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provided clinical data. Mauro Krampera reviewed the paper. Roberta Zanotti designed the research study, analyzed data and reviewed the paper. All authors read and approved the final manuscript.

BackgroundDelirium is a frequently misdiagnosed and inadequately treated neuropsychiatric complication most commonly observed in terminally ill cancer patients. To our knowledge this is the first report describing delirium in two patients aged less than 60 years and enrolled in an intensive chemotherapeutic protocol for acute promyelocytic leukemia.Case presentationTwo female Caucasian acute promyelocytic leukemia patients aged 46 and 56 years developed delirium during their induction treatment with all-trans retinoic acid and idarubicin. In both cases symptoms were initially attributed to all-trans retinoic acid that was therefore immediately suspended. In these two patients several situations may have contribute to the delirium: in patient 1 a previous psychiatric disorder, concomitant treatments with steroids and benzodiazepines, a severe infection and central nervous system bleeding while in patient 2 steroid treatment and isolation. In patient 1 delirium was treated with short-term low-doses of haloperidol while in patient 2 non-pharmacologic interventions had a beneficial role. When the diagnosis of delirium was clear, induction treatment was resumed and both patients completed their therapeutic program without any relapse of the psychiatric symptoms. Both patients are alive and in complete remission as far as their leukemia is concerned.ConclusionsWe suggest that patients with acute promyelocytic leukemia eligible to intensive chemotherapy should be carefully evaluated by a multisciplinary team including psychiatrists in order to early recognize symptoms of delirium and avoid inadequate treatments. In case of delirium, both pharmacologic and non-pharmacologic interventions may be considered.

There is still some concern about the use of biologics for patients with psoriasis and concurrent hepatitis B virus (HBV) or hepatitis C virus (HCV) infection. In particular, there are scarce data regarding the safety of IL-23 inhibitors in this group of patients. We performed a multicentric retrospective cohort study on 26 consecutive psoriasis patients with HBV infection and 23 patients with HCV infection treated with risankizumab. Patients were monitored for liver function tests (LFTs) at baseline and every 3 months thereafter. Liver stiffness measurement (LSM) by FibroScan was performed in 9 HCV patients. Demographic and clinical data on HBV-patients are listed in Table 1. Eleven of the 26 patients (42.3%) had chronic HBV infection, seven (26.9%) had a serology compatible with a previous or an occult HBV infection, and eight (30.8%) had resolved HBV infection.Patients with chronic HBV infection were under antiviral therapy, except for one patient with undetectable HBV-DNA who underwent only strict serological and biochemical follow-up. Serum HBV-DNA load was undetectable in all patients with previous/occult and resolved HBV infection, and in 7/11 patients with chronic HBV infection. During follow-up, all patients showed stable LFTs and HBV-DNA load with respect to baseline levels; no patients developed hepatocellular carcinoma during risankizumab treatment. Demographic and clinical data on HCV patients are listed in Table 2. Thirteen of the 23 patients (56.5%) had a resolved HCV infection with undetectable HCV-RNA after successful treatment with direct-acting antivirals. Ten patients with detectable HCV-RNA at baseline started concomitant treatment with direct-acting antiviral drugs, all achieving sustained virologic response. All patients were stable with regard to their baseline LFTs and HCV-RNA load, and no patients developed hepatocellular carcinoma during risankizumab treatment. Data on liver fibrosis were collected for nine patients, showing a slight but significant decrease of fibrosis after a median time of risankizumab therapy (mean 3.44 ± 0.88 kPa at baseline and 2.89 ± 0.78 kPa at the end of follow-up; p-value = 0.025). According to the World Health Organization's last global report, in 2019 around 296-million people and 58-million C

DEAR EDITOR, A 65-year-old healthy man presented with an acute-onset painful ulcer with a purulent base and soft undetermined edges on the frenulum (a), in the absence of inguinal lymphadenopathy. Infectious aetiologies were carefully excluded. Serological tests for syphilis were repeatedly negative. Polymerase chain reaction testing of ulcer scraping for Haemophilus ducreyi and herpes simplex virus were negative. Culture for Chlamydia trachomatis and intracytoplasmic Donovan bodies on Wright's stain from the ulcer swab were also negative. Microscopic examination revealed massive necrosis of the overlying epidermis, granulomatous cell infiltrate and perifollicular abscesses (b; original magnification 9 40), supporting the diagnosis of pyoderma gangrenosum. 1 The patient received oral therapy with azathioprine (2Á5 mg kg À1 ) associated with prednisone (0Á5 mg kg À1 ) and topical therapy with potent topical corticosteroids and local wound care, achieving a complete clinical remission after 3 months (c).The patient has given informed consent to publication of the photos. Protection of anonymity is guaranteed.