We report on a young woman who survived acute liver failure (ALF) without liver transplant. During the ALF, she developed a disabling, levodopa-unresponsive, symmetrical Parkinsonism. This was characterized by severe bradykinesia, mild rigidity, mutism, and prominent gait impairment. Magnetic resonance imaging (MRI) showed bilateral T1W pallidal hyperintensities. Parkinsonism and MRI changes remitted in parallel with normalization of hepatic function. We implicate excessive pallidal manganese deposition secondary to ALF in the pathogenesis of this neuroradiological syndrome. Though hitherto unreported, we propose that Parkinsonism with T1W pallidal hyperintensities may not be uncommon in ALF.
This paper identifies clinical factors that could be used to assess risk of surgical site infection following Mohs. Support is provided for some elements of existing guidelines: the type of repair appears to influence risk. 1 We found no support for differing locations on the head and neck being at increased risk or that flaps on the nose were more at risk than flaps elsewhere. We propose that this could be explained if the microbiome accounts for most of the risk for surgical site infection and is uniform in terms of the presence of S. aureus for an individual on the head and neck. Further detailed anatomical work on the head and neck microbiome would be needed to support this. 2 We did not have enough data to comment specifically on the risk from wedge closure or locations such as the groin and lower leg as risk factors. The surgical site infection risk synergy demonstrated between nasal S. aureus carriage and graft repair seems likely to result from occlusion of the skin which has been demonstrated to increase bacteria after 48 h. 3 Strategies for reducing this particular risk would include preoperative topical decolonisation of nasal S. aureus 4,5 and reducing the time period for which occlusive dressings are applied following grafting. An additional approach, applicable for all patients, would include enhanced clinical surveillance post-operatively for those who by the data from this analysis appear to be at increased risk of surgical site infection.
Granuloma faciale (GF) is a rare cutaneous disorder characterized by one to several soft, erythematous to livid papules, plaques or nodules, usually occurring on the face. Extrafacial lesions are uncommon. A 52-year-old lady with multiple asymptomatic, variously sized brownish-black colored, firm, sharply circumscribed plaques resembling keloids on both cheeks and extrafacial lesions on the right arm and the right breast is presented for its unusual keloidal appearance and typical histopathological findings. She failed to respond to oral dapsone 100 mg daily administered for 3 months. Local infiltration of triamcinolone combined with cryotherapy led to only partial flattening of the lesions. All the skin lesions were excised surgically followed by flap transfer grafting on both cheeks. The cosmetic outcome was highly satisfactory.
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