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Background Onychomycosis is an important public health problem because of the increase in immunosuppressive states. Large-scale studies in India are scarce, and so the baseline incidence of onychomycosis is not firmly established. Methods Three hundred and two clinically suspected cases of onychomycosis were included in this study. Nail samples were collected for direct microscopic examination and culture. Clinical patterns and associated relevant factors were noted according to a predetermined protocol. Results The associated predisposing conditions included diabetes mellitus (3.9%) and systemic lupus erythematosus (2.3%). Distal and lateral subungual onychomycosis was the most common clinical pattern (62%), followed by total dystrophic onychomycosis (20.2%). The most common fungal isolates were dermatophytes (49.5%), followed by Candida spp. (40.4%) and nondermatophyte molds (10.1%). Of the dermatophytes, Trichophyton rubrum (47%) was the most common isolate, followed by Trichophyton tonsurans (20.4%). Of the Candida spp., Candida albicans was the most common (60%). Conclusions Until recently, yeasts and nondermatophyte molds were regarded as contaminants, but their emergence as a significant cause of onychomycosis in immunocompromised patients calls for mycologic diagnosis and antifungal susceptibility testing in onychomycosis. The recognition of the changing patterns of onychomycosis will aid in the therapeutic approach and the implementation of control measures.

A 33-year-old man presented with asymptomatic, gradually progressing, reddish nodules on the thigh of 1 year's duration. Six months later, nodules were noticed on the buttock of the same side. At the same time, the inguinal and femoral lymph nodes increased in size and could be seen as an elevated mass in the groin which, although painless, made the patient limp when walking. On examination, a cluster of pink nodules on an erythematous, oval, indurated area, measuring 10 cm × 5 cm, was seen on the lower medial aspect of the right thigh (Fig. 1). A small, almost circular, cluster of papules was present on the lower part of the right buttock. Some of these lesions, according to the patient, were reducing in size. The right inguinal and femoral lymph nodes were markedly enlarged and firm. The overlying skin was normal. Clinical differential diagnoses of dermatofibrosarcoma and localized, cutaneous T-cell lymphoma were considered in this patient. Systemic examination revealed no abnormality. Figure 1. Cluster of reddish nodules over the thigh Download figure to PowerPoint Routine investigations showed a normal hemogram with an erythrocyte sedimentation rate (ESR) of 25 mm/h. Urinanalysis, serum proteins, liver and renal function, chest X-ray, and paranasal sinuses were within normal limits. Peripheral blood smear examination did not show any abnormal cells. Immunoglobulin (Ig) levels showed: IgG, 12.9 g/L (reference range, 5.6–14.5 g/L); IgA, 4.6 g/L (reference range, 0.45–3.64 g/L); IgM, 0.7 g/L (reference range, 0.03–2.09 g/L). An incisional biopsy was taken from the skin lesion and fine needle aspiration (FNA) of the inguinal nodes was performed. FNA smears were moderately cellular. The cell population, predominantly polymorphic, comprised mature lymphocytes, plasma cells, neutrophils, and histiocytes. The histiocytes were large, having abundant cytoplasm, and the most prominent feature was the presence of lymphocytes and plasma cells engulfed within the histiocyte cytoplasm (emperipolesis) (Fig. 2). Skin biopsy from the lesion showed an essentially unremarkable epidermis. The entire dermis was densely infiltrated by a polymorphic inflammatory cell population. The predominant cell population was made up of large histiocytes having abundant pale cytoplasm. Plenty of lymphocytes arranged in a nodular pattern were also seen between the histiocytes. Plasma cells, neutrophils, and a few eosinophils were also interspersed. The striking feature was, however, engulfed neutrophils and lymphocytes within the histiocyte cytoplasm (emperipolesis) (Fig. 3). Immunohistochemical stains revealed S-100 positivity in the histiocytes (Fig. 4). The cytologic, histologic, and immunohistochemical findings were correlated and a diagnosis of Rosai–Dorfman disease was made. Figure 2. Photomicrograph of fine needle aspiration smears showing large histiocytes with engulfed lymphocytes and plasma cells (emperipolesis) (Giemsa, × 400) Download figure to PowerPoint Figure 3. Photomicrograph from the cutaneous nodule showing a dermal infiltrate of histiocytes, lymphocytes, neutrophils, and plasma cells. The large histiocytes reveal emperipolesis (hematoxylin and eosin, × 400) Download figure to PowerPoint Figure 4. Photomicrograph from the skin lesion showing a positive staining reaction with S-100 antibody within the histiocyte cytoplasm (avidin–biotin peroxidase, × 400) Download figure to PowerPoint

Background. This is an unusual presentation of lepromatous leprosy (ll) in a young boy, 12 years of age. The study forms part of a large scale immunotherapeutic trial with Mycobacterium w (M.w) antileprosy vaccine. The trial is being conducted in two major hospitals in New Delhi, India. Materials and Methods. This patient presented with three lesions: one on each forearm and the third on the left leg. He was classified initially as borderline tuberculoid leprosy. Slit-skin smears and histopathology from the lesions proved the diagnosis to be lepromatous leprosy with a bacterial index (bi) 6+. The initial lepromin test was negative. The patient was treated with chemo-immunotherapy (standard multidrug therapy and immunotherapy with Mycobacterium w vaccine). Results. Investigations after 1 year (15 months) of multidrug therapy and three doses of vaccine, showed a remarkable fall in the bi from 6 to 0 in the lesions, a lepromin positivity of 5 mm, and a histological upgrading from lepromatous leprosy to borderline tuberculoid. Immunologic studies at 15 months revealed a good LTT response and high levels of cytokines, specifically IL-2 and IFN-γ. Conclusions. This report presents an LL patient with disease limited to a few sites. It stresses the importance of slit-smear and biopsy in all patients of leprosy, and it highlights the upgrading observed on administration of chemo-immunotherapy.

Background. When multidrug therapy was introduced a decade ago to shorten the duration of treatment, paucibacillary leprosy was advocated 6 months of treatment. The diagnosis is based mainly on clinical and histopathologic examination, negative slit-skin smear examination, and positive lepromin test. Methods. The case records of 508 paucibacillary leprosy patients attending our urban leprosy center have been analyzed with reference to regularity of therapy, response to multidrug regimen, follow-up, and relapse. Results. The incidence of paucibacillary leprosy was found to be 37%. Defaulter rate was 45%. Nine percent of the cases attended the center with deformities emphasizing the need for corrective surgery and early case detection to prevent them. Conclusions. The main problem that we faced was the optimum duration of treatment, which is as yet an unsettled question. The opinions of other workers have been given, and a slight modification in current WHO regimen has been suggested without significantly affecting the cost of therapy.

Ten patients with fully treated paucibacillary leprosy, mainly tuberculoid, had asymptomatic nodules present along the peripheral nerves that persisted even after the skin lesions had completely subsided and treatment was stopped. Histopathology of the nodules revealed no signs of activity of the disease. The evolution, follow-up care, and significance of these nodules are discussed.

Observation chez un homme de 25 ans qui presente des eruptions cutanees depuis sa naissance. Bien que l'etiopathogenie exacte ne soit pas claire, on suggere le role possible de l'heredite, d'un traumatisme ou d'une augmentation du taux d'œstrogene sanguin