. The data suggest that changing from formal attire to fitted scrubs in an outpatient dermatology clinic had little impact on overall patient satisfaction. Only 1 positive comment and no negative comments were received regarding providers wearing fitted scrubs.

A prior study in an outpatient gynecology/obstetrics clinic showed similar results.⁶ In that study, providers were randomly assigned to business attire, casual attire, or scrubs. A 10-question patient satisfaction survey was designed that specifically avoided asking about provider attire to reduce any bias. The study found that over a 3-month period, attire had no influence on patient satisfaction.⁶

Our data suggest that factors beyond provider attire have the greatest influence on patient satisfaction scores. Patient satisfaction is likely driven by other factors such as provider communication skills, concern for patient well-being, ability to empathize, and timeliness. Given the biologic plausibility of increased infection rate from contaminated provider attire, we feel that comfortable, washable, fitted scrubs provide a sanitary and acceptable alternative to more traditional formal provider attire in the office setting. Bearman et al¹ suggest consideration of a bare-below-the-elbows policy (with or without scrubs) for inpatient services and lab coats (if worn per facility policy), and other articles of clothing should be laundered frequently or if visibly soiled. We feel these policies also can be applied to outpatient dermatology clinics, as long as the rationale is well communicated to all parties.

Several items on the patient satisfaction survey were statistically improved during the second study period; however, it is impossible to determine if provider attire was an important factor in this change. Improvement in satisfaction scores could be attributed to ongoing departmental and institutional emphasis on patient care and servic

Anecdotally, most providers in our department were enthusiastic and supportive of the change to fitted scrubs. It is possible that provider happiness is reflected in improved patient satisfaction scores. Provider satisfaction has been shown to correlate with patient satisfaction.⁷

Limitations include possible other unmeasured variables that had a more substantial impact on patient satisfaction survey results. We also recognize that the survey used in this study contained no questions that directly asked patients about their satisfaction with provider attire; however, bias or any preconception patients may have had regarding attire may have been avoided in the process. We also were not able to separate patient surveys based on age or other demographics. Finally, our results may not be generalizable to other settings where patient perceptions may be different from those of central Pennsylvania.

Conclusion

Transitioning from formal provider attire to fitted scrubs did not have a strong impact on overall patient satisfaction scores in an outpatient dermatology clinic. Providers and institutions should consider this information when developing dress code policies.

Provider attire has come under scrutiny in the more recent medical literature. Epidemiologic data have shown that lab coats, ties, and other articles of clothing are frequently contaminated with disease-causing pathogens including methicillin-resistant Staphylococcus aureus , vancomycin-resistant enterococci, Acinetobacter species, Enterobacteriaceae, Pseudomona s species, and Clostridium difficile.¹ Clothing may serve as a vector for spread of these bacteria and may contribute to hospital-acquired infections, increased cost of care, and patient morbidity. Prior to February 2015, the dermatology service line at Geisinger Medical Center in Danville, Pennsylvania, had followed a formal dress code that included white lab coats (white coats) along with long-sleeve shirts and ties/bowties for male providers and blouses, skirts, dress pants, and dresses for female providers. After a review of the recent literature on contamination rates of provider attire,² we transitioned away from formal attire to adopt fitted, embroidered, black or navy blue scrubs to be worn in the clinic (Figure). Fitted scrubs differ from traditional unisex operating room scrubs, conferring a more professional appearance.

Limited research has shown that dermatology patients may have a slight preference for formal provider attire.^2,3 In these studies, patients were shown photographs of providers in various dress (ie, professional attire, business attire, casual attire, scrubs). Patients preferred or had more confidence in the photograph of the provider in professional attire^2,3; however, it is unclear if dermatology provider attire has any measurable effect on overall patient satisfaction. Patient satisfaction relies on a myriad of factors, including both spoken and unspoken communication skills. Patient satisfaction has become an integral part of health care, and with an emphasis on value-based care, it will likely be one determining factor in how providers are reimbursed for their services.^4,5 In this study, we investigated if a change from formal attire to fitted scrubs influenced patient satisfaction using a common third-party patient satisfaction survey.

Methods

Patient Satisfaction Survey
We conducted a retrospective cohort study analyzing 10 questions from the care provider section of the Press Ganey third-party patient satisfaction survey regarding providers in our dermatology service line. Only providers with at least 12 months of survey data before (study period 1) and after (study period 2) the change in attire were included in the study. Mohs surgeons were excluded, as they already wore fitted scrubs in the clinic. Residents also were excluded, as they are rapidly developing their patient communication skills and may have a notable change in patient satisfaction over a 2-year period.

The survey data were collected, and provider names were removed and replaced with alphanumeric codes to protect anonymity while still allowing individual provider analysis. Aggregate patient comments from surveys before and after the change in attire were digitally searched using the terms scrub, coat, white, attire, and clothing for pertinent positive or negative comments.

Outcomes
We compared individual and aggregate satisfaction scores for our providers during the 12-month periods before and after the adoption of fitted scrubs. The primary outcome was statistically significant change in patient satisfaction scores before and after the institution of fitted scrubs. Secondary outcomes included summation of patient comments, both positive and negative, regarding provider attire, as recorded on satisfaction surveys.

Statistical Analysis
Overall survey scores and scores on individual survey items were summarized using mean (SD), median and interquartile range, or frequency counts and percentage, as appropriate. The overall satisfaction score and responses to individual survey items were compared using Mantel-Haenszel or Pearson χ² tests, as appropriate.

Assuming an equal number of surveys would be completed during study periods 1 and 2, an average (SD) satisfaction score of 95.4 (15), we calculated that as many as 2136 surveys would be needed to conclude satisfaction scores are the same for equivalence limits of −1.9 and 1.9 (a 1% difference). As few as 352 surveys would be needed to conclude satisfaction scores are the same for equivalence limits of −4.7 and 4.7 (a 5% difference). Sample size calculations assume 80% power and a significance level of 0.05. Comparison of responses for study periods 1 and 2 were made using the Mantel-Haenszel χ² test.

Because more than 80% of respondents selected very good for each question, the responses also were treated as dichotomous variables with a category for very good and a category for responses that were lower than very good (ie, good, fair, poor, very poor). Responses of very good versus less than very good were compared for the study periods 1 and 2 using the Pearson χ² test.

Two versions of an overall score were analyzed. The first version was for patients who responded to at least 1 of 10 survey items. If responses to all the items were very good, the patient was assigned to the category of all very good. If a patient answered any of the questions with a response less than very good, he/she was categorized as at least 1 less than very good. The second version was for patients who responded to all 10 survey items. If all 10 responses were very good, the patient was assigned to a category of all very good. If any of the 10 responses were less than very good, he/she was categorized as at least 1 less than very good. Differences between study periods for both score versions were tested using the Pearson χ² test.

Results

Data for 22 providers in the dermatology service line—13 staff dermatologists, 6 physician assistants, 1 nurse practitioner, and 2 podiatrists—were included in the study, with a total of 7702 patient satisfaction surveys completed between February 1, 2014, and January 31, 2016: 3511 were completed between February 1, 2014, and January 31, 2015 (study period 1), and 4191 were completed between February 1, 2015, and January 31, 2016 (study period 2).

Analysis of the overall distribution of possible responses for each survey item showed significant differences between study periods 1 and 2 for friendliness/courtesy of the care provider (P=.0307), explanations the care provider gave about the problem or condition (P=.0038), concern the care provider showed for questions or worries (P=.0087), care provider’s efforts to include the patient in decisions about treatment (P=.0377), and patient confidence in the care provider (P=.0156). These survey items trended toward more positive responses in study period 2. The full results are provided in eTable 1.

The analysis that looked at responses as binary (very good vs less than very good) showed a greater proportion of very good responses for friendliness/courtesy of the care provider (P=.0438), explanations the care provider gave about the problem or condition (P=.0115), concern the care provider showed for questions or worries (P=.0188), and patient confidence in the care provider (P=.0417). The full results are provided in eTable 2.

There were no significant differences in the overall satisfaction scores between the first and second study periods. The differences were statistically significant when the overall score was calculated if any questions were answered (P=.5177) and when the overall score was calculated if all 10 questions were answered (P=.9959). For patients who responded to all survey items, 75.3% selected all very good responses for both the first and second study periods.

Review of the surveys for comments from both study periods revealed only a single patient comment pertaining to attire. The comment, which was submitted during study period 2, was considered positive, referring to the fitted scrubs as neat and professional. No negative comments were found during either period.

Comment

In this study, we did not find that a change from formal attire to fitted scrubs had a measurable negative impact on patient satisfaction scores. Conversely, we found a small but statistically significant improvement on several survey items after the change to fitted scrubs. The data suggest that changing from formal attire to fitted scrubs in an outpatient dermatology clinic had little impact on overall patient satisfaction. Only 1 positive comment and no negative comments were received regarding providers wearing fitted scrubs.

A prior study in an outpatient gynecology/obstetrics clinic showed similar results.⁶ In that study, providers were randomly assigned to business attire, casual attire, or scrubs. A 10-question patient satisfaction survey was designed that specifically avoided asking about provider attire to reduce any bias. The study found that over a 3-month period, attire had no influence on patient satisfaction.⁶

Our data suggest that factors beyond provider attire have the greatest influence on patient satisfaction scores. Patient satisfaction is likely driven by other factors such as provider communication skills, concern for patient well-being, ability to empathize, and timeliness. Given the biologic plausibility of increased infection rate from contaminated provider attire, we feel that comfortable, washable, fitted scrubs provide a sanitary and acceptable alternative to more traditional formal provider attire in the office setting. Bearman et al¹ suggest consideration of a bare-below-the-elbows policy (with or without scrubs) for inpatient services and lab coats (if worn per facility policy), and other articles of clothing should be laundered frequently or if visibly soiled. We feel these policies also can be applied to outpatient dermatology clinics, as long as the rationale is well communicated to all parties.

Several items on the patient satisfaction survey were statistically improved during the second study period; however, it is impossible to determine if provider attire was an important factor in this change. Improvement in satisfaction scores could be attributed to ongoing departmental and institutional emphasis on patient care and servic

Anecdotally, most providers in our department were enthusiastic and supportive of the change to fitted scrubs. It is possible that provider happiness is reflected in improved patient satisfaction scores. Provider satisfaction has been shown to correlate with patient satisfaction.⁷

Limitations include possible other unmeasured variables that had a more substantial impact on patient satisfaction survey results. We also recognize that the survey used in this study contained no questions that directly asked patients about their satisfaction with provider attire; however, bias or any preconception patients may have had regarding attire may have been avoided in the process. We also were not able to separate patient surveys based on age or other demographics. Finally, our results may not be generalizable to other settings where patient perceptions may be different from those of central Pennsylvania.

Conclusion

Transitioning from formal provider attire to fitted scrubs did not have a strong impact on overall patient satisfaction scores in an outpatient dermatology clinic. Providers and institutions should consider this information when developing dress code policies.

Provider attire has come under scrutiny in the more recent medical literature. Epidemiologic data have shown that lab coats, ties, and other articles of clothing are frequently contaminated with disease-causing pathogens including methicillin-resistant Staphylococcus aureus , vancomycin-resistant enterococci, Acinetobacter species, Enterobacteriaceae, Pseudomona s species, and Clostridium difficile.¹ Clothing may serve as a vector for spread of these bacteria and may contribute to hospital-acquired infections, increased cost of care, and patient morbidity. Prior to February 2015, the dermatology service line at Geisinger Medical Center in Danville, Pennsylvania, had followed a formal dress code that included white lab coats (white coats) along with long-sleeve shirts and ties/bowties for male providers and blouses, skirts, dress pants, and dresses for female providers. After a review of the recent literature on contamination rates of provider attire,² we transitioned away from formal attire to adopt fitted, embroidered, black or navy blue scrubs to be worn in the clinic (Figure). Fitted scrubs differ from traditional unisex operating room scrubs, conferring a more professional appearance.

Limited research has shown that dermatology patients may have a slight preference for formal provider attire.^2,3 In these studies, patients were shown photographs of providers in various dress (ie, professional attire, business attire, casual attire, scrubs). Patients preferred or had more confidence in the photograph of the provider in professional attire^2,3; however, it is unclear if dermatology provider attire has any measurable effect on overall patient satisfaction. Patient satisfaction relies on a myriad of factors, including both spoken and unspoken communication skills. Patient satisfaction has become an integral part of health care, and with an emphasis on value-based care, it will likely be one determining factor in how providers are reimbursed for their services.^4,5 In this study, we investigated if a change from formal attire to fitted scrubs influenced patient satisfaction using a common third-party patient satisfaction survey.

Methods

Patient Satisfaction Survey
We conducted a retrospective cohort study analyzing 10 questions from the care provider section of the Press Ganey third-party patient satisfaction survey regarding providers in our dermatology service line. Only providers with at least 12 months of survey data before (study period 1) and after (study period 2) the change in attire were included in the study. Mohs surgeons were excluded, as they already wore fitted scrubs in the clinic. Residents also were excluded, as they are rapidly developing their patient communication skills and may have a notable change in patient satisfaction over a 2-year period.

The survey data were collected, and provider names were removed and replaced with alphanumeric codes to protect anonymity while still allowing individual provider analysis. Aggregate patient comments from surveys before and after the change in attire were digitally searched using the terms scrub, coat, white, attire, and clothing for pertinent positive or negative comments.

Outcomes
We compared individual and aggregate satisfaction scores for our providers during the 12-month periods before and after the adoption of fitted scrubs. The primary outcome was statistically significant change in patient satisfaction scores before and after the institution of fitted scrubs. Secondary outcomes included summation of patient comments, both positive and negative, regarding provider attire, as recorded on satisfaction surveys.

Statistical Analysis
Overall survey scores and scores on individual survey items were summarized using mean (SD), median and interquartile range, or frequency counts and percentage, as appropriate. The overall satisfaction score and responses to individual survey items were compared using Mantel-Haenszel or Pearson χ² tests, as appropriate.

Assuming an equal number of surveys would be completed during study periods 1 and 2, an average (SD) satisfaction score of 95.4 (15), we calculated that as many as 2136 surveys would be needed to conclude satisfaction scores are the same for equivalence limits of −1.9 and 1.9 (a 1% difference). As few as 352 surveys would be needed to conclude satisfaction scores are the same for equivalence limits of −4.7 and 4.7 (a 5% difference). Sample size calculations assume 80% power and a significance level of 0.05. Comparison of responses for study periods 1 and 2 were made using the Mantel-Haenszel χ² test.

Because more than 80% of respondents selected very good for each question, the responses also were treated as dichotomous variables with a category for very good and a category for responses that were lower than very good (ie, good, fair, poor, very poor). Responses of very good versus less than very good were compared for the study periods 1 and 2 using the Pearson χ² test.

Two versions of an overall score were analyzed. The first version was for patients who responded to at least 1 of 10 survey items. If responses to all the items were very good, the patient was assigned to the category of all very good. If a patient answered any of the questions with a response less than very good, he/she was categorized as at least 1 less than very good. The second version was for patients who responded to all 10 survey items. If all 10 responses were very good, the patient was assigned to a category of all very good. If any of the 10 responses were less than very good, he/she was categorized as at least 1 less than very good. Differences between study periods for both score versions were tested using the Pearson χ² test.

Results

Data for 22 providers in the dermatology service line—13 staff dermatologists, 6 physician assistants, 1 nurse practitioner, and 2 podiatrists—were included in the study, with a total of 7702 patient satisfaction surveys completed between February 1, 2014, and January 31, 2016: 3511 were completed between February 1, 2014, and January 31, 2015 (study period 1), and 4191 were completed between February 1, 2015, and January 31, 2016 (study period 2).

Analysis of the overall distribution of possible responses for each survey item showed significant differences between study periods 1 and 2 for friendliness/courtesy of the care provider (P=.0307), explanations the care provider gave about the problem or condition (P=.0038), concern the care provider showed for questions or worries (P=.0087), care provider’s efforts to include the patient in decisions about treatment (P=.0377), and patient confidence in the care provider (P=.0156). These survey items trended toward more positive responses in study period 2. The full results are provided in eTable 1.

The analysis that looked at responses as binary (very good vs less than very good) showed a greater proportion of very good responses for friendliness/courtesy of the care provider (P=.0438), explanations the care provider gave about the problem or condition (P=.0115), concern the care provider showed for questions or worries (P=.0188), and patient confidence in the care provider (P=.0417). The full results are provided in eTable 2.

There were no significant differences in the overall satisfaction scores between the first and second study periods. The differences were statistically significant when the overall score was calculated if any questions were answered (P=.5177) and when the overall score was calculated if all 10 questions were answered (P=.9959). For patients who responded to all survey items, 75.3% selected all very good responses for both the first and second study periods.

Review of the surveys for comments from both study periods revealed only a single patient comment pertaining to attire. The comment, which was submitted during study period 2, was considered positive, referring to the fitted scrubs as neat and professional. No negative comments were found during either period.

Comment

In this study, we did not find that a change from formal attire to fitted scrubs had a measurable negative impact on patient satisfaction scores. Conversely, we found a small but statistically significant improvement on several survey items after the change to fitted scrubs. The data suggest that changing from formal attire to fitted scrubs in an outpatient dermatology clinic had little impact on overall patient satisfaction. Only 1 positive comment and no negative comments were received regarding providers wearing fitted scrubs.

A prior study in an outpatient gynecology/obstetrics clinic showed similar results.⁶ In that study, providers were randomly assigned to business attire, casual attire, or scrubs. A 10-question patient satisfaction survey was designed that specifically avoided asking about provider attire to reduce any bias. The study found that over a 3-month period, attire had no influence on patient satisfaction.⁶

Our data suggest that factors beyond provider attire have the greatest influence on patient satisfaction scores. Patient satisfaction is likely driven by other factors such as provider communication skills, concern for patient well-being, ability to empathize, and timeliness. Given the biologic plausibility of increased infection rate from contaminated provider attire, we feel that comfortable, washable, fitted scrubs provide a sanitary and acceptable alternative to more traditional formal provider attire in the office setting. Bearman et al¹ suggest consideration of a bare-below-the-elbows policy (with or without scrubs) for inpatient services and lab coats (if worn per facility policy), and other articles of clothing should be laundered frequently or if visibly soiled. We feel these policies also can be applied to outpatient dermatology clinics, as long as the rationale is well communicated to all parties.

Several items on the patient satisfaction survey were statistically improved during the second study period; however, it is impossible to determine if provider attire was an important factor in this change. Improvement in satisfaction scores could be attributed to ongoing departmental and institutional emphasis on patient care and servic

Anecdotally, most providers in our department were enthusiastic and supportive of the change to fitted scrubs. It is possible that provider happiness is reflected in improved patient satisfaction scores. Provider satisfaction has been shown to correlate with patient satisfaction.⁷

Limitations include possible other unmeasured variables that had a more substantial impact on patient satisfaction survey results. We also recognize that the survey used in this study contained no questions that directly asked patients about their satisfaction with provider attire; however, bias or any preconception patients may have had regarding attire may have been avoided in the process. We also were not able to separate patient surveys based on age or other demographics. Finally, our results may not be generalizable to other settings where patient perceptions may be different from those of central Pennsylvania.

Conclusion

Transitioning from formal provider attire to fitted scrubs did not have a strong impact on overall patient satisfaction scores in an outpatient dermatology clinic. Providers and institutions should consider this information when developing dress code policies.

The number of U.S. emergency department visits for acute pancreatitis associated with alcohol abuse, chronic pancreatitis history, and younger age was on the rise in recent years, an analysis of a nationally representative database has suggested.

Katarzyna Bialasiewicz/Thinkstock

Help your patients better understand pancreatitis and available tests and treatments by using AGA patient education materials, https://www.gastro.org/practice-guidance/gi-patient-center/topic/pancreatitis.

SOURCE: Garg SK et al. J Clin Gastroenterol. 2018 Apr 6. doi: 10.1097/MCG.0000000000001030.

The number of U.S. emergency department visits for acute pancreatitis associated with alcohol abuse, chronic pancreatitis history, and younger age was on the rise in recent years, an analysis of a nationally representative database has suggested.

Katarzyna Bialasiewicz/Thinkstock

Help your patients better understand pancreatitis and available tests and treatments by using AGA patient education materials, https://www.gastro.org/practice-guidance/gi-patient-center/topic/pancreatitis.

SOURCE: Garg SK et al. J Clin Gastroenterol. 2018 Apr 6. doi: 10.1097/MCG.0000000000001030.

The number of U.S. emergency department visits for acute pancreatitis associated with alcohol abuse, chronic pancreatitis history, and younger age was on the rise in recent years, an analysis of a nationally representative database has suggested.

Katarzyna Bialasiewicz/Thinkstock

Help your patients better understand pancreatitis and available tests and treatments by using AGA patient education materials, https://www.gastro.org/practice-guidance/gi-patient-center/topic/pancreatitis.

SOURCE: Garg SK et al. J Clin Gastroenterol. 2018 Apr 6. doi: 10.1097/MCG.0000000000001030.

A 46-year-old man presents to your clinic with hearing loss and ear fullness. He awoke with sudden and unexplained right-sided hearing loss with aural fullness 6 days prior to presentation and reports associated unilateral tinnitus and vertigo. He denies otorrhea and otalgia. Hearing on the left is otherwise preserved, and he has no prior otologic history. He denies inciting events. He has never experienced this before.

On examination, the auricles are normal, and there are no vesicular lesions. His ear canals are patent and without occluding cerumen. Tympanic membranes are translucent and intact without effusion or retraction. On tuning fork examination, Weber lateralizes to the left, and air conduction is greater than bone conduction bilaterally.


What is the most likely diagnosis?

A. Otitis media with effusion.

B. Ménière’s disease.

C. Ramsay Hunt syndrome.

D. Sudden sensorineural hearing loss.

E. Bell’s palsy.

F. Otosclerosis.

G. Benign paroxysmal positional vertigo.

This patient is presenting with sudden sensorineural hearing loss (SSNHL). There are approximately 4,000 new cases of SSNHL reported each year in the United States, and many primary care physicians will encounter this disorder.¹

Idiopathic SSNHL is an otolaryngology emergency, and recognition and prompt treatment is imperative to potentially salvage hearing and improve quality of life.² The rates of spontaneous recovery within the literature vary widely from 32% to 65%. However, this constitutes a significant portion of patients who still require the use of hearing aids. Recovery at lower frequencies occurs more commonly, and the rates of true spontaneous recovery are likely approximately one-third of all cases, with only 15% of patients who recover fully.³

Patients with SSNHL present to an otolaryngologist on average 55 days after symptom onset. Yet it is believed that the earlier the intervention, the more improved the recovery, especially if instituted within 1-2 weeks.⁴ Most patients, however, initially present to their primary care physicians.

The history and physical are particularly important to rule out other etiologies of hearing loss, including otitis media with effusion, acute otitis media, and cerumen impaction.

The onset and progression of SSNHL are unique, in that patients will experience near immediate unilateral hearing loss, typically with a normal ear examination. Aural pressure and tinnitus are frequently reported in SSNHL. In fact, ear fullness is the most common presenting symptom, and tinnitus is reported nearly universally. Dizziness or vertigo does not refute the diagnosis of SSNHL, as this occurs in 30%-40% of cases and is a negative prognostic factor, along with profound sensorineural loss, contralateral hearing impairment, and delayed treatment.^3,5

In 9 out of 10 patients with SSNHL, a precipitating factor or cause will never be identified, and approximately one-third of patients will spontaneously recover hearing.⁶

This has created controversial treatment options. Regardless, specialty guidelines advocate for early medical treatment with systemic corticosteroids within the first 14 days of symptom onset. Clinicians must be prepared to empirically and rapidly treat patients with suspected SSNHL without understanding the etiology and without conclusive audiologic or imaging data.

Other causes indeterminate of sudden hearing loss include autoimmune and Ménière’s disease; however, diagnosis and management of these disorders does not have the same urgency as that of SSNHL.

Otolaryngology follow-up for SSNHL is recommended to provide treatment options and counseling, monitor hearing thresholds, provide ongoing evaluation for hearing augmentation, and establish expert consultation to ensure there are no underlying causes.

Primary care providers need to institute the initial treatment recommendations, which include systemic steroids, potentially in combination with alternative treatment options. There is conflicting evidence on the efficacy of early high-dose steroid therapy in SSNHL. But, unfortunately, the alternative may include permanent unilateral deafness.⁷ The earlier the treatment, the better the outcomes, although oral steroids may contribute to significant improvement even at late presentation.⁴

Dosing recommendations vary, but include prednisone 1 mg/kg per day (maximum of 60 mg), methylprednisolone 48 mg/day, and dexamethasone 10 mg/day for 7-14 days prior to tapering. Examination and audiometry are ideally obtained at the time of symptom onset and immediately after treatment for full evaluation.

Evidence supports the use of intratympanic steroid injections after primary treatment failure, although there is increasing interest in combining transtympanic perfusion with oral steroids for primary treatment.^7,8 In a survey of otolaryngologists, 86% of respondents reported the concomitant use of intratympanic steroid injections for primary treatment.⁹ Of these, greater than 50% and 32% used steroid injections up to 1 month, and up to 3 months following the onset of symptoms, respectively.

There may be benefit with hyperbaric oxygen therapy, which is rarely used in the United States.⁶ There may be benefit with a low side effect profile in combining systemic steroids with antioxidants, such as vitamins A, C, and E.¹⁰

In summary, SSNHL is not uncommon; ear fullness and tinnitus are common and may represent the chief complaint. A high index of suspicion is necessary, and decisions are often made without full knowledge of the etiology. Conductive hearing loss should be ruled out on history and examination. Initial diagnostic workup includes formal audiometry with initiation of high-dose corticosteroid therapy, ideally within 2 weeks of symptom onset.

Consultation to otolaryngology or neurotology is important for ongoing discussions regarding potential recovery, hearing augmentation, and to ensure there is no underlying condition.
 

Dr. Shinn is with the department of otolaryngology–head and neck surgery at Vanderbilt University Medical Center in Nashville, Tenn. Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].

References

1. Otolaryngol Head Neck Surg. 2012;146(3 Suppl):S1-35.

2. JAMA Otolaryngol Head Neck Surg. 2018 Jun 21. doi: 10.1001/jamaoto.2018.1072.

3. Braz J Otorhinolaryngol. 2015 Oct-Sep;81(5):520-6.

4. Cureus. 2017 Dec;9(12):e1945.

5. JAMA Otolaryngol Head Neck Surg. 2018 Jun 21. doi: 10.1001/jamaoto.2018.0648.

6. Otolaryngol Clin North Am. 2008;41(3):633-49.

7. Curr Opin Otolaryngol Head Neck Surg. 2016 Oct;24(5):413-9.

8. Eur Arch Otorhinolaryngol. 2015 Oct;272(10):2777-82.

9. Ann Otol Rhinol Laryngol. 2018 Jul;127(7):481-2.

10. Audiol Neurotol. 2018 Jun 22;23(1):1-7.

A 46-year-old man presents to your clinic with hearing loss and ear fullness. He awoke with sudden and unexplained right-sided hearing loss with aural fullness 6 days prior to presentation and reports associated unilateral tinnitus and vertigo. He denies otorrhea and otalgia. Hearing on the left is otherwise preserved, and he has no prior otologic history. He denies inciting events. He has never experienced this before.

On examination, the auricles are normal, and there are no vesicular lesions. His ear canals are patent and without occluding cerumen. Tympanic membranes are translucent and intact without effusion or retraction. On tuning fork examination, Weber lateralizes to the left, and air conduction is greater than bone conduction bilaterally.


What is the most likely diagnosis?

A. Otitis media with effusion.

B. Ménière’s disease.

C. Ramsay Hunt syndrome.

D. Sudden sensorineural hearing loss.

E. Bell’s palsy.

F. Otosclerosis.

G. Benign paroxysmal positional vertigo.

This patient is presenting with sudden sensorineural hearing loss (SSNHL). There are approximately 4,000 new cases of SSNHL reported each year in the United States, and many primary care physicians will encounter this disorder.¹

Idiopathic SSNHL is an otolaryngology emergency, and recognition and prompt treatment is imperative to potentially salvage hearing and improve quality of life.² The rates of spontaneous recovery within the literature vary widely from 32% to 65%. However, this constitutes a significant portion of patients who still require the use of hearing aids. Recovery at lower frequencies occurs more commonly, and the rates of true spontaneous recovery are likely approximately one-third of all cases, with only 15% of patients who recover fully.³

Patients with SSNHL present to an otolaryngologist on average 55 days after symptom onset. Yet it is believed that the earlier the intervention, the more improved the recovery, especially if instituted within 1-2 weeks.⁴ Most patients, however, initially present to their primary care physicians.

The history and physical are particularly important to rule out other etiologies of hearing loss, including otitis media with effusion, acute otitis media, and cerumen impaction.

The onset and progression of SSNHL are unique, in that patients will experience near immediate unilateral hearing loss, typically with a normal ear examination. Aural pressure and tinnitus are frequently reported in SSNHL. In fact, ear fullness is the most common presenting symptom, and tinnitus is reported nearly universally. Dizziness or vertigo does not refute the diagnosis of SSNHL, as this occurs in 30%-40% of cases and is a negative prognostic factor, along with profound sensorineural loss, contralateral hearing impairment, and delayed treatment.^3,5

In 9 out of 10 patients with SSNHL, a precipitating factor or cause will never be identified, and approximately one-third of patients will spontaneously recover hearing.⁶

This has created controversial treatment options. Regardless, specialty guidelines advocate for early medical treatment with systemic corticosteroids within the first 14 days of symptom onset. Clinicians must be prepared to empirically and rapidly treat patients with suspected SSNHL without understanding the etiology and without conclusive audiologic or imaging data.

Other causes indeterminate of sudden hearing loss include autoimmune and Ménière’s disease; however, diagnosis and management of these disorders does not have the same urgency as that of SSNHL.

Otolaryngology follow-up for SSNHL is recommended to provide treatment options and counseling, monitor hearing thresholds, provide ongoing evaluation for hearing augmentation, and establish expert consultation to ensure there are no underlying causes.

Primary care providers need to institute the initial treatment recommendations, which include systemic steroids, potentially in combination with alternative treatment options. There is conflicting evidence on the efficacy of early high-dose steroid therapy in SSNHL. But, unfortunately, the alternative may include permanent unilateral deafness.⁷ The earlier the treatment, the better the outcomes, although oral steroids may contribute to significant improvement even at late presentation.⁴

Dosing recommendations vary, but include prednisone 1 mg/kg per day (maximum of 60 mg), methylprednisolone 48 mg/day, and dexamethasone 10 mg/day for 7-14 days prior to tapering. Examination and audiometry are ideally obtained at the time of symptom onset and immediately after treatment for full evaluation.

Evidence supports the use of intratympanic steroid injections after primary treatment failure, although there is increasing interest in combining transtympanic perfusion with oral steroids for primary treatment.^7,8 In a survey of otolaryngologists, 86% of respondents reported the concomitant use of intratympanic steroid injections for primary treatment.⁹ Of these, greater than 50% and 32% used steroid injections up to 1 month, and up to 3 months following the onset of symptoms, respectively.

There may be benefit with hyperbaric oxygen therapy, which is rarely used in the United States.⁶ There may be benefit with a low side effect profile in combining systemic steroids with antioxidants, such as vitamins A, C, and E.¹⁰

In summary, SSNHL is not uncommon; ear fullness and tinnitus are common and may represent the chief complaint. A high index of suspicion is necessary, and decisions are often made without full knowledge of the etiology. Conductive hearing loss should be ruled out on history and examination. Initial diagnostic workup includes formal audiometry with initiation of high-dose corticosteroid therapy, ideally within 2 weeks of symptom onset.

Consultation to otolaryngology or neurotology is important for ongoing discussions regarding potential recovery, hearing augmentation, and to ensure there is no underlying condition.
 

Dr. Shinn is with the department of otolaryngology–head and neck surgery at Vanderbilt University Medical Center in Nashville, Tenn. Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].

References

1. Otolaryngol Head Neck Surg. 2012;146(3 Suppl):S1-35.

2. JAMA Otolaryngol Head Neck Surg. 2018 Jun 21. doi: 10.1001/jamaoto.2018.1072.

3. Braz J Otorhinolaryngol. 2015 Oct-Sep;81(5):520-6.

4. Cureus. 2017 Dec;9(12):e1945.

5. JAMA Otolaryngol Head Neck Surg. 2018 Jun 21. doi: 10.1001/jamaoto.2018.0648.

6. Otolaryngol Clin North Am. 2008;41(3):633-49.

7. Curr Opin Otolaryngol Head Neck Surg. 2016 Oct;24(5):413-9.

8. Eur Arch Otorhinolaryngol. 2015 Oct;272(10):2777-82.

9. Ann Otol Rhinol Laryngol. 2018 Jul;127(7):481-2.

10. Audiol Neurotol. 2018 Jun 22;23(1):1-7.

A 46-year-old man presents to your clinic with hearing loss and ear fullness. He awoke with sudden and unexplained right-sided hearing loss with aural fullness 6 days prior to presentation and reports associated unilateral tinnitus and vertigo. He denies otorrhea and otalgia. Hearing on the left is otherwise preserved, and he has no prior otologic history. He denies inciting events. He has never experienced this before.

On examination, the auricles are normal, and there are no vesicular lesions. His ear canals are patent and without occluding cerumen. Tympanic membranes are translucent and intact without effusion or retraction. On tuning fork examination, Weber lateralizes to the left, and air conduction is greater than bone conduction bilaterally.


What is the most likely diagnosis?

A. Otitis media with effusion.

B. Ménière’s disease.

C. Ramsay Hunt syndrome.

D. Sudden sensorineural hearing loss.

E. Bell’s palsy.

F. Otosclerosis.

G. Benign paroxysmal positional vertigo.

This patient is presenting with sudden sensorineural hearing loss (SSNHL). There are approximately 4,000 new cases of SSNHL reported each year in the United States, and many primary care physicians will encounter this disorder.¹

Idiopathic SSNHL is an otolaryngology emergency, and recognition and prompt treatment is imperative to potentially salvage hearing and improve quality of life.² The rates of spontaneous recovery within the literature vary widely from 32% to 65%. However, this constitutes a significant portion of patients who still require the use of hearing aids. Recovery at lower frequencies occurs more commonly, and the rates of true spontaneous recovery are likely approximately one-third of all cases, with only 15% of patients who recover fully.³

Patients with SSNHL present to an otolaryngologist on average 55 days after symptom onset. Yet it is believed that the earlier the intervention, the more improved the recovery, especially if instituted within 1-2 weeks.⁴ Most patients, however, initially present to their primary care physicians.

The history and physical are particularly important to rule out other etiologies of hearing loss, including otitis media with effusion, acute otitis media, and cerumen impaction.

The onset and progression of SSNHL are unique, in that patients will experience near immediate unilateral hearing loss, typically with a normal ear examination. Aural pressure and tinnitus are frequently reported in SSNHL. In fact, ear fullness is the most common presenting symptom, and tinnitus is reported nearly universally. Dizziness or vertigo does not refute the diagnosis of SSNHL, as this occurs in 30%-40% of cases and is a negative prognostic factor, along with profound sensorineural loss, contralateral hearing impairment, and delayed treatment.^3,5

In 9 out of 10 patients with SSNHL, a precipitating factor or cause will never be identified, and approximately one-third of patients will spontaneously recover hearing.⁶

This has created controversial treatment options. Regardless, specialty guidelines advocate for early medical treatment with systemic corticosteroids within the first 14 days of symptom onset. Clinicians must be prepared to empirically and rapidly treat patients with suspected SSNHL without understanding the etiology and without conclusive audiologic or imaging data.

Other causes indeterminate of sudden hearing loss include autoimmune and Ménière’s disease; however, diagnosis and management of these disorders does not have the same urgency as that of SSNHL.

Otolaryngology follow-up for SSNHL is recommended to provide treatment options and counseling, monitor hearing thresholds, provide ongoing evaluation for hearing augmentation, and establish expert consultation to ensure there are no underlying causes.

Primary care providers need to institute the initial treatment recommendations, which include systemic steroids, potentially in combination with alternative treatment options. There is conflicting evidence on the efficacy of early high-dose steroid therapy in SSNHL. But, unfortunately, the alternative may include permanent unilateral deafness.⁷ The earlier the treatment, the better the outcomes, although oral steroids may contribute to significant improvement even at late presentation.⁴

Dosing recommendations vary, but include prednisone 1 mg/kg per day (maximum of 60 mg), methylprednisolone 48 mg/day, and dexamethasone 10 mg/day for 7-14 days prior to tapering. Examination and audiometry are ideally obtained at the time of symptom onset and immediately after treatment for full evaluation.

Evidence supports the use of intratympanic steroid injections after primary treatment failure, although there is increasing interest in combining transtympanic perfusion with oral steroids for primary treatment.^7,8 In a survey of otolaryngologists, 86% of respondents reported the concomitant use of intratympanic steroid injections for primary treatment.⁹ Of these, greater than 50% and 32% used steroid injections up to 1 month, and up to 3 months following the onset of symptoms, respectively.

There may be benefit with hyperbaric oxygen therapy, which is rarely used in the United States.⁶ There may be benefit with a low side effect profile in combining systemic steroids with antioxidants, such as vitamins A, C, and E.¹⁰

In summary, SSNHL is not uncommon; ear fullness and tinnitus are common and may represent the chief complaint. A high index of suspicion is necessary, and decisions are often made without full knowledge of the etiology. Conductive hearing loss should be ruled out on history and examination. Initial diagnostic workup includes formal audiometry with initiation of high-dose corticosteroid therapy, ideally within 2 weeks of symptom onset.

Consultation to otolaryngology or neurotology is important for ongoing discussions regarding potential recovery, hearing augmentation, and to ensure there is no underlying condition.
 

Dr. Shinn is with the department of otolaryngology–head and neck surgery at Vanderbilt University Medical Center in Nashville, Tenn. Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].

References

1. Otolaryngol Head Neck Surg. 2012;146(3 Suppl):S1-35.

2. JAMA Otolaryngol Head Neck Surg. 2018 Jun 21. doi: 10.1001/jamaoto.2018.1072.

3. Braz J Otorhinolaryngol. 2015 Oct-Sep;81(5):520-6.

4. Cureus. 2017 Dec;9(12):e1945.

5. JAMA Otolaryngol Head Neck Surg. 2018 Jun 21. doi: 10.1001/jamaoto.2018.0648.

6. Otolaryngol Clin North Am. 2008;41(3):633-49.

7. Curr Opin Otolaryngol Head Neck Surg. 2016 Oct;24(5):413-9.

8. Eur Arch Otorhinolaryngol. 2015 Oct;272(10):2777-82.

9. Ann Otol Rhinol Laryngol. 2018 Jul;127(7):481-2.

10. Audiol Neurotol. 2018 Jun 22;23(1):1-7.

Andrew N. Wilner, MD, FAAN, FACP

Angels Neurological Centers

Abington, MA

Clinical History

A 37-year-old pregnant African American woman with a history of epilepsy and polysubstance abuse was found unresponsive in a hotel room. She had four convulsions en route to the hospital. In transit, she received levetiracetam and phenytoin, resulting in the cessation of the clinical seizures.

According to her mother, seizures began at age 16 during her first pregnancy, which was complicated by hypertension. She was prescribed medications for hypertension and phenytoin for seizures. The patient provided a different history, claiming that her seizures began 2 years ago. She denied taking medication for seizures or other health problems.

The patient has two children, ages 22 and 11 years. Past medical history is otherwise unremarkable. She has no allergies. Social history includes cigarette smoking, and alcohol and substance abuse. She lives with her boyfriend and does not work. She is 25 weeks pregnant. Family history was notable only for migraine in her mother and grandmother.

Physical Examination    

In the emergency department, blood pressure was 135/65, pulse 121 beats per minute, and oxygen saturation was 97%. She was oriented only to self and did not follow commands. Pupils were equal and reactive. There was no facial asymmetry. She moved all 4 extremities spontaneously. Reflexes were brisk. Oral mucosa was dry. She had no edema in the lower extremities.

Laboratories

Chest x-ray was normal. EKG revealed tachycardia and nonspecific ST changes. Hemoglobin was 11.1 g/dl, hematocrit 32%, white blood cell count 10,900, and platelets 181,000. Electrolytes were normal except for a low sodium of 132 mmol/l (135-145) and bicarbonate of 17 mmol/l (21-31). Glucose was initially 67 mg/dl and dropped to 46 mg/dl. Total protein was 6 g/dl (6.7-8.2) and albumin was 2.7 g/dl (3.2-5.5). Metabolic panel was otherwise normal. Urinalysis was positive for glucose, ketones, and a small amount of blood and protein. There were no bacteria. Blood and urine cultures were negative. Phenytoin level was undetectable. Urine drug screen was positive for cannabinoids and cocaine.

Hospital Course

Hypoglycemia was treated with an ampule of D50 and intravenous fluids. On the obstetrics ward, nurses observed several episodes of head and eye deviation to the right accompanied by decreased responsiveness that lasted approximately 30 seconds. The patient was sent to the electrophysiology lab where an EEG revealed a diffusely slow background (Figure 1).

Figure 1. Generalized Slowing

During the 20-minute EEG recording, the patient had six clinical seizures similar to those described by the nurses. These events correlated with an ictal pattern consisting of 11 HZ_sharp activity in the right occipital temporal region that spread to the right parietal and left occipital temporal regions (Figure 2). Head CT revealed mild generalized atrophy and an enlarged right occipital horn, but no acute lesions (Figure 3).

Figure 2. Partial seizure originating in right occipital temporal region

Figure 3. Mild generalized arophy, greater in right hemisphere

The patient was transferred to intensive care and received fosphenytoin. No further clinical and /or electrographic seizures were identified. The following day, an EEG revealed diffuse slowing without focal seizures (Figure 4). The patient gradually became more alert and cooperative over the next 24 hours. However, the next day no fetal heartbeat was detected. Labor was induced and a stillborn baby delivered. The pathology report indicated that the placenta was between the 5^th and 10^th percentile for gestational age.

Figure 4. Improved generalized slowing

Discussion

Status epilepticus is associated with significant morbidity and mortality (Claassen et al. 2002). This 37-year-old pregnant woman had an episode of focal status epilepticus with impaired awareness likely provoked by nonadherence to antiepileptic drugs (AEDs). Cocaine may have contributed to the episode of status epilepticus (Majlesi et al. 2010). The obstetric service did not diagnose preeclampsia.

The patient’s seizures started in the right occipital region, which was abnormal on neuroimaging. An MRI might have revealed more subtle structural abnormalities such as cortical dysplasia as the etiology of her epilepsy, but she refused the scan.

Women with epilepsy are at increased risk for adverse pregnancy outcomes such as preeclampsia, preterm labor, and stillbirth and should be considered high risk (MacDonald et al. 2015). Serum levels of AEDs such as lamotrigine, levetiracetam and phenytoin may decrease during pregnancy and contribute to breakthrough seizures. Accordingly, monthly measurements of serum levels of AEDs during the entire course of the pregnancy are strongly recommended. These measurements allow for a timely adjustment of AED doses to prevent significant drop in their serum concentrations and minimize the occurrence of breakthrough seizures. In the case of phenytoin, measurement of free and total serum concentrations are recommended. Supplementation with at least 0.4 mg/day to 1 mg /day of folic acid (and up to 4 mg /day) has been recommended (Harden et al. 2009a). Of note, there is no increase in the incidence of status epilepticus due to pregnancy per se (Harden et al. 2009b).

Although the patient survived this episode of status epilepticus, her fetus did not. Antiseizure drug nonadherence and polysubstance abuse probably contributed to fetal demise.

References

Claassen J, Lokin JK, Fitzsimons BFM et al. Predictors of functional disability and mortality after status epilepticus. Neurology. 2002;58:139-142.

Harden CL, Pennell PB, Koppel BS et al. Practice Parameter update: Management issues for women with epilepsy Focus on pregnancy (an evidence-based review): Vitamin K, folic acid, blood levels, and breastfeeding: Neurology 2009a;73:142-149.

Harden CL, Hopp J, Ting TY et al. Practice Parameter update: Management issues for women with epilepsy-focus on pregnancy (an evidence-based review): Obstetrical complications and change in seizure frequency. Neurology 2009b;50(5):1229-36.

MacDonald SC, Bateman BT, McElrath TF, Hernandez-Diaz S. Mortality and morbidity during delivery hospitalization among pregnant women with epilepsy in the United States. JAMA Neurol. 2015;72(9):981-988.

Majlesi N, Shih R, Fiesseler FW et al. Cocaine-associated seizures and incidence of status epilepticus. Western Journal of Emergency Medicine. 2010;XI(2):157-160.

Andrew N. Wilner, MD, FAAN, FACP

Angels Neurological Centers

Abington, MA

Clinical History

A 37-year-old pregnant African American woman with a history of epilepsy and polysubstance abuse was found unresponsive in a hotel room. She had four convulsions en route to the hospital. In transit, she received levetiracetam and phenytoin, resulting in the cessation of the clinical seizures.

According to her mother, seizures began at age 16 during her first pregnancy, which was complicated by hypertension. She was prescribed medications for hypertension and phenytoin for seizures. The patient provided a different history, claiming that her seizures began 2 years ago. She denied taking medication for seizures or other health problems.

The patient has two children, ages 22 and 11 years. Past medical history is otherwise unremarkable. She has no allergies. Social history includes cigarette smoking, and alcohol and substance abuse. She lives with her boyfriend and does not work. She is 25 weeks pregnant. Family history was notable only for migraine in her mother and grandmother.

Physical Examination    

In the emergency department, blood pressure was 135/65, pulse 121 beats per minute, and oxygen saturation was 97%. She was oriented only to self and did not follow commands. Pupils were equal and reactive. There was no facial asymmetry. She moved all 4 extremities spontaneously. Reflexes were brisk. Oral mucosa was dry. She had no edema in the lower extremities.

Laboratories

Chest x-ray was normal. EKG revealed tachycardia and nonspecific ST changes. Hemoglobin was 11.1 g/dl, hematocrit 32%, white blood cell count 10,900, and platelets 181,000. Electrolytes were normal except for a low sodium of 132 mmol/l (135-145) and bicarbonate of 17 mmol/l (21-31). Glucose was initially 67 mg/dl and dropped to 46 mg/dl. Total protein was 6 g/dl (6.7-8.2) and albumin was 2.7 g/dl (3.2-5.5). Metabolic panel was otherwise normal. Urinalysis was positive for glucose, ketones, and a small amount of blood and protein. There were no bacteria. Blood and urine cultures were negative. Phenytoin level was undetectable. Urine drug screen was positive for cannabinoids and cocaine.

Hospital Course

Hypoglycemia was treated with an ampule of D50 and intravenous fluids. On the obstetrics ward, nurses observed several episodes of head and eye deviation to the right accompanied by decreased responsiveness that lasted approximately 30 seconds. The patient was sent to the electrophysiology lab where an EEG revealed a diffusely slow background (Figure 1).

Figure 1. Generalized Slowing

During the 20-minute EEG recording, the patient had six clinical seizures similar to those described by the nurses. These events correlated with an ictal pattern consisting of 11 HZ_sharp activity in the right occipital temporal region that spread to the right parietal and left occipital temporal regions (Figure 2). Head CT revealed mild generalized atrophy and an enlarged right occipital horn, but no acute lesions (Figure 3).

Figure 2. Partial seizure originating in right occipital temporal region

Figure 3. Mild generalized arophy, greater in right hemisphere

The patient was transferred to intensive care and received fosphenytoin. No further clinical and /or electrographic seizures were identified. The following day, an EEG revealed diffuse slowing without focal seizures (Figure 4). The patient gradually became more alert and cooperative over the next 24 hours. However, the next day no fetal heartbeat was detected. Labor was induced and a stillborn baby delivered. The pathology report indicated that the placenta was between the 5^th and 10^th percentile for gestational age.

Figure 4. Improved generalized slowing

Discussion

Status epilepticus is associated with significant morbidity and mortality (Claassen et al. 2002). This 37-year-old pregnant woman had an episode of focal status epilepticus with impaired awareness likely provoked by nonadherence to antiepileptic drugs (AEDs). Cocaine may have contributed to the episode of status epilepticus (Majlesi et al. 2010). The obstetric service did not diagnose preeclampsia.

The patient’s seizures started in the right occipital region, which was abnormal on neuroimaging. An MRI might have revealed more subtle structural abnormalities such as cortical dysplasia as the etiology of her epilepsy, but she refused the scan.

Women with epilepsy are at increased risk for adverse pregnancy outcomes such as preeclampsia, preterm labor, and stillbirth and should be considered high risk (MacDonald et al. 2015). Serum levels of AEDs such as lamotrigine, levetiracetam and phenytoin may decrease during pregnancy and contribute to breakthrough seizures. Accordingly, monthly measurements of serum levels of AEDs during the entire course of the pregnancy are strongly recommended. These measurements allow for a timely adjustment of AED doses to prevent significant drop in their serum concentrations and minimize the occurrence of breakthrough seizures. In the case of phenytoin, measurement of free and total serum concentrations are recommended. Supplementation with at least 0.4 mg/day to 1 mg /day of folic acid (and up to 4 mg /day) has been recommended (Harden et al. 2009a). Of note, there is no increase in the incidence of status epilepticus due to pregnancy per se (Harden et al. 2009b).

Although the patient survived this episode of status epilepticus, her fetus did not. Antiseizure drug nonadherence and polysubstance abuse probably contributed to fetal demise.

References

Claassen J, Lokin JK, Fitzsimons BFM et al. Predictors of functional disability and mortality after status epilepticus. Neurology. 2002;58:139-142.

Harden CL, Pennell PB, Koppel BS et al. Practice Parameter update: Management issues for women with epilepsy Focus on pregnancy (an evidence-based review): Vitamin K, folic acid, blood levels, and breastfeeding: Neurology 2009a;73:142-149.

Harden CL, Hopp J, Ting TY et al. Practice Parameter update: Management issues for women with epilepsy-focus on pregnancy (an evidence-based review): Obstetrical complications and change in seizure frequency. Neurology 2009b;50(5):1229-36.

MacDonald SC, Bateman BT, McElrath TF, Hernandez-Diaz S. Mortality and morbidity during delivery hospitalization among pregnant women with epilepsy in the United States. JAMA Neurol. 2015;72(9):981-988.

Majlesi N, Shih R, Fiesseler FW et al. Cocaine-associated seizures and incidence of status epilepticus. Western Journal of Emergency Medicine. 2010;XI(2):157-160.

Andrew N. Wilner, MD, FAAN, FACP

Angels Neurological Centers

Abington, MA

Clinical History

A 37-year-old pregnant African American woman with a history of epilepsy and polysubstance abuse was found unresponsive in a hotel room. She had four convulsions en route to the hospital. In transit, she received levetiracetam and phenytoin, resulting in the cessation of the clinical seizures.

According to her mother, seizures began at age 16 during her first pregnancy, which was complicated by hypertension. She was prescribed medications for hypertension and phenytoin for seizures. The patient provided a different history, claiming that her seizures began 2 years ago. She denied taking medication for seizures or other health problems.

The patient has two children, ages 22 and 11 years. Past medical history is otherwise unremarkable. She has no allergies. Social history includes cigarette smoking, and alcohol and substance abuse. She lives with her boyfriend and does not work. She is 25 weeks pregnant. Family history was notable only for migraine in her mother and grandmother.

Physical Examination    

In the emergency department, blood pressure was 135/65, pulse 121 beats per minute, and oxygen saturation was 97%. She was oriented only to self and did not follow commands. Pupils were equal and reactive. There was no facial asymmetry. She moved all 4 extremities spontaneously. Reflexes were brisk. Oral mucosa was dry. She had no edema in the lower extremities.

Laboratories

Chest x-ray was normal. EKG revealed tachycardia and nonspecific ST changes. Hemoglobin was 11.1 g/dl, hematocrit 32%, white blood cell count 10,900, and platelets 181,000. Electrolytes were normal except for a low sodium of 132 mmol/l (135-145) and bicarbonate of 17 mmol/l (21-31). Glucose was initially 67 mg/dl and dropped to 46 mg/dl. Total protein was 6 g/dl (6.7-8.2) and albumin was 2.7 g/dl (3.2-5.5). Metabolic panel was otherwise normal. Urinalysis was positive for glucose, ketones, and a small amount of blood and protein. There were no bacteria. Blood and urine cultures were negative. Phenytoin level was undetectable. Urine drug screen was positive for cannabinoids and cocaine.

Hospital Course

Hypoglycemia was treated with an ampule of D50 and intravenous fluids. On the obstetrics ward, nurses observed several episodes of head and eye deviation to the right accompanied by decreased responsiveness that lasted approximately 30 seconds. The patient was sent to the electrophysiology lab where an EEG revealed a diffusely slow background (Figure 1).

Figure 1. Generalized Slowing

During the 20-minute EEG recording, the patient had six clinical seizures similar to those described by the nurses. These events correlated with an ictal pattern consisting of 11 HZ_sharp activity in the right occipital temporal region that spread to the right parietal and left occipital temporal regions (Figure 2). Head CT revealed mild generalized atrophy and an enlarged right occipital horn, but no acute lesions (Figure 3).

Figure 2. Partial seizure originating in right occipital temporal region

Figure 3. Mild generalized arophy, greater in right hemisphere

The patient was transferred to intensive care and received fosphenytoin. No further clinical and /or electrographic seizures were identified. The following day, an EEG revealed diffuse slowing without focal seizures (Figure 4). The patient gradually became more alert and cooperative over the next 24 hours. However, the next day no fetal heartbeat was detected. Labor was induced and a stillborn baby delivered. The pathology report indicated that the placenta was between the 5^th and 10^th percentile for gestational age.

Figure 4. Improved generalized slowing

Discussion

Status epilepticus is associated with significant morbidity and mortality (Claassen et al. 2002). This 37-year-old pregnant woman had an episode of focal status epilepticus with impaired awareness likely provoked by nonadherence to antiepileptic drugs (AEDs). Cocaine may have contributed to the episode of status epilepticus (Majlesi et al. 2010). The obstetric service did not diagnose preeclampsia.

The patient’s seizures started in the right occipital region, which was abnormal on neuroimaging. An MRI might have revealed more subtle structural abnormalities such as cortical dysplasia as the etiology of her epilepsy, but she refused the scan.

Women with epilepsy are at increased risk for adverse pregnancy outcomes such as preeclampsia, preterm labor, and stillbirth and should be considered high risk (MacDonald et al. 2015). Serum levels of AEDs such as lamotrigine, levetiracetam and phenytoin may decrease during pregnancy and contribute to breakthrough seizures. Accordingly, monthly measurements of serum levels of AEDs during the entire course of the pregnancy are strongly recommended. These measurements allow for a timely adjustment of AED doses to prevent significant drop in their serum concentrations and minimize the occurrence of breakthrough seizures. In the case of phenytoin, measurement of free and total serum concentrations are recommended. Supplementation with at least 0.4 mg/day to 1 mg /day of folic acid (and up to 4 mg /day) has been recommended (Harden et al. 2009a). Of note, there is no increase in the incidence of status epilepticus due to pregnancy per se (Harden et al. 2009b).

Although the patient survived this episode of status epilepticus, her fetus did not. Antiseizure drug nonadherence and polysubstance abuse probably contributed to fetal demise.

References

Claassen J, Lokin JK, Fitzsimons BFM et al. Predictors of functional disability and mortality after status epilepticus. Neurology. 2002;58:139-142.

Harden CL, Pennell PB, Koppel BS et al. Practice Parameter update: Management issues for women with epilepsy Focus on pregnancy (an evidence-based review): Vitamin K, folic acid, blood levels, and breastfeeding: Neurology 2009a;73:142-149.

Harden CL, Hopp J, Ting TY et al. Practice Parameter update: Management issues for women with epilepsy-focus on pregnancy (an evidence-based review): Obstetrical complications and change in seizure frequency. Neurology 2009b;50(5):1229-36.

MacDonald SC, Bateman BT, McElrath TF, Hernandez-Diaz S. Mortality and morbidity during delivery hospitalization among pregnant women with epilepsy in the United States. JAMA Neurol. 2015;72(9):981-988.

Majlesi N, Shih R, Fiesseler FW et al. Cocaine-associated seizures and incidence of status epilepticus. Western Journal of Emergency Medicine. 2010;XI(2):157-160.

Any economist could have predicted it: As the price of electronic cigarettes goes down, sales increase.

Price decreases for the three products available in 2012 were all significant: The average price per unit was down 48% for rechargeables by 2016, 14% for disposables, and 12% for prefilled cartridges. E-liquids were 9% cheaper by 2016, but that change did not reach significance, they noted.

“Overall, the increase in e-cigarette sales and decrease in price is consistent with previous studies demonstrating that e-cigarette sales are responsive to their own price changes. These trends suggest that, if e-cigarette prices continue to decrease, their sales may also continue to rise,” Dr. Wang and her associates wrote.

The data for the study came from the Nielsen Company and were based on retail sales at convenience stores; supermarkets; drug, dollar, and club stores; and military commissaries in the 48 contiguous states and Washington, D.C. One study limitation was the lack of data from tobacco/vape shops and the Internet.

[email protected]

SOURCE: Wang TW et al. Prev Chronic Dis. 2018;15:170555. doi: 10.5888/pcd15.170555.

Any economist could have predicted it: As the price of electronic cigarettes goes down, sales increase.

Price decreases for the three products available in 2012 were all significant: The average price per unit was down 48% for rechargeables by 2016, 14% for disposables, and 12% for prefilled cartridges. E-liquids were 9% cheaper by 2016, but that change did not reach significance, they noted.

“Overall, the increase in e-cigarette sales and decrease in price is consistent with previous studies demonstrating that e-cigarette sales are responsive to their own price changes. These trends suggest that, if e-cigarette prices continue to decrease, their sales may also continue to rise,” Dr. Wang and her associates wrote.

The data for the study came from the Nielsen Company and were based on retail sales at convenience stores; supermarkets; drug, dollar, and club stores; and military commissaries in the 48 contiguous states and Washington, D.C. One study limitation was the lack of data from tobacco/vape shops and the Internet.

[email protected]

SOURCE: Wang TW et al. Prev Chronic Dis. 2018;15:170555. doi: 10.5888/pcd15.170555.

Any economist could have predicted it: As the price of electronic cigarettes goes down, sales increase.

Price decreases for the three products available in 2012 were all significant: The average price per unit was down 48% for rechargeables by 2016, 14% for disposables, and 12% for prefilled cartridges. E-liquids were 9% cheaper by 2016, but that change did not reach significance, they noted.

“Overall, the increase in e-cigarette sales and decrease in price is consistent with previous studies demonstrating that e-cigarette sales are responsive to their own price changes. These trends suggest that, if e-cigarette prices continue to decrease, their sales may also continue to rise,” Dr. Wang and her associates wrote.

The data for the study came from the Nielsen Company and were based on retail sales at convenience stores; supermarkets; drug, dollar, and club stores; and military commissaries in the 48 contiguous states and Washington, D.C. One study limitation was the lack of data from tobacco/vape shops and the Internet.

[email protected]

SOURCE: Wang TW et al. Prev Chronic Dis. 2018;15:170555. doi: 10.5888/pcd15.170555.

Case Report

A 31-year-old man presented to the dermatology clinic 1 day after mountain biking in the woods in Hartford County, Connecticut. He stated that he found a tick attached to his shirt after riding (Figure). Careful examination of the patient showed no signs of a bite reaction. The insect was identified via microscopy as the deer ked Lipoptena cervi.

Comment

Lipoptena cervi, known as the deer ked, is an ectoparasite of cervids traditionally found in Norway, Sweden, and Finland.¹ The deer ked was first reported in American deer in 2 independent sightings in Pennsylvania and New Hampshire in 1907.² More recently deer keds have been reported in Massachusetts, New York, Pennsylvania, and New Hampshire.³ In the United States, L cervi is thought to be an invasive species transported from Europe in the 1800s.^4,5 The main host is thought to be the white-tailed deer (Odocoileus viginianus). Once a suitable host is found, the deer ked sheds its wings and crawls into the fur. After engorging on a blood meal, it deposits prepupae that fall from the host and mature into winged adults during the late summer into the autumn. Adults may exhibit swarming behavior, and it is during this host-seeking activity that they land on humans.³

Following the bite of a deer ked, there are reports of long-lasting dermatitis in both humans and dogs.^1,4,6 One case series involving 19 patients following deer ked bites reported pruritic bite papules.⁴ The reaction appeared to be treatment resistant and lasted from 2 weeks to 12 months. Histologic examination was typical for arthropod assault. Of 11 papules that were biopsied, most (7/11) showed C3 deposition in dermal vessel walls under direct immunofluorescence. Of 19 patients, 57% had elevated serum IgE levels.⁴

In addition to the associated dermatologic findings, the deer ked is a vector of various infectious agents. Bartonella schoenbuchensis has been isolated from deer ked in Massachusettes.⁷ A recent study found a 75% prevalence of Bartonella species in 217 deer keds collected from red deer in Poland.⁵ The first incidence of Borrelia burgdorferi and Anaplasma phagocytophylum in deer keds was reported in the United States in 2016. Of 48 adult deer keds collected from an unknown number of deer, 19 (40%), 14 (29%), and 3 (6%) were positive for B burgdorferi, A phagocytophylum, and both on polymerase chain reaction, respectively.³

A recent study from Europe showed deer keds are now more frequently found in regions where they had not previously been observed.⁸ It stands to reason that with climate change, L cervi and other disease-carrying vectors are likely to migrate to and inhabit new regions of the country. Even in the current climate, there are more disease-carrying arthropods than are routinely studied in medicine, and all patients who experience an arthropod assault should be monitored for signs of systemic disease.

Case Report

A 31-year-old man presented to the dermatology clinic 1 day after mountain biking in the woods in Hartford County, Connecticut. He stated that he found a tick attached to his shirt after riding (Figure). Careful examination of the patient showed no signs of a bite reaction. The insect was identified via microscopy as the deer ked Lipoptena cervi.

Comment

Lipoptena cervi, known as the deer ked, is an ectoparasite of cervids traditionally found in Norway, Sweden, and Finland.¹ The deer ked was first reported in American deer in 2 independent sightings in Pennsylvania and New Hampshire in 1907.² More recently deer keds have been reported in Massachusetts, New York, Pennsylvania, and New Hampshire.³ In the United States, L cervi is thought to be an invasive species transported from Europe in the 1800s.^4,5 The main host is thought to be the white-tailed deer (Odocoileus viginianus). Once a suitable host is found, the deer ked sheds its wings and crawls into the fur. After engorging on a blood meal, it deposits prepupae that fall from the host and mature into winged adults during the late summer into the autumn. Adults may exhibit swarming behavior, and it is during this host-seeking activity that they land on humans.³

Following the bite of a deer ked, there are reports of long-lasting dermatitis in both humans and dogs.^1,4,6 One case series involving 19 patients following deer ked bites reported pruritic bite papules.⁴ The reaction appeared to be treatment resistant and lasted from 2 weeks to 12 months. Histologic examination was typical for arthropod assault. Of 11 papules that were biopsied, most (7/11) showed C3 deposition in dermal vessel walls under direct immunofluorescence. Of 19 patients, 57% had elevated serum IgE levels.⁴

In addition to the associated dermatologic findings, the deer ked is a vector of various infectious agents. Bartonella schoenbuchensis has been isolated from deer ked in Massachusettes.⁷ A recent study found a 75% prevalence of Bartonella species in 217 deer keds collected from red deer in Poland.⁵ The first incidence of Borrelia burgdorferi and Anaplasma phagocytophylum in deer keds was reported in the United States in 2016. Of 48 adult deer keds collected from an unknown number of deer, 19 (40%), 14 (29%), and 3 (6%) were positive for B burgdorferi, A phagocytophylum, and both on polymerase chain reaction, respectively.³

A recent study from Europe showed deer keds are now more frequently found in regions where they had not previously been observed.⁸ It stands to reason that with climate change, L cervi and other disease-carrying vectors are likely to migrate to and inhabit new regions of the country. Even in the current climate, there are more disease-carrying arthropods than are routinely studied in medicine, and all patients who experience an arthropod assault should be monitored for signs of systemic disease.

Case Report

A 31-year-old man presented to the dermatology clinic 1 day after mountain biking in the woods in Hartford County, Connecticut. He stated that he found a tick attached to his shirt after riding (Figure). Careful examination of the patient showed no signs of a bite reaction. The insect was identified via microscopy as the deer ked Lipoptena cervi.

Comment

Lipoptena cervi, known as the deer ked, is an ectoparasite of cervids traditionally found in Norway, Sweden, and Finland.¹ The deer ked was first reported in American deer in 2 independent sightings in Pennsylvania and New Hampshire in 1907.² More recently deer keds have been reported in Massachusetts, New York, Pennsylvania, and New Hampshire.³ In the United States, L cervi is thought to be an invasive species transported from Europe in the 1800s.^4,5 The main host is thought to be the white-tailed deer (Odocoileus viginianus). Once a suitable host is found, the deer ked sheds its wings and crawls into the fur. After engorging on a blood meal, it deposits prepupae that fall from the host and mature into winged adults during the late summer into the autumn. Adults may exhibit swarming behavior, and it is during this host-seeking activity that they land on humans.³

Following the bite of a deer ked, there are reports of long-lasting dermatitis in both humans and dogs.^1,4,6 One case series involving 19 patients following deer ked bites reported pruritic bite papules.⁴ The reaction appeared to be treatment resistant and lasted from 2 weeks to 12 months. Histologic examination was typical for arthropod assault. Of 11 papules that were biopsied, most (7/11) showed C3 deposition in dermal vessel walls under direct immunofluorescence. Of 19 patients, 57% had elevated serum IgE levels.⁴

In addition to the associated dermatologic findings, the deer ked is a vector of various infectious agents. Bartonella schoenbuchensis has been isolated from deer ked in Massachusettes.⁷ A recent study found a 75% prevalence of Bartonella species in 217 deer keds collected from red deer in Poland.⁵ The first incidence of Borrelia burgdorferi and Anaplasma phagocytophylum in deer keds was reported in the United States in 2016. Of 48 adult deer keds collected from an unknown number of deer, 19 (40%), 14 (29%), and 3 (6%) were positive for B burgdorferi, A phagocytophylum, and both on polymerase chain reaction, respectively.³

A recent study from Europe showed deer keds are now more frequently found in regions where they had not previously been observed.⁸ It stands to reason that with climate change, L cervi and other disease-carrying vectors are likely to migrate to and inhabit new regions of the country. Even in the current climate, there are more disease-carrying arthropods than are routinely studied in medicine, and all patients who experience an arthropod assault should be monitored for signs of systemic disease.

Women in the United States do not appear to be delaying pregnancy after a diagnosis of melanoma, despite general recommendations to wait at least 2 years to attempt pregnancy because it might increase the risk of recurrence or exacerbate disease, investigators reported in the Journal of Surgical Research.

A review of records from a large national health care database showed that women aged 18-40 years with melanoma who were not pregnant on the index date had a significantly higher rate of pregnancy within 2 years, compared with matched controls, reported Julie A. DiSano, MD, from Penn State University, Hershey.

“These results suggest that a diagnosis of melanoma may serve as an impetus for some families to begin childbearing or have additional children sooner than they otherwise would have,” they wrote.

The investigators also found, reassuringly, that women who became pregnant after a melanoma diagnosis were not at increased risk for requiring additional therapy for the malignancy, at least in the short term.

Although earlier studies suggested that women who were pregnant at the time of a melanoma diagnosis had worse prognoses when compared with women who were not pregnant at the time of diagnosis, more recent studies have indicated women who are pregnant when diagnosed have similar outcomes as nonpregnant women with the same disease stage, the investigators noted.

“What is unclear and difficult to study is the relationship between melanoma and subsequent pregnancy rates, and pregnancy on melanoma outcomes. Very little data exist to guide women and physicians as to the safety of pregnancy after a diagnosis of melanoma. As a result, there are no formal guidelines for physicians who wish to counsel their patients regarding pregnancy after melanoma, and it is unknown whether women receive any counseling at all,” they wrote.

To get a clearer picture of the link between melanoma and subsequent pregnancy, the investigators scanned the Truven Health MarketScan database and identified 11,801 women from 18-40 years with melanoma who were not pregnant on the index date, determined by the earliest claim for melanoma diagnosis or therapy.

Each patient was matched on a 1:1 basis with women who did not have a melanoma claim at any time; cases were matched with controls on the basis of year of index date, age at index date, state of residence, and pregnancy status in the 90 days before the index date.

The authors found that the rate of pregnancy within 2 years of the index date was 15.8% for cases, compared with 13.6% for controls (P less than .001).

They also found, however, that women who required postsurgical therapy, suggesting more advanced disease stage or early recurrence, had a significantly lower probability of becoming pregnant within the first 9 months after the index date (hazard ratio, 0.26; P = .003).

There were no significant differences in the rate of postsurgical treatment by pregnancy status at either 3, 6, 9, or 12 months after surgery (P less than .05 for each), or in a Cox regression model for all time points (HR, 0.68, P = .23).

SOURCE: DiSano JA et al. J Surg Res. 2018 Jun 16. doi: 10.1016/j.jss.2018.05.026.
 

Women in the United States do not appear to be delaying pregnancy after a diagnosis of melanoma, despite general recommendations to wait at least 2 years to attempt pregnancy because it might increase the risk of recurrence or exacerbate disease, investigators reported in the Journal of Surgical Research.

A review of records from a large national health care database showed that women aged 18-40 years with melanoma who were not pregnant on the index date had a significantly higher rate of pregnancy within 2 years, compared with matched controls, reported Julie A. DiSano, MD, from Penn State University, Hershey.

“These results suggest that a diagnosis of melanoma may serve as an impetus for some families to begin childbearing or have additional children sooner than they otherwise would have,” they wrote.

The investigators also found, reassuringly, that women who became pregnant after a melanoma diagnosis were not at increased risk for requiring additional therapy for the malignancy, at least in the short term.

Although earlier studies suggested that women who were pregnant at the time of a melanoma diagnosis had worse prognoses when compared with women who were not pregnant at the time of diagnosis, more recent studies have indicated women who are pregnant when diagnosed have similar outcomes as nonpregnant women with the same disease stage, the investigators noted.

“What is unclear and difficult to study is the relationship between melanoma and subsequent pregnancy rates, and pregnancy on melanoma outcomes. Very little data exist to guide women and physicians as to the safety of pregnancy after a diagnosis of melanoma. As a result, there are no formal guidelines for physicians who wish to counsel their patients regarding pregnancy after melanoma, and it is unknown whether women receive any counseling at all,” they wrote.

To get a clearer picture of the link between melanoma and subsequent pregnancy, the investigators scanned the Truven Health MarketScan database and identified 11,801 women from 18-40 years with melanoma who were not pregnant on the index date, determined by the earliest claim for melanoma diagnosis or therapy.

Each patient was matched on a 1:1 basis with women who did not have a melanoma claim at any time; cases were matched with controls on the basis of year of index date, age at index date, state of residence, and pregnancy status in the 90 days before the index date.

The authors found that the rate of pregnancy within 2 years of the index date was 15.8% for cases, compared with 13.6% for controls (P less than .001).

They also found, however, that women who required postsurgical therapy, suggesting more advanced disease stage or early recurrence, had a significantly lower probability of becoming pregnant within the first 9 months after the index date (hazard ratio, 0.26; P = .003).

There were no significant differences in the rate of postsurgical treatment by pregnancy status at either 3, 6, 9, or 12 months after surgery (P less than .05 for each), or in a Cox regression model for all time points (HR, 0.68, P = .23).

SOURCE: DiSano JA et al. J Surg Res. 2018 Jun 16. doi: 10.1016/j.jss.2018.05.026.
 

Women in the United States do not appear to be delaying pregnancy after a diagnosis of melanoma, despite general recommendations to wait at least 2 years to attempt pregnancy because it might increase the risk of recurrence or exacerbate disease, investigators reported in the Journal of Surgical Research.

A review of records from a large national health care database showed that women aged 18-40 years with melanoma who were not pregnant on the index date had a significantly higher rate of pregnancy within 2 years, compared with matched controls, reported Julie A. DiSano, MD, from Penn State University, Hershey.

“These results suggest that a diagnosis of melanoma may serve as an impetus for some families to begin childbearing or have additional children sooner than they otherwise would have,” they wrote.

The investigators also found, reassuringly, that women who became pregnant after a melanoma diagnosis were not at increased risk for requiring additional therapy for the malignancy, at least in the short term.

Although earlier studies suggested that women who were pregnant at the time of a melanoma diagnosis had worse prognoses when compared with women who were not pregnant at the time of diagnosis, more recent studies have indicated women who are pregnant when diagnosed have similar outcomes as nonpregnant women with the same disease stage, the investigators noted.

“What is unclear and difficult to study is the relationship between melanoma and subsequent pregnancy rates, and pregnancy on melanoma outcomes. Very little data exist to guide women and physicians as to the safety of pregnancy after a diagnosis of melanoma. As a result, there are no formal guidelines for physicians who wish to counsel their patients regarding pregnancy after melanoma, and it is unknown whether women receive any counseling at all,” they wrote.

To get a clearer picture of the link between melanoma and subsequent pregnancy, the investigators scanned the Truven Health MarketScan database and identified 11,801 women from 18-40 years with melanoma who were not pregnant on the index date, determined by the earliest claim for melanoma diagnosis or therapy.

Each patient was matched on a 1:1 basis with women who did not have a melanoma claim at any time; cases were matched with controls on the basis of year of index date, age at index date, state of residence, and pregnancy status in the 90 days before the index date.

The authors found that the rate of pregnancy within 2 years of the index date was 15.8% for cases, compared with 13.6% for controls (P less than .001).

They also found, however, that women who required postsurgical therapy, suggesting more advanced disease stage or early recurrence, had a significantly lower probability of becoming pregnant within the first 9 months after the index date (hazard ratio, 0.26; P = .003).

There were no significant differences in the rate of postsurgical treatment by pregnancy status at either 3, 6, 9, or 12 months after surgery (P less than .05 for each), or in a Cox regression model for all time points (HR, 0.68, P = .23).

SOURCE: DiSano JA et al. J Surg Res. 2018 Jun 16. doi: 10.1016/j.jss.2018.05.026.
 

SAN FRANCISCO—Chronic migraine is associated with increased age-related cortical thinning of some brain areas and decreased age-related cortical thinning in other areas, according to research presented at the 60th Annual Scientific Meeting of the American Headache Society. It remains uncertain whether these cortical changes are a cause or an effect of chronic migraine.

Age-related cortical integrity had not been explored in chronic migraine previously. To investigate this topic, Yohannes Woubishet Woldeamanuel, MD, Instructor in Neurology and Neurologic Sciences at Stanford University in California, and colleagues enrolled 30 patients with chronic migraine and 30 age- and sex-matched healthy controls into a study. All participants were right-handed. The mean age in the chronic migraine group was 40.5, and the male-to-female ratio was 1:4. Investigators obtained the duration of chronic migraine and lifetime migraine from participants with chronic migraine.

Suggested Reading

Chong CD, Dodick DW, Schlaggar BL, Schwedt TJ. Atypical age-related cortical thinning in episodic migraine. Cephalalgia. 2014;34(14):1115-1124.

Schwedt TJ, Berisha V, Chong CD. Temporal lobe cortical thickness correlations differentiate the migraine brain from the healthy brain. PLoS One. 2015 Feb 13;10(2):e0116687.

SAN FRANCISCO—Chronic migraine is associated with increased age-related cortical thinning of some brain areas and decreased age-related cortical thinning in other areas, according to research presented at the 60th Annual Scientific Meeting of the American Headache Society. It remains uncertain whether these cortical changes are a cause or an effect of chronic migraine.

Age-related cortical integrity had not been explored in chronic migraine previously. To investigate this topic, Yohannes Woubishet Woldeamanuel, MD, Instructor in Neurology and Neurologic Sciences at Stanford University in California, and colleagues enrolled 30 patients with chronic migraine and 30 age- and sex-matched healthy controls into a study. All participants were right-handed. The mean age in the chronic migraine group was 40.5, and the male-to-female ratio was 1:4. Investigators obtained the duration of chronic migraine and lifetime migraine from participants with chronic migraine.

Suggested Reading

Chong CD, Dodick DW, Schlaggar BL, Schwedt TJ. Atypical age-related cortical thinning in episodic migraine. Cephalalgia. 2014;34(14):1115-1124.

Schwedt TJ, Berisha V, Chong CD. Temporal lobe cortical thickness correlations differentiate the migraine brain from the healthy brain. PLoS One. 2015 Feb 13;10(2):e0116687.

SAN FRANCISCO—Chronic migraine is associated with increased age-related cortical thinning of some brain areas and decreased age-related cortical thinning in other areas, according to research presented at the 60th Annual Scientific Meeting of the American Headache Society. It remains uncertain whether these cortical changes are a cause or an effect of chronic migraine.

Age-related cortical integrity had not been explored in chronic migraine previously. To investigate this topic, Yohannes Woubishet Woldeamanuel, MD, Instructor in Neurology and Neurologic Sciences at Stanford University in California, and colleagues enrolled 30 patients with chronic migraine and 30 age- and sex-matched healthy controls into a study. All participants were right-handed. The mean age in the chronic migraine group was 40.5, and the male-to-female ratio was 1:4. Investigators obtained the duration of chronic migraine and lifetime migraine from participants with chronic migraine.

Suggested Reading

Chong CD, Dodick DW, Schlaggar BL, Schwedt TJ. Atypical age-related cortical thinning in episodic migraine. Cephalalgia. 2014;34(14):1115-1124.

Schwedt TJ, Berisha V, Chong CD. Temporal lobe cortical thickness correlations differentiate the migraine brain from the healthy brain. PLoS One. 2015 Feb 13;10(2):e0116687.

An allergic reaction is an exaggerated immune response that is known as a type I or immediate hypersensitivity reaction when provoked by reexposure to an allergen or antigen. Upon initial exposure to the antigen, dendritic cells bind it for presentation to helper T (T_H2) lymphocytes. The T_H2 cells then interact with B cells, stimulating them to become plasma cells and produce IgE antibodies to the antigen. When exposed to the same allergen a second time, IgE antibodies bind the allergen and cross-link on mast cells and basophils in the blood. Cross-linking stimulates degranulation of the cells, releasing histamine, leukotrienes, prostaglandins, and other cytokines. The major effects of the release of these mediators include vasodilation, increased vascular permeability, and bronchoconstriction. Leukotrienes also are responsible for chemotaxis of white blood cells, further propagating the immune response.¹

Effects of a type I hypersensitivity reaction can be either local or systemic, resulting in symptoms ranging from mild irritation to anaphylactic shock and death. Latex allergy is a common example of a type I hypersensitivity reaction. Latex is found in many medical products, including gloves, rubber, elastics, blood pressure cuffs, bandages, dressings, and syringes. Reactions can include runny nose, tearing eyes, itching, hives, wheals, wheezing, and in rare cases anaphylaxis.² Diagnosis can be suspected based on history and physical examination. Screening is performed with radioallergosorbent testing, which identifies specific IgE antibodies to latex; however, the reported sensitivity and specificity for the latex-specific IgE antibody varies widely in the literature, and the test cannot reliably rule in or rule out a true latex allergy.³

Allergic responses to latex in psoriasis patients receiving frequent injections with biologic agents are not commonly reported in the literature. We report the case of a patient with a long history of psoriasis who developed an allergic response after exposure to injection devices that contained latex components while undergoing treatment with biologic agents.

Case Report

A 72-year-old man presented with an extensive history of severe psoriasis with frequent flares. Treatment with topical agents and etanercept 6 months prior at an outside facility failed. At the time of presentation, the patient had more than 10% body surface area (BSA) involvement, which included the scalp, legs, chest, and back. He subsequently was started on ustekinumab injections. He initially responded well to therapy, but after 8 months of treatment, he began to have recurrent episodes of acute eruptive rashes over the trunk with associated severe pruritus that reproducibly recurred within 24 hours after each ustekinumab injection. It was decided to discontinue ustekinumab due to concern for intolerance, and the patient was switched to secukinumab. 

After starting secukinumab, the patient's BSA involvement was reduced to 2% after 1 month; however, he began to develop an eruptive rash with severe pruritus again that reproducibly recurred after each secukinumab injection. On physical examination the patient had ill-defined, confluent, erythematous patches over much of the trunk and extremities. Punch biopsies of the eruptive dermatitis showed spongiform psoriasis and eosinophils with dermal hypersensitivity, consistent with a drug eruption. Upon further questioning, the patient noted that he had a long history of a strong latex allergy and he would develop a blistering dermatitis when coming into contact with latex, which caused a high suspicion for a latex allergy as the cause of the patient's acute dermatitis flares from his prior ustekinumab and secukinumab injections. Although it was confirmed with the manufacturers that both the ustekinumab syringe and secukinumab pen did not contain latex, the caps of these medications (and many other biologic injections) do have latex (Table). Other differential diagnoses included an atypical paradoxical   psoriasis flare and a drug eruption to secukinumab, which previously has been reported.⁴

Based on the suspected cause of the eruption, the patient was instructed not to touch the cap of the secukinumab pen. Despite this recommendation, the rash was still present at the next appointment 1 month later. Repeat punch biopsy showed similar findings to the one prior with likely dermal hypersensitivity. The rash improved with steroid injections and continued to improve after holding the secukinumab for 1 month.

After resolution of the hypersensitivity reaction, the patient was started on ixekizumab, which does not contain latex in any component according to the manufacturer. After 2 months of treatment, the patient had 2% BSA involvement of psoriasis and has had no further reports of itching, rash, or other symptoms of a hypersensitivity reaction. On follow-up, the patient's psoriasis symptoms continue to be controlled without further reactions after injections of ixekizumab. Radioallergosorbent testing was not performed due to the lack of specificity and sensitivity of the test3 as well as the patient's known history of latex allergy and characteristic dermatitis that developed after exposure to latex and resolution with removal of the agent. These clinical manifestations are highly indicative of a type I hypersensitivity to injection devices that contain latex components during biologic therapy.

Comment

Allergic responses to latex are most commonly seen in those exposed to gloves or rubber, but little has been reported on reactions to injections with pens or syringes that contain latex components. Some case reports have demonstrated allergic responses in diabetic patients receiving insulin injections.^5,6 MacCracken et al⁵ reported the case of a young boy who had an allergic response to an insulin injection with a syringe containing latex. The patient had a history of bladder exstrophy with a recent diagnosis of diabetes mellitus. It is well known that patients with spina bifida and other conditions who undergo frequent urological procedures more commonly develop latex allergies. This patient reported a history of swollen lips after a dentist visit, presumably due to contact with latex gloves. Because of the suspected allergy, his first insulin injection was given using a glass syringe and insulin was withdrawn with the top removed due to the top containing latex. He did not experience any complications. After being injected later with insulin drawn through the top using a syringe that contained latex, he developed a flare-up of a 0.5-cm erythematous wheal within minutes with associated pruritus.⁵

Towse et al⁶ described another patient with diabetes who developed a local allergic reaction at the site of insulin injections. Workup by the physician ruled out insulin allergy but showed elevated latex-specific IgE antibodies. Future insulin draws through a latex-containing top produced a wheal at the injection site. After switching to latex-free syringes, the allergic reaction resolved.⁶

Latex allergies are common in medical practice, as latex is found in a wide variety of medical supplies, including syringes used for injections and their caps. Physicians need to be aware of latex allergies in their patients and exercise extreme caution in the use of latex-containing products. In the treatment of psoriasis, care must be given when injecting biologic agents. Although many injection devices contain latex limited to the cap, it may be enough to invoke an allergic response. If such a response is elicited, therapy with injection devices that do not contain latex in either the cap or syringe should be considered.

An allergic reaction is an exaggerated immune response that is known as a type I or immediate hypersensitivity reaction when provoked by reexposure to an allergen or antigen. Upon initial exposure to the antigen, dendritic cells bind it for presentation to helper T (T_H2) lymphocytes. The T_H2 cells then interact with B cells, stimulating them to become plasma cells and produce IgE antibodies to the antigen. When exposed to the same allergen a second time, IgE antibodies bind the allergen and cross-link on mast cells and basophils in the blood. Cross-linking stimulates degranulation of the cells, releasing histamine, leukotrienes, prostaglandins, and other cytokines. The major effects of the release of these mediators include vasodilation, increased vascular permeability, and bronchoconstriction. Leukotrienes also are responsible for chemotaxis of white blood cells, further propagating the immune response.¹

Effects of a type I hypersensitivity reaction can be either local or systemic, resulting in symptoms ranging from mild irritation to anaphylactic shock and death. Latex allergy is a common example of a type I hypersensitivity reaction. Latex is found in many medical products, including gloves, rubber, elastics, blood pressure cuffs, bandages, dressings, and syringes. Reactions can include runny nose, tearing eyes, itching, hives, wheals, wheezing, and in rare cases anaphylaxis.² Diagnosis can be suspected based on history and physical examination. Screening is performed with radioallergosorbent testing, which identifies specific IgE antibodies to latex; however, the reported sensitivity and specificity for the latex-specific IgE antibody varies widely in the literature, and the test cannot reliably rule in or rule out a true latex allergy.³

Allergic responses to latex in psoriasis patients receiving frequent injections with biologic agents are not commonly reported in the literature. We report the case of a patient with a long history of psoriasis who developed an allergic response after exposure to injection devices that contained latex components while undergoing treatment with biologic agents.

Case Report

A 72-year-old man presented with an extensive history of severe psoriasis with frequent flares. Treatment with topical agents and etanercept 6 months prior at an outside facility failed. At the time of presentation, the patient had more than 10% body surface area (BSA) involvement, which included the scalp, legs, chest, and back. He subsequently was started on ustekinumab injections. He initially responded well to therapy, but after 8 months of treatment, he began to have recurrent episodes of acute eruptive rashes over the trunk with associated severe pruritus that reproducibly recurred within 24 hours after each ustekinumab injection. It was decided to discontinue ustekinumab due to concern for intolerance, and the patient was switched to secukinumab. 

After starting secukinumab, the patient's BSA involvement was reduced to 2% after 1 month; however, he began to develop an eruptive rash with severe pruritus again that reproducibly recurred after each secukinumab injection. On physical examination the patient had ill-defined, confluent, erythematous patches over much of the trunk and extremities. Punch biopsies of the eruptive dermatitis showed spongiform psoriasis and eosinophils with dermal hypersensitivity, consistent with a drug eruption. Upon further questioning, the patient noted that he had a long history of a strong latex allergy and he would develop a blistering dermatitis when coming into contact with latex, which caused a high suspicion for a latex allergy as the cause of the patient's acute dermatitis flares from his prior ustekinumab and secukinumab injections. Although it was confirmed with the manufacturers that both the ustekinumab syringe and secukinumab pen did not contain latex, the caps of these medications (and many other biologic injections) do have latex (Table). Other differential diagnoses included an atypical paradoxical   psoriasis flare and a drug eruption to secukinumab, which previously has been reported.⁴

Based on the suspected cause of the eruption, the patient was instructed not to touch the cap of the secukinumab pen. Despite this recommendation, the rash was still present at the next appointment 1 month later. Repeat punch biopsy showed similar findings to the one prior with likely dermal hypersensitivity. The rash improved with steroid injections and continued to improve after holding the secukinumab for 1 month.

After resolution of the hypersensitivity reaction, the patient was started on ixekizumab, which does not contain latex in any component according to the manufacturer. After 2 months of treatment, the patient had 2% BSA involvement of psoriasis and has had no further reports of itching, rash, or other symptoms of a hypersensitivity reaction. On follow-up, the patient's psoriasis symptoms continue to be controlled without further reactions after injections of ixekizumab. Radioallergosorbent testing was not performed due to the lack of specificity and sensitivity of the test3 as well as the patient's known history of latex allergy and characteristic dermatitis that developed after exposure to latex and resolution with removal of the agent. These clinical manifestations are highly indicative of a type I hypersensitivity to injection devices that contain latex components during biologic therapy.

Comment

Allergic responses to latex are most commonly seen in those exposed to gloves or rubber, but little has been reported on reactions to injections with pens or syringes that contain latex components. Some case reports have demonstrated allergic responses in diabetic patients receiving insulin injections.^5,6 MacCracken et al⁵ reported the case of a young boy who had an allergic response to an insulin injection with a syringe containing latex. The patient had a history of bladder exstrophy with a recent diagnosis of diabetes mellitus. It is well known that patients with spina bifida and other conditions who undergo frequent urological procedures more commonly develop latex allergies. This patient reported a history of swollen lips after a dentist visit, presumably due to contact with latex gloves. Because of the suspected allergy, his first insulin injection was given using a glass syringe and insulin was withdrawn with the top removed due to the top containing latex. He did not experience any complications. After being injected later with insulin drawn through the top using a syringe that contained latex, he developed a flare-up of a 0.5-cm erythematous wheal within minutes with associated pruritus.⁵

Towse et al⁶ described another patient with diabetes who developed a local allergic reaction at the site of insulin injections. Workup by the physician ruled out insulin allergy but showed elevated latex-specific IgE antibodies. Future insulin draws through a latex-containing top produced a wheal at the injection site. After switching to latex-free syringes, the allergic reaction resolved.⁶

Latex allergies are common in medical practice, as latex is found in a wide variety of medical supplies, including syringes used for injections and their caps. Physicians need to be aware of latex allergies in their patients and exercise extreme caution in the use of latex-containing products. In the treatment of psoriasis, care must be given when injecting biologic agents. Although many injection devices contain latex limited to the cap, it may be enough to invoke an allergic response. If such a response is elicited, therapy with injection devices that do not contain latex in either the cap or syringe should be considered.

An allergic reaction is an exaggerated immune response that is known as a type I or immediate hypersensitivity reaction when provoked by reexposure to an allergen or antigen. Upon initial exposure to the antigen, dendritic cells bind it for presentation to helper T (T_H2) lymphocytes. The T_H2 cells then interact with B cells, stimulating them to become plasma cells and produce IgE antibodies to the antigen. When exposed to the same allergen a second time, IgE antibodies bind the allergen and cross-link on mast cells and basophils in the blood. Cross-linking stimulates degranulation of the cells, releasing histamine, leukotrienes, prostaglandins, and other cytokines. The major effects of the release of these mediators include vasodilation, increased vascular permeability, and bronchoconstriction. Leukotrienes also are responsible for chemotaxis of white blood cells, further propagating the immune response.¹

Effects of a type I hypersensitivity reaction can be either local or systemic, resulting in symptoms ranging from mild irritation to anaphylactic shock and death. Latex allergy is a common example of a type I hypersensitivity reaction. Latex is found in many medical products, including gloves, rubber, elastics, blood pressure cuffs, bandages, dressings, and syringes. Reactions can include runny nose, tearing eyes, itching, hives, wheals, wheezing, and in rare cases anaphylaxis.² Diagnosis can be suspected based on history and physical examination. Screening is performed with radioallergosorbent testing, which identifies specific IgE antibodies to latex; however, the reported sensitivity and specificity for the latex-specific IgE antibody varies widely in the literature, and the test cannot reliably rule in or rule out a true latex allergy.³

Allergic responses to latex in psoriasis patients receiving frequent injections with biologic agents are not commonly reported in the literature. We report the case of a patient with a long history of psoriasis who developed an allergic response after exposure to injection devices that contained latex components while undergoing treatment with biologic agents.

Case Report

A 72-year-old man presented with an extensive history of severe psoriasis with frequent flares. Treatment with topical agents and etanercept 6 months prior at an outside facility failed. At the time of presentation, the patient had more than 10% body surface area (BSA) involvement, which included the scalp, legs, chest, and back. He subsequently was started on ustekinumab injections. He initially responded well to therapy, but after 8 months of treatment, he began to have recurrent episodes of acute eruptive rashes over the trunk with associated severe pruritus that reproducibly recurred within 24 hours after each ustekinumab injection. It was decided to discontinue ustekinumab due to concern for intolerance, and the patient was switched to secukinumab. 

After starting secukinumab, the patient's BSA involvement was reduced to 2% after 1 month; however, he began to develop an eruptive rash with severe pruritus again that reproducibly recurred after each secukinumab injection. On physical examination the patient had ill-defined, confluent, erythematous patches over much of the trunk and extremities. Punch biopsies of the eruptive dermatitis showed spongiform psoriasis and eosinophils with dermal hypersensitivity, consistent with a drug eruption. Upon further questioning, the patient noted that he had a long history of a strong latex allergy and he would develop a blistering dermatitis when coming into contact with latex, which caused a high suspicion for a latex allergy as the cause of the patient's acute dermatitis flares from his prior ustekinumab and secukinumab injections. Although it was confirmed with the manufacturers that both the ustekinumab syringe and secukinumab pen did not contain latex, the caps of these medications (and many other biologic injections) do have latex (Table). Other differential diagnoses included an atypical paradoxical   psoriasis flare and a drug eruption to secukinumab, which previously has been reported.⁴

Based on the suspected cause of the eruption, the patient was instructed not to touch the cap of the secukinumab pen. Despite this recommendation, the rash was still present at the next appointment 1 month later. Repeat punch biopsy showed similar findings to the one prior with likely dermal hypersensitivity. The rash improved with steroid injections and continued to improve after holding the secukinumab for 1 month.

After resolution of the hypersensitivity reaction, the patient was started on ixekizumab, which does not contain latex in any component according to the manufacturer. After 2 months of treatment, the patient had 2% BSA involvement of psoriasis and has had no further reports of itching, rash, or other symptoms of a hypersensitivity reaction. On follow-up, the patient's psoriasis symptoms continue to be controlled without further reactions after injections of ixekizumab. Radioallergosorbent testing was not performed due to the lack of specificity and sensitivity of the test3 as well as the patient's known history of latex allergy and characteristic dermatitis that developed after exposure to latex and resolution with removal of the agent. These clinical manifestations are highly indicative of a type I hypersensitivity to injection devices that contain latex components during biologic therapy.

Comment

Allergic responses to latex are most commonly seen in those exposed to gloves or rubber, but little has been reported on reactions to injections with pens or syringes that contain latex components. Some case reports have demonstrated allergic responses in diabetic patients receiving insulin injections.^5,6 MacCracken et al⁵ reported the case of a young boy who had an allergic response to an insulin injection with a syringe containing latex. The patient had a history of bladder exstrophy with a recent diagnosis of diabetes mellitus. It is well known that patients with spina bifida and other conditions who undergo frequent urological procedures more commonly develop latex allergies. This patient reported a history of swollen lips after a dentist visit, presumably due to contact with latex gloves. Because of the suspected allergy, his first insulin injection was given using a glass syringe and insulin was withdrawn with the top removed due to the top containing latex. He did not experience any complications. After being injected later with insulin drawn through the top using a syringe that contained latex, he developed a flare-up of a 0.5-cm erythematous wheal within minutes with associated pruritus.⁵

Towse et al⁶ described another patient with diabetes who developed a local allergic reaction at the site of insulin injections. Workup by the physician ruled out insulin allergy but showed elevated latex-specific IgE antibodies. Future insulin draws through a latex-containing top produced a wheal at the injection site. After switching to latex-free syringes, the allergic reaction resolved.⁶

Latex allergies are common in medical practice, as latex is found in a wide variety of medical supplies, including syringes used for injections and their caps. Physicians need to be aware of latex allergies in their patients and exercise extreme caution in the use of latex-containing products. In the treatment of psoriasis, care must be given when injecting biologic agents. Although many injection devices contain latex limited to the cap, it may be enough to invoke an allergic response. If such a response is elicited, therapy with injection devices that do not contain latex in either the cap or syringe should be considered.