Metastatic melanoma of unknown primary origin often presents a major diagnostic and therapeutic challenge to the clinician. Herein, we present a case of metastatic brain melanoma of unknown primary origin in a patient with generalized lentiginosis and features of Leopard syndrome, which is the first case reported to date as of reviewing the literature. This case presents features suggestive of Leopard syndrome. Clinicians must be aware that a malignancy may occur even in the absence of the complete clinical picture of Leopard syndrome.

Sir, A small descriptive study in a tertiary hospital in Greece was conducted on the comorbidities of alopecia areata in infancy and childhood. Alopecia areata is a non-scarring alopecia of autoimmune origin linked also to genetic and environmental factors [1], affecting 2% of the general population and is considered a disease of young adults. Attempts have been made to detect the comorbidities in infants and children suffering from alopecia areata. Sorell Jennifer et al. established a strong association of alopecia areata with atopy, psoriasis thyroid disease, and juvenile idiopathic arthritis [2]. More recently, Comiz et al. [3] added anemia, obesity, vitamin D deficiency, hypothyroidism, vitiligo, psoriasis, hyperlipidemia, and depression to the list of the comorbidities detected in the pediatric population with alopecia areata. The purpose of the study was to detect the comorbidities in infants and children with alopecia areata in an outpatient dermatology clinic during a period of six years from 2013 through 2019. All those examined as outpatients and those hospitalized for several reasons in the pediatric ward who were diagnosed with alopecia areata were included in the study. Laboratory tests, a full blood count, and vitamin D, IgE, and thyroid tests were performed in the laboratories of our hospital. During these seven years, 71 patients were diagnosed with alopecia areata and 7 (approx. 10%) were children. Four (57.1%) were males, and the rest three were females. The males were aged 23 months, and 6-, 7-, and 11-years. The females were 2-, 7-, and 11-year-old. Clinical atopy confirmed by high levels of IgE in the serum was detected in two males and in all three females. Thyroid dysfunction, hypothyroidism, was only detected in one infant associated with atopy; this was in a 23-month-old who at the time of the diagnosis of alopecia areata was hospitalized with severe asthma. Vitamin D deficiency was found in one male patient. A family history of alopecia areata was found in only one male patient. A family history of atopy was reported in only one boy, aged 7 years. A family history of thyroid dysfunction was detected in two males 28%: The 23-month-old infant whose father suffered from hyperthyroidism and the 12-year-old male whose both parents suffered from hypothyroidism. A family history of rheumatoid arthritis was found in one female patient. All patients presented with a mild disease limited to the scalp at the time of diagnosis. No nail pitting was observed, and neither clinical signs of psoriasis, nor of vitiligo. Folliculitis of the scalp preceded the onset of alopecia areata in one of the females (Table 1). Although males comprised 57.1% of our cases, most studies have found a preponderance of females in the pediatric population with AA. Atopy was the most frequent comorbidity (5/7; 70%) and was more frequent in females; all three girls were atopic. The second most frequently found comorbidity was thyroid dysfunction, hypothyroidism., detected in one patient (14%). Vitamin D deficiency was noted in one (14%) patient. A family history of AA was found in one patient as well as a family history of atopy. A family history of thyroid dysfunction was found in two patients (28%). The precipitating factor in our case was staphylococcal infection of the scalp. Staphylococcus, probably acting as a super antigen, was observed in only one patient (14%). Both atopy and thyroid dysfunction should be sought for in pediatric patients with AA in this order.

Genital ulcers may be associated with a variety of clinical disorders such as infectious conditions (streptococcal, staphylococcal infections), syphilis, immune disorders such as lupus erythematosus or scleroderma as well as tumors (squamous cell carcinoma etc). Other conditions such as Behcet or Crohn disease have been associated with genital ulcers.

Sir, A 74-year-old female patient treated with angiotensin-converting enzyme inhibitor for arterial hypertension with metformin and atorvastatin for insulin-independent diabetes mellitus and hyperlipidemia, respectively, consulted the outpatient dermatological clinic for a rash that appeared fifteen days prior to consultation. The patient received the second dose of mRNA COVID-19 vaccine on July 29, 2021, and was due to receive the third dose on December 29, yet she fell ill on day 6 of the same month, probably being infected by one of her grandchildren. The eruption consisted of erythematous, purpuric macules on the anterior face of both tibia (Fig. 1a), of a solitary papule on the left hand (Fig. 1b), and of erythematous papules with a scale on the border on the left buttock (Fig. 1c). A collarette formed on the trailing edge of the advancing border of the hand lesion, a clinical sign pathognomonic of pityriasis rosea. Intense pruritus accompanied the eruption. No herald patch was observed, nor lesions on the trunk, being the typical location of lesions of pityriasis rosea, while lesions on the hands are absent in the typical cases of the disease. The oral and genital mucosae were intact. The cutaneous manifestations of COVID-19 include purpuric, chilblain, vesicular, urticarial, and pityriasis rosea-like lesions. Acral lesions are the most frequent location of the cutaneous manifestations associated with COVID-19 infection [1]. An acral distribution of lesions is a feature of mouth, hand, and foot disease due to infection with Coxsackie A16 virus [2], although no reactivation of this virus has been detected during the COVID-19 pandemic, while the reactivation of herpes 6 and herpes 7 virus associated with pityriasis rosea has occurred