No abstract

A 51-year-old woman of Chinese origin with no relevant medical history presented to the outpatient dermatology department with a severe dermatitis of the vulva, perineum and groin. This was initially thought to be irritant, with superimposed candidal infection. Contact dermatitis was also considered, as the patient had been using topical haemorrhoid treatments. Topical corticosteroid/antifungal treatment was instituted, resulting in partial improvement, but the condition then progressively and rapidly deteriorated. Mycology swabs were negative. A single bacteriology swab grew Pseudomonas aeruginosa, presumed to represent colonization. Escalation of topical corticosteroid and oral antimicrobials failed to produce improvement. The

Iatrogenic Kaposi sarcoma (KS) is a relatively frequent occurrence following solid-organ transplants (0–5%), in part due to prolonged immunosuppression. However, its occurrence after haematopoietic stem cell transplantation (HSCT) is rare, with only 15 cases described in the literature. We report a case of KS presenting in the skin of a patient who had received a matched unrelated donor allogeneic HSCT for IgG kappa myeloma. A 55-year-old HIV-negative white man with myeloma underwent an allogeneic HSCT from a matched, unrelated donor following conditioning chemotherapy with fludarabine–melphalan and antithymocyte globulin. Post-transplant, he was maintained on ciclosporin as graft-versus-host disease (GVHD) prophylaxis. On day 14 post-transplant, he developed a widespread eczematous eruption that rapidly evolved into an erythroderma; a skin biopsy was consistent with acute GVHD. He was managed with superpotent topical steroids and a 5-day course of oral prednisolone. He began extracorporeal photopheresis (ECP) on day 33 post-transplant, having failed to respond adequately to systemic steroids. He also completed four cycles of rituximab. Ciclosporin was stopped by day 130 post-transplant. He had completed 14 cycles of ECP by day 139 post-transplant, with resolution of cutaneous GVHD; however, he had developed a rapidly growing solitary dusky-red nodule on his right neck that was excised due to diagnostic uncertainty. Histology revealed a dermal haemorrhagic exophytic vascular tumour composed of lobules and sheets of epithelioid cells with an eosinophilic cytoplasm and pleomorphic nuclei. Immunoperoxidase staining was negative for S100, MNF-116 and AE1/AE3. The same cells were strongly and diffusely positive for the vascular markers CD31, CD34 and ERG. The lesional cells were positive for human herpesvirus (HHV)-8 confirming a diagnosis of Kaposi sarcoma. He subsequently developed a second lesion on his left forearm, despite being off all immunosuppression. A repeat bone biopsy confirmed that he remains in morphological remission from his myeloma. Positron emission tomography–computed tomography has not identified extracutaneous disease. KS following HSCT is rare, but it can be fatal. Skin lesions are the dominant clinical presentation. HHV-8 has an important role in the pathogenesis, and transplant-related KS may occur secondary to reactivation of the virus as a result of significant immunosuppression following HSCT. However, it could also occur as primary infection or be transmitted with donor cells. The outcome of KS after HSCT is variable. A watch and wait strategy can be applied if immune recovery is expected. In our patient, it developed 5 months after HSCT; shortly after immunosuppression had been tapered, he remains well and will be closely monitored for further suspicious lesions.

We present an agent based simulation supplemented with two novel social network interconnectivity measures, `clumpiness' and `hoprank,' that are the same concept defined at global and local levels, respectively. The measures may be computed from samples of readily available demographic data, and are useful for measuring probabilistic packet transmission through social networks. For simplicity, agents in our simulation group together through homophily, the principle of `like attracts like'. In three studies we apply clumpiness to measure the effects, on disease transmission, caused by social networks of both homophilic physical proximity and homophilic information replication. The particular characteristic we are interested in about disease transmission is herd immunity, the percentage of a population that has to be immune in order to prevent infection from spreading to those who are not. Two studies demonstrate innovations measuring herd immunity levels and predicting future outbreak locations, procedures relevant to epidemiological control policy. In the first study, we look at how homophilic physical proximity networks form natural bubbles that act as frictive surfaces that affect the speed of transmission of packets and influence herd immunity levels. In the second study, we test clumpiness in homophilic proximity social networks as a predictor of future infection outbreaks at the level of individual schools, restaurants, and workplaces. Our third study demonstrates that protective social bubbles form naturally from homophilic information replication networks, and enhance the natural bubbles that come from the homophilic physical proximity networks. Accurate description of this information environment lays the foundation for epidemiological messaging policy formation.