Discussion | Acrodermatitis continua of Hallopeau, also known as acrodermatitis perstans and dermatitis repens, is a rare inflammatory pustular dermatosis of the distal fingers and toes. It is considered a variant of pustular psoriasis or, less commonly, its own pustular psoriasis-like independent entity. 1 Precise pathophysiology and incidence are unknown. Case literature suggests predominance in women, but the disease affects both sexes and, rarely, children. 2 Acrodermatitis continua of Hallopeau initially presents as erythema overlying the distal digits that evolves into pustules. 2 The nail bed is often involved, with paronychial and subungual involvement and atrophic skin changes. 3 Most patients experience a chronic, relapsing course involving the proximal digit as the condition worsens. 4 Acrodermatitis continua of Hallopeau has been reported to both evolve into and stem from generalized plaque or pustular psoriasis. 3 The present patient was noted to have plaque psoriasis lesions nearly 1 year after the onset of her disease. Psoriatic arthritis is a rare complication, 3 but distal phalanx osteolysis is an important comorbidity. 1 The differential diagnosis includes infectious paronychia of viral, fungal, or bacterial etiology, infected contact dermatitis, and dyshidrotic eczema. 4 Gram stain, potassium hydroxide mount, culture, and microscopy may be useful in diagnosis. Histopathologically, ACH is characterized by neutrophil-rich spongiform pustules within the epidermis, dermal edema, and lymphohistiocytosis. 4 As in pustular psoriasis, biopsy from the nail bed often reveals acanthosis and spongiform pustules. 3 Treatment with topical corticosteroids, tacrolimus, fluorouracil, calcipotriol, methotrexate, acitretin, cyclosporine, and phototherapy have produced inconsistent responses. Successful treatment with tumor necrosis factor inhibitors and the IL-1 inhibitor anakinra 5 have been reported. However, these agents are not always efficacious and may even have the potential to incite pustular psoriasis. 6 Two cases of ACH treated with concomitant ustekinumab and acitretin have been reported, one successfully, 1 the other unsuccessfully. 5 The present case is the first to our knowledge to be successfully treated with ustekinumab as monotherapy. Given that the literature supports ustekinumab as monotherapy and concomitant therapy for pustular psoriasis, ustekinumab was a reasonable choice for our patient and succeeded when other agents had failed.
BackgroundRegadenoson is a vasodilator stress agent that selectively activates the A2A receptor. Compared to adenosine, regadenoson is easier to administer and results in fewer side effects. Although extensively studied in patients undergoing nuclear perfusion imaging (MPI), its use for perfusion cardiovascular magnetic resonance (CMR) is not well described. The aim of this study was to determine the prognostic value of a normal regadenoson perfusion CMR in patients with known or suspected coronary artery disease.MethodsPatients with known or suspected coronary artery disease were prospectively enrolled to receive perfusion CMR (Philips 1.5 T) with regadenoson. Three short-axis slices of the left ventricle (LV) were obtained during first pass of contrast using a hybrid GRE-EPI pulse sequence (0.075 mmol/kg Gadolinium-DTPA-BMA at 4 ml/sec). Imaging was performed 1 minute after injection of regadenoson (0.4 mg) and repeated 15 minutes after reversal of hyperemia with aminophylline (125 mg). Perfusion defects were documented if they persisted for ≥2 frames after peak enhancement of the LV cavity. CMR was considered abnormal if there was a resting wall motion abnormality, decreased LVEF (<40%), presence of LGE, or the presence of a perfusion defect during hyperemia. All patients were followed for a minimum of 1 year for major adverse cardiovascular event (MACE) defined as coronary revascularization, non-fatal myocardial infarction, and cardiovascular death.Results149 patients were included in the final analysis. Perfusion defects were noted in 43/149 (29%) patients; 59/149 (40%) had any abnormality on CMR. During the mean follow-up period of 24 ± 9 months, 17/149 (11.4%) patients experienced MACE. The separation in the survival distributions for those with perfusion defects and those without perfusion defects was highly significant (log-rank p = 0.0001). When the absence of perfusion defects was added to the absence of other resting CMR abnormalities, the negative predictive value improved from 96% to 99%.ConclusionRegadenoson perfusion CMR provides high confidence for excellent prognosis in patients with normal perfusion.
SummaryRegadenoson is a new vasodilator myocardial stress agent that is easier-to-use and more tolerable than adenosine. We demonstrate that, in patients undergoing cardiovascular magnetic resonance myocardial perfusion imaging, regadenoson is safe and effective in producing hyperemia and identifying the need for future revascularization.
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