PARIS—McArdle’s sign, a rapidly reversible motor weakness induced by head flexion in patients with suspected multiple sclerosis (MS), may facilitate diagnosis in certain clinical situations, according to a study presented at the Seventh Joint ECTRIMS–ACTRIMS Meeting. “McArdle’s sign, when defined as a greater than 10% neck flexion-induced reduction using isoinertial finger extension on a measurement device, is highly specific and moderately sensitive for a diagnosis of MS,” said Brian G. Weinshenker, MD, and colleagues. Dr. Weinshenker is Professor of Neurology at the Mayo Clinic in Rochester, Minnesota.

Dr. Weinshenker and colleagues quantified McArdle’s sign in finger extensors using a torque measuring device and assessed its specificity for MS. They enrolled 25 healthy controls and 76 patients with detectable finger extensor weakness, 52 with MS, 24 with other myelopathies, and five with peripheral nerve lesions. Patients were not selected for having McArdle’s sign. Dr. Weinshenker and his team evaluated McArdle’s sign blinded to diagnosis by measuring change in finger extensor strength in successive trials of head extension and flexion, first clinically and then with a torque measuring device. McArdle’s sign was clinically rated from zero (absent) to three (marked). In the quantitative measurement, the patient applied maximum extension strength of four fingers on a bar using isometric (against fixed object) and isoinertial (against a constant resistance) maneuvers. The researchers then averaged the percentage decrease in strength over four trials.

Baseline strength was similar in the three patient groups. The median clinical McArdle’s sign was one (range, zero to three) in patients with MS, zero (range, zero to two) in other myelopathies, zero (range, zero to one) in healthy controls, and zero in all patients with peripheral nerve lesions. The isometric and isoinertial maneuvers provided similar quantitative results, but the isoinertial maneuver had superior diagnostic performance. Head flexion resulted in 17% (± 17%) isoinertial strength reduction in patients with MS versus 1% (± 6%) in other myelopathies, 1% (± 5%) in healthy controls and -3% (± 10%) in patients with peripheral nerve lesions.

A multivariate regression analysis eliminated confounding by baseline strength. Receiver operator curves were generated to assess the diagnostic properties of the test; the area under the curve was 0.82 in patients with MS versus healthy controls and 0.83 in patients with MS versus other myelopathies for isoinertial testing. A 10% drop in strength with flexion was 100% specific and 62% sensitive for MS compared with other myelopathies and a 6% drop, 92% specific and 73% sensitive, for MS compared with healthy controls. Quantitative McArdle’s sign correlated with clinical McArdle’s sign by referring physician and technician (r = 0.58). McArdle’s sign correlated with Expanded Disability Status Scale (r = 0.41) and pyramidal score (r = 0.49) in patients with MS, but was evident in some patients in very early phases of MS and minor disability.

PARIS—McArdle’s sign, a rapidly reversible motor weakness induced by head flexion in patients with suspected multiple sclerosis (MS), may facilitate diagnosis in certain clinical situations, according to a study presented at the Seventh Joint ECTRIMS–ACTRIMS Meeting. “McArdle’s sign, when defined as a greater than 10% neck flexion-induced reduction using isoinertial finger extension on a measurement device, is highly specific and moderately sensitive for a diagnosis of MS,” said Brian G. Weinshenker, MD, and colleagues. Dr. Weinshenker is Professor of Neurology at the Mayo Clinic in Rochester, Minnesota.

Dr. Weinshenker and colleagues quantified McArdle’s sign in finger extensors using a torque measuring device and assessed its specificity for MS. They enrolled 25 healthy controls and 76 patients with detectable finger extensor weakness, 52 with MS, 24 with other myelopathies, and five with peripheral nerve lesions. Patients were not selected for having McArdle’s sign. Dr. Weinshenker and his team evaluated McArdle’s sign blinded to diagnosis by measuring change in finger extensor strength in successive trials of head extension and flexion, first clinically and then with a torque measuring device. McArdle’s sign was clinically rated from zero (absent) to three (marked). In the quantitative measurement, the patient applied maximum extension strength of four fingers on a bar using isometric (against fixed object) and isoinertial (against a constant resistance) maneuvers. The researchers then averaged the percentage decrease in strength over four trials.

Baseline strength was similar in the three patient groups. The median clinical McArdle’s sign was one (range, zero to three) in patients with MS, zero (range, zero to two) in other myelopathies, zero (range, zero to one) in healthy controls, and zero in all patients with peripheral nerve lesions. The isometric and isoinertial maneuvers provided similar quantitative results, but the isoinertial maneuver had superior diagnostic performance. Head flexion resulted in 17% (± 17%) isoinertial strength reduction in patients with MS versus 1% (± 6%) in other myelopathies, 1% (± 5%) in healthy controls and -3% (± 10%) in patients with peripheral nerve lesions.

A multivariate regression analysis eliminated confounding by baseline strength. Receiver operator curves were generated to assess the diagnostic properties of the test; the area under the curve was 0.82 in patients with MS versus healthy controls and 0.83 in patients with MS versus other myelopathies for isoinertial testing. A 10% drop in strength with flexion was 100% specific and 62% sensitive for MS compared with other myelopathies and a 6% drop, 92% specific and 73% sensitive, for MS compared with healthy controls. Quantitative McArdle’s sign correlated with clinical McArdle’s sign by referring physician and technician (r = 0.58). McArdle’s sign correlated with Expanded Disability Status Scale (r = 0.41) and pyramidal score (r = 0.49) in patients with MS, but was evident in some patients in very early phases of MS and minor disability.

PARIS—McArdle’s sign, a rapidly reversible motor weakness induced by head flexion in patients with suspected multiple sclerosis (MS), may facilitate diagnosis in certain clinical situations, according to a study presented at the Seventh Joint ECTRIMS–ACTRIMS Meeting. “McArdle’s sign, when defined as a greater than 10% neck flexion-induced reduction using isoinertial finger extension on a measurement device, is highly specific and moderately sensitive for a diagnosis of MS,” said Brian G. Weinshenker, MD, and colleagues. Dr. Weinshenker is Professor of Neurology at the Mayo Clinic in Rochester, Minnesota.

Dr. Weinshenker and colleagues quantified McArdle’s sign in finger extensors using a torque measuring device and assessed its specificity for MS. They enrolled 25 healthy controls and 76 patients with detectable finger extensor weakness, 52 with MS, 24 with other myelopathies, and five with peripheral nerve lesions. Patients were not selected for having McArdle’s sign. Dr. Weinshenker and his team evaluated McArdle’s sign blinded to diagnosis by measuring change in finger extensor strength in successive trials of head extension and flexion, first clinically and then with a torque measuring device. McArdle’s sign was clinically rated from zero (absent) to three (marked). In the quantitative measurement, the patient applied maximum extension strength of four fingers on a bar using isometric (against fixed object) and isoinertial (against a constant resistance) maneuvers. The researchers then averaged the percentage decrease in strength over four trials.

Baseline strength was similar in the three patient groups. The median clinical McArdle’s sign was one (range, zero to three) in patients with MS, zero (range, zero to two) in other myelopathies, zero (range, zero to one) in healthy controls, and zero in all patients with peripheral nerve lesions. The isometric and isoinertial maneuvers provided similar quantitative results, but the isoinertial maneuver had superior diagnostic performance. Head flexion resulted in 17% (± 17%) isoinertial strength reduction in patients with MS versus 1% (± 6%) in other myelopathies, 1% (± 5%) in healthy controls and -3% (± 10%) in patients with peripheral nerve lesions.

A multivariate regression analysis eliminated confounding by baseline strength. Receiver operator curves were generated to assess the diagnostic properties of the test; the area under the curve was 0.82 in patients with MS versus healthy controls and 0.83 in patients with MS versus other myelopathies for isoinertial testing. A 10% drop in strength with flexion was 100% specific and 62% sensitive for MS compared with other myelopathies and a 6% drop, 92% specific and 73% sensitive, for MS compared with healthy controls. Quantitative McArdle’s sign correlated with clinical McArdle’s sign by referring physician and technician (r = 0.58). McArdle’s sign correlated with Expanded Disability Status Scale (r = 0.41) and pyramidal score (r = 0.49) in patients with MS, but was evident in some patients in very early phases of MS and minor disability.

PARIS—It is possible to gauge the effects of disease-modifying therapies (DMTs) for multiple sclerosis (MS) by measuring serum levels of neurofilament light (NFL), according to research presented at the Seventh Joint ECTRIMS–ACTRIMS Meeting. DMTs with greater efficacy appear to be associated with lower serum NFL concentrations.

NFL is a biomarker of axonal damage that has been measured primarily in CSF. In patients with MS, the CSF NFL concentration reflects disease activity and the efficacy of DMTs. Investigators recently developed an ultrasensitive immunoassay that can determine NFL levels in serum.

The investigators measured serum NFL concentrations using an in-house ultrasensitive single molecule array immunoassay. The intra-assay and inter-assay coefficient of variation was less than 10%.

Median serum NFL concentration decreased significantly in treatment-naïve patients who initiated second-line DMTs (ie, from 22.7 ng/L to 18.5 ng/L) or escalated from a first-line to a second-line DMT (ie, from 17.9 ng/L to 12.6 ng/L). The median serum NFL concentration was stable in patients who switched between second-line DMTs (14.9 ng/L before the switch and 13.7 ng/L after the switch). Similarly, the median serum NFL concentration did not change significantly in patients who stayed untreated (40.7 ng/L at first measurement and 37.1 ng/L at second measurement), initiated first-line treatment (20.6 ng/L vs 25.5 ng/L), or switched between first-line DMTs (17.3 ng/L vs 16.7 ng/L).

“The goal of DMTs in MS is to reduce axonal degeneration,” said Dr. Nováková. “Repeated analysis of serum NFL may represent a new possibility to monitor this process and may provide objective support in treatment decisions.”

PARIS—It is possible to gauge the effects of disease-modifying therapies (DMTs) for multiple sclerosis (MS) by measuring serum levels of neurofilament light (NFL), according to research presented at the Seventh Joint ECTRIMS–ACTRIMS Meeting. DMTs with greater efficacy appear to be associated with lower serum NFL concentrations.

NFL is a biomarker of axonal damage that has been measured primarily in CSF. In patients with MS, the CSF NFL concentration reflects disease activity and the efficacy of DMTs. Investigators recently developed an ultrasensitive immunoassay that can determine NFL levels in serum.

The investigators measured serum NFL concentrations using an in-house ultrasensitive single molecule array immunoassay. The intra-assay and inter-assay coefficient of variation was less than 10%.

Median serum NFL concentration decreased significantly in treatment-naïve patients who initiated second-line DMTs (ie, from 22.7 ng/L to 18.5 ng/L) or escalated from a first-line to a second-line DMT (ie, from 17.9 ng/L to 12.6 ng/L). The median serum NFL concentration was stable in patients who switched between second-line DMTs (14.9 ng/L before the switch and 13.7 ng/L after the switch). Similarly, the median serum NFL concentration did not change significantly in patients who stayed untreated (40.7 ng/L at first measurement and 37.1 ng/L at second measurement), initiated first-line treatment (20.6 ng/L vs 25.5 ng/L), or switched between first-line DMTs (17.3 ng/L vs 16.7 ng/L).

“The goal of DMTs in MS is to reduce axonal degeneration,” said Dr. Nováková. “Repeated analysis of serum NFL may represent a new possibility to monitor this process and may provide objective support in treatment decisions.”

PARIS—It is possible to gauge the effects of disease-modifying therapies (DMTs) for multiple sclerosis (MS) by measuring serum levels of neurofilament light (NFL), according to research presented at the Seventh Joint ECTRIMS–ACTRIMS Meeting. DMTs with greater efficacy appear to be associated with lower serum NFL concentrations.

NFL is a biomarker of axonal damage that has been measured primarily in CSF. In patients with MS, the CSF NFL concentration reflects disease activity and the efficacy of DMTs. Investigators recently developed an ultrasensitive immunoassay that can determine NFL levels in serum.

The investigators measured serum NFL concentrations using an in-house ultrasensitive single molecule array immunoassay. The intra-assay and inter-assay coefficient of variation was less than 10%.

Median serum NFL concentration decreased significantly in treatment-naïve patients who initiated second-line DMTs (ie, from 22.7 ng/L to 18.5 ng/L) or escalated from a first-line to a second-line DMT (ie, from 17.9 ng/L to 12.6 ng/L). The median serum NFL concentration was stable in patients who switched between second-line DMTs (14.9 ng/L before the switch and 13.7 ng/L after the switch). Similarly, the median serum NFL concentration did not change significantly in patients who stayed untreated (40.7 ng/L at first measurement and 37.1 ng/L at second measurement), initiated first-line treatment (20.6 ng/L vs 25.5 ng/L), or switched between first-line DMTs (17.3 ng/L vs 16.7 ng/L).

“The goal of DMTs in MS is to reduce axonal degeneration,” said Dr. Nováková. “Repeated analysis of serum NFL may represent a new possibility to monitor this process and may provide objective support in treatment decisions.”

PARIS—A noninvasive test that assesses immunoglobulin (Ig) free light chains in saliva may detect immunopathologic changes in the multiple sclerosis (MS) disease state and evaluate response to treatment, according to research presented at the Seventh Joint ECTRIMS–ACTRIMS Meeting. The technique has a specificity of 80% and sensitivity of 89% for diagnosing active MS, said lead author Esther Ganelin-Cohen, MD, PhD, Director of the Neuro-Immunology Clinic at Schneider Children’s Medical Center of Israel, Petach Tikva, Israel, on behalf of her research colleagues.

The complexity of MS requires different biomarkers to evaluate the various aspects of the disease. CSF analysis is commonly used, but the need for lumbar puncture makes CSF tests impractical for monitoring disease activity and response to treatment. In their search for noninvasive diagnostic methods, Dr. Ganelin-Cohen and colleagues hypothesized that Ig free light chain analysis in saliva may help detect immunopathologic changes in patients with MS. This assumption relied on prior reports indicating changes in mucosal immunity in patients with MS, and on a growing body of evidence for a potential diagnostic role of free light chains in MS.

A new technique based on Western blot analysis was developed to study kappa (k) and lambda (λ) free light chain monomers and dimers in saliva. Normal saliva showed high proportion of dimeric free light chains compared to that in the serum. “This finding might be explained by structural peculiarities of Ig in saliva,” Dr. Ganelin-Cohen said. “In contrast to most serum Ig, saliva IgA2 molecules incorporate the dimeric (not monomeric) light chains that may require production of larger amounts of dimeric light chains by the B cells synthesizing IgA2.”

Dr. Ganelin-Cohen and her colleagues compared free light chain monomer and dimer patterns in the saliva of patients with MS with those in healthy subjects. The intensity of the immunoreactive free light chain was measured, and the free light chain indices accounting for the total free light chain level and for monomer/dimer ratios (k monomer/dimer index and λ monomer/dimer index) were computed.

Most patients with active MS showed abnormally high free light chain levels, or a high proportion of monomeric free light chains. The reasons for such pathologic free light chain changes in patients with active MS are not clear, but they might be due to peripheral B lymphocytes penetrating oral mucosa and producing larger amounts of monomeric free light chains. Statistical analysis of these indices showed significant differences not only between patients with active MS (n = 27) and healthy subjects (n = 28), but also between patients with active MS (n = 27) and those in remission (n = 58).

Cut-off values were established to distinguish a healthy state from the pathologic conditions in MS: total free light chain level index = 17, k monomer/dimer index = 4.0, λ monomer/dimer index = 2.4. Most patients with active MS showed free light chain indices above these cut-off values.

The high specificity and sensitivity of the technique for diagnosing active MS enable this test to become a new noninvasive complementary tool to evaluate MS, Dr. Ganelin-Cohen and colleagues concluded.

PARIS—A noninvasive test that assesses immunoglobulin (Ig) free light chains in saliva may detect immunopathologic changes in the multiple sclerosis (MS) disease state and evaluate response to treatment, according to research presented at the Seventh Joint ECTRIMS–ACTRIMS Meeting. The technique has a specificity of 80% and sensitivity of 89% for diagnosing active MS, said lead author Esther Ganelin-Cohen, MD, PhD, Director of the Neuro-Immunology Clinic at Schneider Children’s Medical Center of Israel, Petach Tikva, Israel, on behalf of her research colleagues.

The complexity of MS requires different biomarkers to evaluate the various aspects of the disease. CSF analysis is commonly used, but the need for lumbar puncture makes CSF tests impractical for monitoring disease activity and response to treatment. In their search for noninvasive diagnostic methods, Dr. Ganelin-Cohen and colleagues hypothesized that Ig free light chain analysis in saliva may help detect immunopathologic changes in patients with MS. This assumption relied on prior reports indicating changes in mucosal immunity in patients with MS, and on a growing body of evidence for a potential diagnostic role of free light chains in MS.

A new technique based on Western blot analysis was developed to study kappa (k) and lambda (λ) free light chain monomers and dimers in saliva. Normal saliva showed high proportion of dimeric free light chains compared to that in the serum. “This finding might be explained by structural peculiarities of Ig in saliva,” Dr. Ganelin-Cohen said. “In contrast to most serum Ig, saliva IgA2 molecules incorporate the dimeric (not monomeric) light chains that may require production of larger amounts of dimeric light chains by the B cells synthesizing IgA2.”

Dr. Ganelin-Cohen and her colleagues compared free light chain monomer and dimer patterns in the saliva of patients with MS with those in healthy subjects. The intensity of the immunoreactive free light chain was measured, and the free light chain indices accounting for the total free light chain level and for monomer/dimer ratios (k monomer/dimer index and λ monomer/dimer index) were computed.

Most patients with active MS showed abnormally high free light chain levels, or a high proportion of monomeric free light chains. The reasons for such pathologic free light chain changes in patients with active MS are not clear, but they might be due to peripheral B lymphocytes penetrating oral mucosa and producing larger amounts of monomeric free light chains. Statistical analysis of these indices showed significant differences not only between patients with active MS (n = 27) and healthy subjects (n = 28), but also between patients with active MS (n = 27) and those in remission (n = 58).

Cut-off values were established to distinguish a healthy state from the pathologic conditions in MS: total free light chain level index = 17, k monomer/dimer index = 4.0, λ monomer/dimer index = 2.4. Most patients with active MS showed free light chain indices above these cut-off values.

The high specificity and sensitivity of the technique for diagnosing active MS enable this test to become a new noninvasive complementary tool to evaluate MS, Dr. Ganelin-Cohen and colleagues concluded.

PARIS—A noninvasive test that assesses immunoglobulin (Ig) free light chains in saliva may detect immunopathologic changes in the multiple sclerosis (MS) disease state and evaluate response to treatment, according to research presented at the Seventh Joint ECTRIMS–ACTRIMS Meeting. The technique has a specificity of 80% and sensitivity of 89% for diagnosing active MS, said lead author Esther Ganelin-Cohen, MD, PhD, Director of the Neuro-Immunology Clinic at Schneider Children’s Medical Center of Israel, Petach Tikva, Israel, on behalf of her research colleagues.

The complexity of MS requires different biomarkers to evaluate the various aspects of the disease. CSF analysis is commonly used, but the need for lumbar puncture makes CSF tests impractical for monitoring disease activity and response to treatment. In their search for noninvasive diagnostic methods, Dr. Ganelin-Cohen and colleagues hypothesized that Ig free light chain analysis in saliva may help detect immunopathologic changes in patients with MS. This assumption relied on prior reports indicating changes in mucosal immunity in patients with MS, and on a growing body of evidence for a potential diagnostic role of free light chains in MS.

A new technique based on Western blot analysis was developed to study kappa (k) and lambda (λ) free light chain monomers and dimers in saliva. Normal saliva showed high proportion of dimeric free light chains compared to that in the serum. “This finding might be explained by structural peculiarities of Ig in saliva,” Dr. Ganelin-Cohen said. “In contrast to most serum Ig, saliva IgA2 molecules incorporate the dimeric (not monomeric) light chains that may require production of larger amounts of dimeric light chains by the B cells synthesizing IgA2.”

Dr. Ganelin-Cohen and her colleagues compared free light chain monomer and dimer patterns in the saliva of patients with MS with those in healthy subjects. The intensity of the immunoreactive free light chain was measured, and the free light chain indices accounting for the total free light chain level and for monomer/dimer ratios (k monomer/dimer index and λ monomer/dimer index) were computed.

Most patients with active MS showed abnormally high free light chain levels, or a high proportion of monomeric free light chains. The reasons for such pathologic free light chain changes in patients with active MS are not clear, but they might be due to peripheral B lymphocytes penetrating oral mucosa and producing larger amounts of monomeric free light chains. Statistical analysis of these indices showed significant differences not only between patients with active MS (n = 27) and healthy subjects (n = 28), but also between patients with active MS (n = 27) and those in remission (n = 58).

Cut-off values were established to distinguish a healthy state from the pathologic conditions in MS: total free light chain level index = 17, k monomer/dimer index = 4.0, λ monomer/dimer index = 2.4. Most patients with active MS showed free light chain indices above these cut-off values.

The high specificity and sensitivity of the technique for diagnosing active MS enable this test to become a new noninvasive complementary tool to evaluate MS, Dr. Ganelin-Cohen and colleagues concluded.

Patients with cancer perceived physicians who did not use a computer as more compassionate, more professional, and better at communication, according to results of a randomized, video-based study presented at the Palliative and Supportive Care in Oncology Symposium.

In addition, the majority of patients said they would prefer having a doctor who communicated face to face (in other words, without aid of a computer) to be their provider, said Ali Haider, MD, of the University of Texas MD Anderson Cancer Center, Houston.

Brian Jackson/iStockphoto

Patients with cancer perceived physicians who did not use a computer as more compassionate, more professional, and better at communication, according to results of a randomized, video-based study presented at the Palliative and Supportive Care in Oncology Symposium.

In addition, the majority of patients said they would prefer having a doctor who communicated face to face (in other words, without aid of a computer) to be their provider, said Ali Haider, MD, of the University of Texas MD Anderson Cancer Center, Houston.

Brian Jackson/iStockphoto

Patients with cancer perceived physicians who did not use a computer as more compassionate, more professional, and better at communication, according to results of a randomized, video-based study presented at the Palliative and Supportive Care in Oncology Symposium.

In addition, the majority of patients said they would prefer having a doctor who communicated face to face (in other words, without aid of a computer) to be their provider, said Ali Haider, MD, of the University of Texas MD Anderson Cancer Center, Houston.

Brian Jackson/iStockphoto

To the Editor:

Chronic UV exposure has been linked to increased skin fragility and the development of purpuric lesions, a benign condition known as actinic purpura and commonly seen in elderly patients. Petechial skin changes acutely following intense sun exposure is a rare phenomenon referred to as sunburn purpura, photolocalized purpura, or solar purpura.

A 19-year-old woman presented with red and purple spots on the pretibial region of both legs extending to the thigh. One week prior to presentation she had a severe sunburn affecting most of the body, which resolved without blistering. Two days later, the spots appeared within the most severely sunburned areas of both legs. The patient reported that the lesions were mildly painful to palpation, but she was more concerned about the appearance. She denied any history of similar skin changes associated with sun exposure. The patient was otherwise healthy and denied any recent illnesses. She noted a history of mild bruising and bleeding with a resulting unremarkable workup by her primary care physician. The only medication taken was etonogestrel-ethinyl estradiol vaginal ring.

The scalp, face, arms, trunk, and legs were examined, and nonpalpable petechial changes were noted on the anterior aspect of the legs (Figure 1), with changes more prominent on the distal aspect of the legs. Mild superficial epidermal exfoliation was noted on both anterior thighs. The area of the lesions was not warm. The lesions were mildly tender to palpation. The remainder of the physical examination was unremarkable.

Given the timing of onset, preceding sun exposure, and the morphologic characteristics of the lesions, sunburn purpura was suspected. A punch biopsy of the anterior aspect of the left thigh was performed to rule out vasculitis. Microscopic examination revealed reactive epidermal changes with mild vascular ectasia and erythrocyte extravasation not associated with appreciable inflammation or evidence of vascular injury (Figure 2). Biopsy exposure to fluorescein-labeled antibodies directed against IgG, IgM, IgA, C3, and polyvalent immunoglobulins (IgG, IgM, and IgA) yielded no immunofluorescence. These biopsy results were consistent with sunburn purpura. Given the patient's normal platelet count, a diagnosis of idiopathic sunburn purpura was made. The patient was informed of the biopsy results and advised that the petechiae should resolve without treatment in 1 to 2 weeks, which occurred.

Sunburn purpura remains a rare phenomenon in which a petechial or purpuric rash develops acutely after intense sun exposure. We prefer the term sunburn purpura because it reflects the acuity of the phenomenon, as opposed to the previous labels solar purpura or photolocalized purpura, which also could suggest causality from chronic sun exposure. It has been proposed that sunburn purpura is a finding associated with a number of conditions rather than a unique entity.¹ The following characteristics can be helpful in describing the development of sunburn purpura: delay following UV exposure, gross morphology, histologic findings, and possible associated medical conditions.¹ Our case represents an important addition to the literature, as it differs from previously reported cases. Most importantly, the nonspecific biopsy findings and unremarkable laboratory findings associated with our case may represent primary or idiopathic sunburn purpura.

Previously reported cases of sunburn purpura have occurred in patients aged 10 to 66 years. It has been seen following UV exposure, vigorous exercise and high-dose aspirin, or concurrent fluoroquinolone therapy, or in the setting of erythropoietic protoporphyria, idiopathic thrombocytopenic purpura, or polymorphous light eruption.^2-8 When performed, histology has revealed capillaritis, solar elastosis, perivascular infiltrate, lymphocytic perivascular infiltrate with dermal edema, or leukocytoclastic vasculitis.^1,2,7-9 Our patient did not have a history of erythropoietic protoporphyria, polymorphous light eruption, or idiopathic thrombocytopenic purpura. She had not recently exercised, was not thrombocytopenic, and was not taking antiplatelet medications. She had no recent history of fluoroquinolone use. On histologic examination, our patient's biopsy demonstrated nonspecific petechial changes without signs of chronic UV exposure, dermal edema, vasculitis, lymphocytic infiltrate, or capillaritis.

Idiopathic sunburn purpura should only be diagnosed after other conditions are excluded. When evaluating a patient who presents with new-onset petechial rash following sun exposure, it is important to rule out vasculitis or thrombocytopenia as the cause, which is best achieved through skin biopsy and a platelet count, respectively. If there are no associated symptoms or thrombocytopenia and biopsy shows nonspecific vascular ectasia and erythrocyte extravasation, the physician should consider the diagnosis of idiopathic sunburn (solar or photolocalized) purpura. Along with regular UV protection, the physician should advise that the rash typically resolves without treatment in 1 to 2 weeks.

To the Editor:

Chronic UV exposure has been linked to increased skin fragility and the development of purpuric lesions, a benign condition known as actinic purpura and commonly seen in elderly patients. Petechial skin changes acutely following intense sun exposure is a rare phenomenon referred to as sunburn purpura, photolocalized purpura, or solar purpura.

A 19-year-old woman presented with red and purple spots on the pretibial region of both legs extending to the thigh. One week prior to presentation she had a severe sunburn affecting most of the body, which resolved without blistering. Two days later, the spots appeared within the most severely sunburned areas of both legs. The patient reported that the lesions were mildly painful to palpation, but she was more concerned about the appearance. She denied any history of similar skin changes associated with sun exposure. The patient was otherwise healthy and denied any recent illnesses. She noted a history of mild bruising and bleeding with a resulting unremarkable workup by her primary care physician. The only medication taken was etonogestrel-ethinyl estradiol vaginal ring.

The scalp, face, arms, trunk, and legs were examined, and nonpalpable petechial changes were noted on the anterior aspect of the legs (Figure 1), with changes more prominent on the distal aspect of the legs. Mild superficial epidermal exfoliation was noted on both anterior thighs. The area of the lesions was not warm. The lesions were mildly tender to palpation. The remainder of the physical examination was unremarkable.

Given the timing of onset, preceding sun exposure, and the morphologic characteristics of the lesions, sunburn purpura was suspected. A punch biopsy of the anterior aspect of the left thigh was performed to rule out vasculitis. Microscopic examination revealed reactive epidermal changes with mild vascular ectasia and erythrocyte extravasation not associated with appreciable inflammation or evidence of vascular injury (Figure 2). Biopsy exposure to fluorescein-labeled antibodies directed against IgG, IgM, IgA, C3, and polyvalent immunoglobulins (IgG, IgM, and IgA) yielded no immunofluorescence. These biopsy results were consistent with sunburn purpura. Given the patient's normal platelet count, a diagnosis of idiopathic sunburn purpura was made. The patient was informed of the biopsy results and advised that the petechiae should resolve without treatment in 1 to 2 weeks, which occurred.

Sunburn purpura remains a rare phenomenon in which a petechial or purpuric rash develops acutely after intense sun exposure. We prefer the term sunburn purpura because it reflects the acuity of the phenomenon, as opposed to the previous labels solar purpura or photolocalized purpura, which also could suggest causality from chronic sun exposure. It has been proposed that sunburn purpura is a finding associated with a number of conditions rather than a unique entity.¹ The following characteristics can be helpful in describing the development of sunburn purpura: delay following UV exposure, gross morphology, histologic findings, and possible associated medical conditions.¹ Our case represents an important addition to the literature, as it differs from previously reported cases. Most importantly, the nonspecific biopsy findings and unremarkable laboratory findings associated with our case may represent primary or idiopathic sunburn purpura.

Previously reported cases of sunburn purpura have occurred in patients aged 10 to 66 years. It has been seen following UV exposure, vigorous exercise and high-dose aspirin, or concurrent fluoroquinolone therapy, or in the setting of erythropoietic protoporphyria, idiopathic thrombocytopenic purpura, or polymorphous light eruption.^2-8 When performed, histology has revealed capillaritis, solar elastosis, perivascular infiltrate, lymphocytic perivascular infiltrate with dermal edema, or leukocytoclastic vasculitis.^1,2,7-9 Our patient did not have a history of erythropoietic protoporphyria, polymorphous light eruption, or idiopathic thrombocytopenic purpura. She had not recently exercised, was not thrombocytopenic, and was not taking antiplatelet medications. She had no recent history of fluoroquinolone use. On histologic examination, our patient's biopsy demonstrated nonspecific petechial changes without signs of chronic UV exposure, dermal edema, vasculitis, lymphocytic infiltrate, or capillaritis.

Idiopathic sunburn purpura should only be diagnosed after other conditions are excluded. When evaluating a patient who presents with new-onset petechial rash following sun exposure, it is important to rule out vasculitis or thrombocytopenia as the cause, which is best achieved through skin biopsy and a platelet count, respectively. If there are no associated symptoms or thrombocytopenia and biopsy shows nonspecific vascular ectasia and erythrocyte extravasation, the physician should consider the diagnosis of idiopathic sunburn (solar or photolocalized) purpura. Along with regular UV protection, the physician should advise that the rash typically resolves without treatment in 1 to 2 weeks.

To the Editor:

Chronic UV exposure has been linked to increased skin fragility and the development of purpuric lesions, a benign condition known as actinic purpura and commonly seen in elderly patients. Petechial skin changes acutely following intense sun exposure is a rare phenomenon referred to as sunburn purpura, photolocalized purpura, or solar purpura.

A 19-year-old woman presented with red and purple spots on the pretibial region of both legs extending to the thigh. One week prior to presentation she had a severe sunburn affecting most of the body, which resolved without blistering. Two days later, the spots appeared within the most severely sunburned areas of both legs. The patient reported that the lesions were mildly painful to palpation, but she was more concerned about the appearance. She denied any history of similar skin changes associated with sun exposure. The patient was otherwise healthy and denied any recent illnesses. She noted a history of mild bruising and bleeding with a resulting unremarkable workup by her primary care physician. The only medication taken was etonogestrel-ethinyl estradiol vaginal ring.

The scalp, face, arms, trunk, and legs were examined, and nonpalpable petechial changes were noted on the anterior aspect of the legs (Figure 1), with changes more prominent on the distal aspect of the legs. Mild superficial epidermal exfoliation was noted on both anterior thighs. The area of the lesions was not warm. The lesions were mildly tender to palpation. The remainder of the physical examination was unremarkable.

Given the timing of onset, preceding sun exposure, and the morphologic characteristics of the lesions, sunburn purpura was suspected. A punch biopsy of the anterior aspect of the left thigh was performed to rule out vasculitis. Microscopic examination revealed reactive epidermal changes with mild vascular ectasia and erythrocyte extravasation not associated with appreciable inflammation or evidence of vascular injury (Figure 2). Biopsy exposure to fluorescein-labeled antibodies directed against IgG, IgM, IgA, C3, and polyvalent immunoglobulins (IgG, IgM, and IgA) yielded no immunofluorescence. These biopsy results were consistent with sunburn purpura. Given the patient's normal platelet count, a diagnosis of idiopathic sunburn purpura was made. The patient was informed of the biopsy results and advised that the petechiae should resolve without treatment in 1 to 2 weeks, which occurred.

Sunburn purpura remains a rare phenomenon in which a petechial or purpuric rash develops acutely after intense sun exposure. We prefer the term sunburn purpura because it reflects the acuity of the phenomenon, as opposed to the previous labels solar purpura or photolocalized purpura, which also could suggest causality from chronic sun exposure. It has been proposed that sunburn purpura is a finding associated with a number of conditions rather than a unique entity.¹ The following characteristics can be helpful in describing the development of sunburn purpura: delay following UV exposure, gross morphology, histologic findings, and possible associated medical conditions.¹ Our case represents an important addition to the literature, as it differs from previously reported cases. Most importantly, the nonspecific biopsy findings and unremarkable laboratory findings associated with our case may represent primary or idiopathic sunburn purpura.

Previously reported cases of sunburn purpura have occurred in patients aged 10 to 66 years. It has been seen following UV exposure, vigorous exercise and high-dose aspirin, or concurrent fluoroquinolone therapy, or in the setting of erythropoietic protoporphyria, idiopathic thrombocytopenic purpura, or polymorphous light eruption.^2-8 When performed, histology has revealed capillaritis, solar elastosis, perivascular infiltrate, lymphocytic perivascular infiltrate with dermal edema, or leukocytoclastic vasculitis.^1,2,7-9 Our patient did not have a history of erythropoietic protoporphyria, polymorphous light eruption, or idiopathic thrombocytopenic purpura. She had not recently exercised, was not thrombocytopenic, and was not taking antiplatelet medications. She had no recent history of fluoroquinolone use. On histologic examination, our patient's biopsy demonstrated nonspecific petechial changes without signs of chronic UV exposure, dermal edema, vasculitis, lymphocytic infiltrate, or capillaritis.

Idiopathic sunburn purpura should only be diagnosed after other conditions are excluded. When evaluating a patient who presents with new-onset petechial rash following sun exposure, it is important to rule out vasculitis or thrombocytopenia as the cause, which is best achieved through skin biopsy and a platelet count, respectively. If there are no associated symptoms or thrombocytopenia and biopsy shows nonspecific vascular ectasia and erythrocyte extravasation, the physician should consider the diagnosis of idiopathic sunburn (solar or photolocalized) purpura. Along with regular UV protection, the physician should advise that the rash typically resolves without treatment in 1 to 2 weeks.

New tools to help minimize the risk of opioid-related adverse events are becoming more widely available, although providers are still struggling over how best to implement them.

A recent study by Shane Mueller, MSW, and Ingrid Binswanger, MD, at Kaiser Permanente Colorado Institute for Health Research, Denver, for instance, found that doctors are frequently uncomfortable prescribing the opioid antagonist naloxone to counteract a potential overdose.¹

References

1. Mueller SR, Koester S, Glanz JM, et al. Attitudes toward naloxone prescribing in clinical settings: A qualitative study of patients prescribed high dose opioids for chronic non-cancer pain. J Gen Intern Med. 2017 March;32(3):277-83.
 

New tools to help minimize the risk of opioid-related adverse events are becoming more widely available, although providers are still struggling over how best to implement them.

A recent study by Shane Mueller, MSW, and Ingrid Binswanger, MD, at Kaiser Permanente Colorado Institute for Health Research, Denver, for instance, found that doctors are frequently uncomfortable prescribing the opioid antagonist naloxone to counteract a potential overdose.¹

References

1. Mueller SR, Koester S, Glanz JM, et al. Attitudes toward naloxone prescribing in clinical settings: A qualitative study of patients prescribed high dose opioids for chronic non-cancer pain. J Gen Intern Med. 2017 March;32(3):277-83.
 

New tools to help minimize the risk of opioid-related adverse events are becoming more widely available, although providers are still struggling over how best to implement them.

A recent study by Shane Mueller, MSW, and Ingrid Binswanger, MD, at Kaiser Permanente Colorado Institute for Health Research, Denver, for instance, found that doctors are frequently uncomfortable prescribing the opioid antagonist naloxone to counteract a potential overdose.¹

References

1. Mueller SR, Koester S, Glanz JM, et al. Attitudes toward naloxone prescribing in clinical settings: A qualitative study of patients prescribed high dose opioids for chronic non-cancer pain. J Gen Intern Med. 2017 March;32(3):277-83.
 

CHICAGO – “All that vomits is not necessarily GERD,” so distinguishing gastroesophageal reflux disease (GERD) from nonerosive reflux disease (NERD) remains essential when doing a differential diagnosis. Fortunately, five questions backed by increasing evidence can help you make the call.

“Everyone in the room knows babies puke, and babies can puke a lot,” Barry K. Wershil, MD, said at the annual meeting of the American Academy of Pediatrics. The approach to diagnosing GERD is age specific. “Kids who puke tend to outgrow it over time. With development, 95% or more are no longer refluxing at 18 months of age.”

captain_galaxy/Thinkstock

Considerations backed by evidence

Unfortunately, symptoms alone do not always differentiate erosive versus nonerosive esophagitis, Dr. Wershil said, although recurrent vomiting, poor weight gain, anemia, feeding problems, and respiratory problems can be signs of complicated GERD.

He recommended the following five considerations to distinguish GERD from NERD:

• Is the patient exhibiting normal weight gain? If not, ask questions about how the child is being fed. Have the parents started diluting the formula because they think that will take care of the vomiting? Have they begun limiting the amount of formula after observing that the child throws up at 4 ounces but not at 2 ounces?
• Is the patient bleeding or anemic? Hematemesis is rarely the presentation of infants with GERD, but anemia may be.
• Does the patient have respiratory problems (for example, a history of aspiration, recurring wheezing, or cough)?
• Is the patient neurologically normal? If so, that can present a special class of patients in which vomiting may not be just normal infant vomiting.
• Is the patient older than 2 years? We expect 95% of children to outgrow reflux by 18 months, and most children who have physiological reflux will outgrow it by 2 years.

“Those five questions in 1983 had little evidence, but in 2017 there is more evidence that these are the questions to focus on,” Dr. Wershil said.
 

The role of diagnostic testing

Diagnostic testing, such as pH monitoring, impedance testing, and endoscopy, can be useful in specific situations but carry limitations for widespread use, Dr. Wershil said. “Each test has reasons and limitations.”

An upper GI tract series looks only for anatomic anomalies, for example. pH monitoring is still used in many centers, but in general, impedance monitoring has become more common because it can detect both acid and nonacid reflux: “You can get a very detailed analysis of events happening in the esophagus over time.” One caveat Dr. Wershil added is that, “in some instances, we’re unsure how to define this in the pediatric age ranges we treat.”

Endoscopy has a limited role for the rare patients with mucosal changes or erosive esophagitis, he added. Endoscopy is ordered to detect mucosal changes that confirm esophageal erosion. “In all the kids we scope with positive pH, we rarely find erosive esophagitis,” Dr. Wershil said. “What we find more often is NERD. That really represents more of what we see in our patient population.”

“I hope this information is a good starting point to understand the algorithms that get generated,” Dr. Wershil said.

He recommended an algorithm for gastroesophageal reflux prepared by the American Academy of Pediatrics’ Section on Gastroenterology, Hepatology, and Nutrition (Pediatrics. 2013 May. doi: 10.1542/peds.2013-0421). “I think this information is really solidly grounded in evidence.”

Dr. Wershil is a consultant for Alexion Pharmaceuticals; is a member of the speakers bureau for Abbott Nutrition, Mead Johnson Nutrition, and Nutricia; and receives funding from the National Institutes of Health Consortium of Eosinophilic Gastrointestinal Disease Researchers.

CHICAGO – “All that vomits is not necessarily GERD,” so distinguishing gastroesophageal reflux disease (GERD) from nonerosive reflux disease (NERD) remains essential when doing a differential diagnosis. Fortunately, five questions backed by increasing evidence can help you make the call.

“Everyone in the room knows babies puke, and babies can puke a lot,” Barry K. Wershil, MD, said at the annual meeting of the American Academy of Pediatrics. The approach to diagnosing GERD is age specific. “Kids who puke tend to outgrow it over time. With development, 95% or more are no longer refluxing at 18 months of age.”

captain_galaxy/Thinkstock

Considerations backed by evidence

Unfortunately, symptoms alone do not always differentiate erosive versus nonerosive esophagitis, Dr. Wershil said, although recurrent vomiting, poor weight gain, anemia, feeding problems, and respiratory problems can be signs of complicated GERD.

He recommended the following five considerations to distinguish GERD from NERD:

• Is the patient exhibiting normal weight gain? If not, ask questions about how the child is being fed. Have the parents started diluting the formula because they think that will take care of the vomiting? Have they begun limiting the amount of formula after observing that the child throws up at 4 ounces but not at 2 ounces?
• Is the patient bleeding or anemic? Hematemesis is rarely the presentation of infants with GERD, but anemia may be.
• Does the patient have respiratory problems (for example, a history of aspiration, recurring wheezing, or cough)?
• Is the patient neurologically normal? If so, that can present a special class of patients in which vomiting may not be just normal infant vomiting.
• Is the patient older than 2 years? We expect 95% of children to outgrow reflux by 18 months, and most children who have physiological reflux will outgrow it by 2 years.

“Those five questions in 1983 had little evidence, but in 2017 there is more evidence that these are the questions to focus on,” Dr. Wershil said.
 

The role of diagnostic testing

Diagnostic testing, such as pH monitoring, impedance testing, and endoscopy, can be useful in specific situations but carry limitations for widespread use, Dr. Wershil said. “Each test has reasons and limitations.”

An upper GI tract series looks only for anatomic anomalies, for example. pH monitoring is still used in many centers, but in general, impedance monitoring has become more common because it can detect both acid and nonacid reflux: “You can get a very detailed analysis of events happening in the esophagus over time.” One caveat Dr. Wershil added is that, “in some instances, we’re unsure how to define this in the pediatric age ranges we treat.”

Endoscopy has a limited role for the rare patients with mucosal changes or erosive esophagitis, he added. Endoscopy is ordered to detect mucosal changes that confirm esophageal erosion. “In all the kids we scope with positive pH, we rarely find erosive esophagitis,” Dr. Wershil said. “What we find more often is NERD. That really represents more of what we see in our patient population.”

“I hope this information is a good starting point to understand the algorithms that get generated,” Dr. Wershil said.

He recommended an algorithm for gastroesophageal reflux prepared by the American Academy of Pediatrics’ Section on Gastroenterology, Hepatology, and Nutrition (Pediatrics. 2013 May. doi: 10.1542/peds.2013-0421). “I think this information is really solidly grounded in evidence.”

Dr. Wershil is a consultant for Alexion Pharmaceuticals; is a member of the speakers bureau for Abbott Nutrition, Mead Johnson Nutrition, and Nutricia; and receives funding from the National Institutes of Health Consortium of Eosinophilic Gastrointestinal Disease Researchers.

CHICAGO – “All that vomits is not necessarily GERD,” so distinguishing gastroesophageal reflux disease (GERD) from nonerosive reflux disease (NERD) remains essential when doing a differential diagnosis. Fortunately, five questions backed by increasing evidence can help you make the call.

“Everyone in the room knows babies puke, and babies can puke a lot,” Barry K. Wershil, MD, said at the annual meeting of the American Academy of Pediatrics. The approach to diagnosing GERD is age specific. “Kids who puke tend to outgrow it over time. With development, 95% or more are no longer refluxing at 18 months of age.”

captain_galaxy/Thinkstock

Considerations backed by evidence

Unfortunately, symptoms alone do not always differentiate erosive versus nonerosive esophagitis, Dr. Wershil said, although recurrent vomiting, poor weight gain, anemia, feeding problems, and respiratory problems can be signs of complicated GERD.

He recommended the following five considerations to distinguish GERD from NERD:

• Is the patient exhibiting normal weight gain? If not, ask questions about how the child is being fed. Have the parents started diluting the formula because they think that will take care of the vomiting? Have they begun limiting the amount of formula after observing that the child throws up at 4 ounces but not at 2 ounces?
• Is the patient bleeding or anemic? Hematemesis is rarely the presentation of infants with GERD, but anemia may be.
• Does the patient have respiratory problems (for example, a history of aspiration, recurring wheezing, or cough)?
• Is the patient neurologically normal? If so, that can present a special class of patients in which vomiting may not be just normal infant vomiting.
• Is the patient older than 2 years? We expect 95% of children to outgrow reflux by 18 months, and most children who have physiological reflux will outgrow it by 2 years.

“Those five questions in 1983 had little evidence, but in 2017 there is more evidence that these are the questions to focus on,” Dr. Wershil said.
 

The role of diagnostic testing

Diagnostic testing, such as pH monitoring, impedance testing, and endoscopy, can be useful in specific situations but carry limitations for widespread use, Dr. Wershil said. “Each test has reasons and limitations.”

An upper GI tract series looks only for anatomic anomalies, for example. pH monitoring is still used in many centers, but in general, impedance monitoring has become more common because it can detect both acid and nonacid reflux: “You can get a very detailed analysis of events happening in the esophagus over time.” One caveat Dr. Wershil added is that, “in some instances, we’re unsure how to define this in the pediatric age ranges we treat.”

Endoscopy has a limited role for the rare patients with mucosal changes or erosive esophagitis, he added. Endoscopy is ordered to detect mucosal changes that confirm esophageal erosion. “In all the kids we scope with positive pH, we rarely find erosive esophagitis,” Dr. Wershil said. “What we find more often is NERD. That really represents more of what we see in our patient population.”

“I hope this information is a good starting point to understand the algorithms that get generated,” Dr. Wershil said.

He recommended an algorithm for gastroesophageal reflux prepared by the American Academy of Pediatrics’ Section on Gastroenterology, Hepatology, and Nutrition (Pediatrics. 2013 May. doi: 10.1542/peds.2013-0421). “I think this information is really solidly grounded in evidence.”

Dr. Wershil is a consultant for Alexion Pharmaceuticals; is a member of the speakers bureau for Abbott Nutrition, Mead Johnson Nutrition, and Nutricia; and receives funding from the National Institutes of Health Consortium of Eosinophilic Gastrointestinal Disease Researchers.

Individuals with rheumatoid arthritis (RA) had an increased risk of hospitalizations from chronic obstructive pulmonary disease (COPD) when compared with the general population in a Canadian retrospective, population-based cohort study.

The risk of COPD hospitalizations was 47% higher in individuals with RA. “This finding emphasizes the need to control inflammation in rheumatoid arthritis, not only to prevent joint damage, but also to prevent complications of systemic inflammation, including the development of comorbidities such as cardiovascular diseases and COPD,” wrote Diane Lacaille, MD, of the University of British Columbia, Vancouver, and her coauthors (Arthritis Care Res. 2017 Oct 19. doi: 10.1002/acr.23410).

Nick Piegari/Frontline Medical News

[email protected]

Individuals with rheumatoid arthritis (RA) had an increased risk of hospitalizations from chronic obstructive pulmonary disease (COPD) when compared with the general population in a Canadian retrospective, population-based cohort study.

The risk of COPD hospitalizations was 47% higher in individuals with RA. “This finding emphasizes the need to control inflammation in rheumatoid arthritis, not only to prevent joint damage, but also to prevent complications of systemic inflammation, including the development of comorbidities such as cardiovascular diseases and COPD,” wrote Diane Lacaille, MD, of the University of British Columbia, Vancouver, and her coauthors (Arthritis Care Res. 2017 Oct 19. doi: 10.1002/acr.23410).

Nick Piegari/Frontline Medical News

[email protected]

Individuals with rheumatoid arthritis (RA) had an increased risk of hospitalizations from chronic obstructive pulmonary disease (COPD) when compared with the general population in a Canadian retrospective, population-based cohort study.

The risk of COPD hospitalizations was 47% higher in individuals with RA. “This finding emphasizes the need to control inflammation in rheumatoid arthritis, not only to prevent joint damage, but also to prevent complications of systemic inflammation, including the development of comorbidities such as cardiovascular diseases and COPD,” wrote Diane Lacaille, MD, of the University of British Columbia, Vancouver, and her coauthors (Arthritis Care Res. 2017 Oct 19. doi: 10.1002/acr.23410).

Nick Piegari/Frontline Medical News

[email protected]

In memory of Anne Marie Regan, CPNP, senior research coordinator, Pediatric HIV Program, Boston City Hospital

Our first child with perinatal HIV presented in 1985 at age 4 weeks with failure to thrive, vomiting, diarrhea, and thrush. Over the next several years, the number of HIV-infected infants grew exponentially, and by 1991, we were caring for more than 50 infants and children at Boston City Hospital.

Dr. Pelton is chief of pediatric infectious diseases and coordinator of the maternal-child HIV program at Boston Medical Center. Ms. Moloney is a certified pediatric nurse practitioner in the division of pediatric infectious diseases. Dr. Pelton said he had no relevant financial disclosures, and Ms. Moloney is a speaker (on vaccines) for Sanofi Pasteur. Email them at [email protected].

In memory of Anne Marie Regan, CPNP, senior research coordinator, Pediatric HIV Program, Boston City Hospital

Our first child with perinatal HIV presented in 1985 at age 4 weeks with failure to thrive, vomiting, diarrhea, and thrush. Over the next several years, the number of HIV-infected infants grew exponentially, and by 1991, we were caring for more than 50 infants and children at Boston City Hospital.

Dr. Pelton is chief of pediatric infectious diseases and coordinator of the maternal-child HIV program at Boston Medical Center. Ms. Moloney is a certified pediatric nurse practitioner in the division of pediatric infectious diseases. Dr. Pelton said he had no relevant financial disclosures, and Ms. Moloney is a speaker (on vaccines) for Sanofi Pasteur. Email them at [email protected].

In memory of Anne Marie Regan, CPNP, senior research coordinator, Pediatric HIV Program, Boston City Hospital

Our first child with perinatal HIV presented in 1985 at age 4 weeks with failure to thrive, vomiting, diarrhea, and thrush. Over the next several years, the number of HIV-infected infants grew exponentially, and by 1991, we were caring for more than 50 infants and children at Boston City Hospital.

Dr. Pelton is chief of pediatric infectious diseases and coordinator of the maternal-child HIV program at Boston Medical Center. Ms. Moloney is a certified pediatric nurse practitioner in the division of pediatric infectious diseases. Dr. Pelton said he had no relevant financial disclosures, and Ms. Moloney is a speaker (on vaccines) for Sanofi Pasteur. Email them at [email protected].

CHICAGO – With no consensus guidelines, rheumatologists and dermatologists have significant practice-based differences in their treatment of children with discoid lupus erythematosus, according to a survey of the two specialties.

The survey’s results from 57 pediatric dermatologists and 47 pediatric rheumatologists showed a lack of consensus between the two specialties in how to screen for systemic lupus erythematosus (SLE). The two specialties also differed in identification of which features of discoid lupus erythematosus (DLE) might predispose children to developing SLE, and in some therapy choices for DLE.

Although rare in children, DLE may develop into systemic lupus erythematosus in about 25%-30% of pediatric patients, according to Lisa Arkin, MD, who shared the survey results during a poster presentation at the World Congress of Pediatric Dermatology.

Dr. Arkin and her colleagues conducted a Web-based survey to examine differences in DLE treatment practice patterns between pediatric dermatologists and pediatric rheumatologists. They sent the survey to 292 members of the Childhood Arthritis and Rheumatology Research Alliance (CARRA), and to 200 members of the Pediatric Dermatology Research Alliance (PeDRA), and received responses from 44% of the rheumatologists and 56% of the dermatologists. Of those, 57 dermatologists and 47 rheumatologists met inclusion criteria for the study.

More than half of the respondents in each specialty had seen fewer than 10 patients with skin-limited DLE, and fewer than 10 patients with SLE and DLE, over the course of their careers, said Dr. Arkin, director of pediatric dermatology at the University of Wisconsin, Madison.

Consensus was defined by Dr. Arkin and her colleagues as greater than 70% agreement from both specialties, and 2-sided P values less than .05 showed practice differences between rheumatologists and dermatologists.

Clinicians reached a consensus that the presence of either arthritis or nephritis in a pediatric patient with DLE put the patient at high risk for SLE. Arthritis was identified as a high-risk feature by 41 of 57 dermatologists (72%) and 36 of 47 rheumatologists (77%), while nephritis was seen as a high-risk feature by 39 dermatologists (68%) and 37 rheumatologists (79%). However, said Dr. Arkin, “no other features from a list of 30 risk factors including demographics, clinical, or laboratory features achieved consensus.”

In deciding which laboratory studies to order to screen for SLE upon DLE diagnosis, 26 dermatologists (46%) and 38 rheumatologists (81%) choose a full screening panel, according to the survey results. That was a significant between-specialty difference (P less than .001). The full panel consisted of obtaining a complete blood count with differential, testing for renal and hepatic function, obtaining the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level, and doing urine studies. The panel also included testing for complements, autoantibodies including anti–double-stranded DNA, single-stranded A and B, ribonucleoprotein, anti-Smith, and antiphospholipid antibodies.

However, when individual laboratory studies were examined, several did achieve consensus for baseline screening. Those included the CBC with differential; urinalysis (but not urine protein creatinine), ESR (but not CRP); complement, renal, and hepatic function testing; and most autoantibody testing (but not antiphospholipid antibody testing). Where there were differences in likelihood to order a test, rheumatologists were more likely to order the test than dermatologists.

In deciding on initial treatment, “rheumatologists were more likely to always initiate hydroxychloroquine than dermatologists,” said Dr. Arkin. Of the rheumatologists, 49% always initiated hydroxychloroquine, compared with 14% of the dermatologists (P less than .001).

In contrast, “dermatologists were more likely to always initiate topical therapy than the rheumatologists,” said Dr. Arkin. Topical therapy was always started by 81% of the dermatologists and 33% of the rheumatologists (P less than .001).

Although the specialties differed in whether they always initiated a certain treatment, “hydroxychloroquine achieved consensus as first-line therapy,” Dr. Arkin noted, with 81% of dermatologists and 87% of rheumatologists choosing hydroxychloroquine when the survey asked for a first-line systemic therapy.

There was no consensus about which agents were best for add-on therapy. Of the dermatologists, 32% would sometimes use methotrexate, which was used by 21% of rheumatologists for refractory skin disease. Quinacrine was used as add-on therapy by 21% of dermatologists and 15% of rheumatologists. Rheumatologists were significantly more likely to add dapsone than dermatologists (28% vs. 5%, P = .002).

The survey points to the need to develop consensus guidelines in the treatment of pediatric DLE, said Dr. Arkin. “Knowledge gaps include risk factors for SLE, optimal screening, and therapy,” she explained. “Collection of robust longitudinal data will aid in developing pediatric consensus guidelines for DLE.”

Dr. Arkin had no conflicts of interest.
 

[email protected]

On Twitter @karioakes

CHICAGO – With no consensus guidelines, rheumatologists and dermatologists have significant practice-based differences in their treatment of children with discoid lupus erythematosus, according to a survey of the two specialties.

The survey’s results from 57 pediatric dermatologists and 47 pediatric rheumatologists showed a lack of consensus between the two specialties in how to screen for systemic lupus erythematosus (SLE). The two specialties also differed in identification of which features of discoid lupus erythematosus (DLE) might predispose children to developing SLE, and in some therapy choices for DLE.

Although rare in children, DLE may develop into systemic lupus erythematosus in about 25%-30% of pediatric patients, according to Lisa Arkin, MD, who shared the survey results during a poster presentation at the World Congress of Pediatric Dermatology.

Dr. Arkin and her colleagues conducted a Web-based survey to examine differences in DLE treatment practice patterns between pediatric dermatologists and pediatric rheumatologists. They sent the survey to 292 members of the Childhood Arthritis and Rheumatology Research Alliance (CARRA), and to 200 members of the Pediatric Dermatology Research Alliance (PeDRA), and received responses from 44% of the rheumatologists and 56% of the dermatologists. Of those, 57 dermatologists and 47 rheumatologists met inclusion criteria for the study.

More than half of the respondents in each specialty had seen fewer than 10 patients with skin-limited DLE, and fewer than 10 patients with SLE and DLE, over the course of their careers, said Dr. Arkin, director of pediatric dermatology at the University of Wisconsin, Madison.

Consensus was defined by Dr. Arkin and her colleagues as greater than 70% agreement from both specialties, and 2-sided P values less than .05 showed practice differences between rheumatologists and dermatologists.

Clinicians reached a consensus that the presence of either arthritis or nephritis in a pediatric patient with DLE put the patient at high risk for SLE. Arthritis was identified as a high-risk feature by 41 of 57 dermatologists (72%) and 36 of 47 rheumatologists (77%), while nephritis was seen as a high-risk feature by 39 dermatologists (68%) and 37 rheumatologists (79%). However, said Dr. Arkin, “no other features from a list of 30 risk factors including demographics, clinical, or laboratory features achieved consensus.”

In deciding which laboratory studies to order to screen for SLE upon DLE diagnosis, 26 dermatologists (46%) and 38 rheumatologists (81%) choose a full screening panel, according to the survey results. That was a significant between-specialty difference (P less than .001). The full panel consisted of obtaining a complete blood count with differential, testing for renal and hepatic function, obtaining the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level, and doing urine studies. The panel also included testing for complements, autoantibodies including anti–double-stranded DNA, single-stranded A and B, ribonucleoprotein, anti-Smith, and antiphospholipid antibodies.

However, when individual laboratory studies were examined, several did achieve consensus for baseline screening. Those included the CBC with differential; urinalysis (but not urine protein creatinine), ESR (but not CRP); complement, renal, and hepatic function testing; and most autoantibody testing (but not antiphospholipid antibody testing). Where there were differences in likelihood to order a test, rheumatologists were more likely to order the test than dermatologists.

In deciding on initial treatment, “rheumatologists were more likely to always initiate hydroxychloroquine than dermatologists,” said Dr. Arkin. Of the rheumatologists, 49% always initiated hydroxychloroquine, compared with 14% of the dermatologists (P less than .001).

In contrast, “dermatologists were more likely to always initiate topical therapy than the rheumatologists,” said Dr. Arkin. Topical therapy was always started by 81% of the dermatologists and 33% of the rheumatologists (P less than .001).

Although the specialties differed in whether they always initiated a certain treatment, “hydroxychloroquine achieved consensus as first-line therapy,” Dr. Arkin noted, with 81% of dermatologists and 87% of rheumatologists choosing hydroxychloroquine when the survey asked for a first-line systemic therapy.

There was no consensus about which agents were best for add-on therapy. Of the dermatologists, 32% would sometimes use methotrexate, which was used by 21% of rheumatologists for refractory skin disease. Quinacrine was used as add-on therapy by 21% of dermatologists and 15% of rheumatologists. Rheumatologists were significantly more likely to add dapsone than dermatologists (28% vs. 5%, P = .002).

The survey points to the need to develop consensus guidelines in the treatment of pediatric DLE, said Dr. Arkin. “Knowledge gaps include risk factors for SLE, optimal screening, and therapy,” she explained. “Collection of robust longitudinal data will aid in developing pediatric consensus guidelines for DLE.”

Dr. Arkin had no conflicts of interest.
 

[email protected]

On Twitter @karioakes

CHICAGO – With no consensus guidelines, rheumatologists and dermatologists have significant practice-based differences in their treatment of children with discoid lupus erythematosus, according to a survey of the two specialties.

The survey’s results from 57 pediatric dermatologists and 47 pediatric rheumatologists showed a lack of consensus between the two specialties in how to screen for systemic lupus erythematosus (SLE). The two specialties also differed in identification of which features of discoid lupus erythematosus (DLE) might predispose children to developing SLE, and in some therapy choices for DLE.

Although rare in children, DLE may develop into systemic lupus erythematosus in about 25%-30% of pediatric patients, according to Lisa Arkin, MD, who shared the survey results during a poster presentation at the World Congress of Pediatric Dermatology.

Dr. Arkin and her colleagues conducted a Web-based survey to examine differences in DLE treatment practice patterns between pediatric dermatologists and pediatric rheumatologists. They sent the survey to 292 members of the Childhood Arthritis and Rheumatology Research Alliance (CARRA), and to 200 members of the Pediatric Dermatology Research Alliance (PeDRA), and received responses from 44% of the rheumatologists and 56% of the dermatologists. Of those, 57 dermatologists and 47 rheumatologists met inclusion criteria for the study.

More than half of the respondents in each specialty had seen fewer than 10 patients with skin-limited DLE, and fewer than 10 patients with SLE and DLE, over the course of their careers, said Dr. Arkin, director of pediatric dermatology at the University of Wisconsin, Madison.

Consensus was defined by Dr. Arkin and her colleagues as greater than 70% agreement from both specialties, and 2-sided P values less than .05 showed practice differences between rheumatologists and dermatologists.

Clinicians reached a consensus that the presence of either arthritis or nephritis in a pediatric patient with DLE put the patient at high risk for SLE. Arthritis was identified as a high-risk feature by 41 of 57 dermatologists (72%) and 36 of 47 rheumatologists (77%), while nephritis was seen as a high-risk feature by 39 dermatologists (68%) and 37 rheumatologists (79%). However, said Dr. Arkin, “no other features from a list of 30 risk factors including demographics, clinical, or laboratory features achieved consensus.”

In deciding which laboratory studies to order to screen for SLE upon DLE diagnosis, 26 dermatologists (46%) and 38 rheumatologists (81%) choose a full screening panel, according to the survey results. That was a significant between-specialty difference (P less than .001). The full panel consisted of obtaining a complete blood count with differential, testing for renal and hepatic function, obtaining the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level, and doing urine studies. The panel also included testing for complements, autoantibodies including anti–double-stranded DNA, single-stranded A and B, ribonucleoprotein, anti-Smith, and antiphospholipid antibodies.

However, when individual laboratory studies were examined, several did achieve consensus for baseline screening. Those included the CBC with differential; urinalysis (but not urine protein creatinine), ESR (but not CRP); complement, renal, and hepatic function testing; and most autoantibody testing (but not antiphospholipid antibody testing). Where there were differences in likelihood to order a test, rheumatologists were more likely to order the test than dermatologists.

In deciding on initial treatment, “rheumatologists were more likely to always initiate hydroxychloroquine than dermatologists,” said Dr. Arkin. Of the rheumatologists, 49% always initiated hydroxychloroquine, compared with 14% of the dermatologists (P less than .001).

In contrast, “dermatologists were more likely to always initiate topical therapy than the rheumatologists,” said Dr. Arkin. Topical therapy was always started by 81% of the dermatologists and 33% of the rheumatologists (P less than .001).

Although the specialties differed in whether they always initiated a certain treatment, “hydroxychloroquine achieved consensus as first-line therapy,” Dr. Arkin noted, with 81% of dermatologists and 87% of rheumatologists choosing hydroxychloroquine when the survey asked for a first-line systemic therapy.

There was no consensus about which agents were best for add-on therapy. Of the dermatologists, 32% would sometimes use methotrexate, which was used by 21% of rheumatologists for refractory skin disease. Quinacrine was used as add-on therapy by 21% of dermatologists and 15% of rheumatologists. Rheumatologists were significantly more likely to add dapsone than dermatologists (28% vs. 5%, P = .002).

The survey points to the need to develop consensus guidelines in the treatment of pediatric DLE, said Dr. Arkin. “Knowledge gaps include risk factors for SLE, optimal screening, and therapy,” she explained. “Collection of robust longitudinal data will aid in developing pediatric consensus guidelines for DLE.”

Dr. Arkin had no conflicts of interest.
 

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