Correspondence

Simply searching for nests and removing them from the from 2000‑ 35000). ANA repeated twice during the vicinity of humans can put an end to an unbearable treatment course was negative. After 1.5 years; child agony of the victims. started developing asymptomatic multiple erythematous annular plaques on face and extremities which were References misdiagnosed at several occasions with possibility of 1. Halliday RB, OConnor BM, Baker AS. “Global Diversity of Tinea and Seborrhoic dermatitis. Six months after Mites”. In Peter H. Raven and Tania Williams. Nature and onset of skin lesions she started developing lesions human society: The quest for a sustainable world: Proceedings of different morphology. She developed annular of the 1997 Forum on Biodiversity. Washington DC: National erythematous and plaques on bilateral malar Academies; 2000. p. 192‑212. 2. Ralph GP. Effects of the haematophagous mite Ornithonyssus area and petechiae, purpura on lower extremities. Many bursa on nestling starlings in New Zealand. New Zealand J discrete papules on face and extremities developed Zool 1977;4:1. central necrosis resembling targetoid lesions. Lesions 3. Owen JP, Mullens BA. Influence of heat and vibration on the healed with evidence of epidermal . She had cold movement of the northern fowl mite (Acari: Macronyssidae). extremities with dusky erythematous macules topped J Med Entomol 2004;41:865‑72. with ulceration on tips of fingers and toes [Figure 1]. Oral examination revealed erosions. Fundus examination

Access this article online revealed evidence of healed choroiditis. Rest of her Quick Response Code: systemic examination was normal. Based on these Website: www.e‑ijd.org findings, her work up was done for probable diagnosis of in setting of SLE with or without pernio and Rowell’s syndrome. DOI: 10.4103/0019-5154.156402 Investigations revealed mild anemia and thrombocytopenia (Platelet: 60000) without any evidence of hemolytic anemia. Her ANA was now positive in a speckled pattern. She had highly positive dsDNA (>1000) suggestive of high disease activity, positive anti Smith Idiopathic Thrombocytopenic antigen (suggestive of disseminated LE) and positive AntiRib P protein. Her coagulation profile, ANCA, β2 Purpura Masquerading Paediatric SLE microglobulin, complement levels and renal function were normal. Lesional biopsy revealed features of Meenu Barara, Taru Garg immune vasculitis. Since she fulfilled 4 out of 11 ARA From the Department of and STD, Lady Hardinge Medical College, New Delhi, India. E‑mail: [email protected] criteria, she was diagnosed as a case of SLE and started on daily oral Prednisolone at dose of 1mg/kg and Indian J Dermatol 2015:6(3):313-314 Hydroxychloroquine at 6mg/kg. Steroids were gradually Sir, tapered with response. Treatment led to stabilization of Idiopathic (ITP) is an platelet count, clearance of skin lesions and fall in titre auto‑immune disease characterized by accelerated of dsDNA to 160 within 2 months of therapy. clearance of auto‑antibody sensitized platelets and suboptimal platelet production. It is a diagnosis of exclusion established after ruling out secondary causes like medication, Auto‑immune diseases, Lympho‑proliferative disorders and chronic infection. We report a case of paediatric Systemic (SLE) which initially manifested as thrombocytopenia and was diagnosed as ITP. Development of cutaneous involvement followed the diagnosis of ITP a year later. A 4 year old girl child was diagnosed as ITP at the age of 2.5 years when she presented with petechiae and thrombocytopenia (Platelet count = 34000). Her bone marrow biopsy revealed a hypercellular marrow with increased number of megakaryocytes. Direct Coombs and ANA at presentation were negative. She underwent multiple (eight) admissions in subsequent Figure 1: Clinical photograph of patient showing targetoid lesions on face; healing 1 year wherein she was treated with systemic steroids with epidermal atrophy and purpuric lesions on extremities with central necrosis which led to fluctuating platelet levels (varying and ulceration

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Thrombocytopenia is seen in 7‑30% of SLE patients.[1] From the Department of Dermatology ESIPGIMSR Basaidarapur, Immune thrombocytopenia may precede SLE in upto 16% New Delhi, India. E-mail: [email protected] patients.[2] Mestanza peralta et al., followed up 115 patients Indian J Dermatol 2015:6(3):314-315 of ITP, who underwent splenectomy for its treatment, for Sir, 7.2 years and found that 14 patients developed SLE.[3] Similar results were found by Anderson et al., and Perez Porokeratosis (PK) is a primary disorder of epidermal et al., However; the studies by Altintas and Kurata had keratinization which presents with typical annular lesions contrasting results. Altintas studied 365 children and 108 with a hyperkeratotic raised border. The localized variants adults for a follow up period ranging from 2.1‑ 7 years. He include classic PK of Mibelli, linear PK, and punctate [1] found 9% children and 33% adults to be ANA positive. But PK. PK of the genitalia is a rare entity with most th th none of the ANA positive patients developed SLE.[4] cases reported in the 4 ‑5 decade. It has traditionally been included within porokeratosis of Mibelli or as a Older age, female gender and positive ANA are significant plaque form, although most published cases share some risk factors for development of ITP in patients of differential characteristics that suggest defining genital PK SLE.[5] Presence of high titre ANA is a sensitive marker as a distinct clinical variant.[2] A 22‑year‑old married man for future development of SLE in these patients. presented with multiple pruritic lesions over scrotum since Our case highlights the importance of a regular follow 4 years. They began as lentil sized lesions 4 years back and up of all patients of ITP and periodic screening with progressed in size and number spreading to involve the ANA. Any cutaneous changes in these patients should penis since 6 months. There was no response to various not be ignored and evaluated thoroughly in light of any topical medicaments including steroids and antifungals. connective tissue diseases as early disease detection can There was no family history of similar complaints and help in better patient management. no history suggestive of immunosuppression. Cutaneous examination revealed multiple well‑defined skin colored References scaly annular plaques approximately 6 to 14 mm in 1. Park SH, Kim JY, Kim SK, Choe JY, Kim SG, Ryoo HM. diameter present over the scrotum and shaft of penis with Regulatory T cells in systemic lupus erythematosus- a slightly depressed center surrounded by a peripheral associated thrombocytopenia: A comparison with idiopathic hyperkeratotic ridge [Figure 1]. On stretching the skin thrombocytopenic purpura. Lupus 2010;19:888‑9. the peripheral ridge revealed a circumferential furrow 2. Karpatkin S. Autoimmune thrombocytopenic purpura. Semin which was further delineated by performing the ink test Hematol 1985;22:260‑88. using gentian violet stain [Figure 2]. Examination of 3. Mestanza‑Peralta M, Ariza‑Ariza R, Cardiel MH, Alcocer‑Varela J. Thrombocytopenic purpura as initial manifestation of systemic the perianal, gluteal cleft and groin was within normal lupus erythematosus. J Rheumatol 1997;24:867‑70. limits. With the differential diagnosis of PK, lichen 4. Altintas A, Ozel A, Okur N, Okur N, Cil T, Pasa S, et al. Prevalence planus, annulare and a punch biopsy and clinical significance of elevated antinuclear antibody test in was taken from the raised peripheral edge. Routine children and adult patients with idiopathic thrombocytopenic investigations revealed no abnormality. Hematoxylin purpura. J Thromb Thrombolysis 2007;24:163‑8. and eosin staining of the biopsy specimen showed the 5. Zimmerman SA, Ware RE. Clinical significance of the presence of cornoid lamella [Figure 3]. A diagnosis of antinuclear antibody test in selected children with idiopathic thrombocytopenic purpura. J Pediatr Hematol Oncol porokeratosis was established. The patient was started 1997;19:297‑303. on capsule isotretinoin 20 mg once a day and twice daily application of fluticasone propionate cream. At Access this article online 6 weeks follow up the pruritus had decreased and there Quick Response Code: was slight flattening of the annular plaques [Figure 4]. Website: www.e‑ijd.org Although PK can nearly involve any area of the body, genital PK is considered extremely rare. Genital PK has traditionally been included within porokeratosis of Mibelli and its true incidence is still undetermined. Repeated DOI: 10.4103/0019-5154.156406 trauma (friction or scratching) might explain a part of pathogenesis.[1] Chen et al.[1] compiled all 11 published cases of porokeratosis confined to the genitalia and found all cases were described only in men except for 1 case reported in the natal cleft of a female. Three cases were associated with itching, one case had decreased CD4/CD8 Genital Porokeratosis: A Distinct without HIV and no malignant transformation was found Clinical Variant? In any of the reported cases. The authors postulated that these aforementioned features differentiate PK Urmi Khanna, Paschal D’Souza, Tapan Kumar Dhali localized to genitalia from PKM.[1] Several therapeutic

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