In adults, lichen planus (LP) is relatively more common than in children. Among 222 cases of LP, there were 25 (11.2%) children in our study. The majority of the cases were females in the age group of 8-14; the youngest child was 3 years old. Papular and linear types of LP were common in children. There was no familial history of LP in any of the cases. The patients with classic LP lesions responded well to dapsone therapy. This study supports the suggestion of Ramsay and Hurley that childhood LP is more common in the tropics.

Basal plasma cortisol levels in 12 controls and 60 patients with different types of leprosy were within normal limits. They were significantly lower in multibacillary leprosy patients; this abnormality might be due to long standing stress leading to adrenal exhaustion. The plasma cortisol level significantly increased after the ACTH (Synacthen) stimulation test in all of the varieties of leprosy tested, which suggests that the adrenal reserve is maintained in such cases.

Colorectal cancers rarely present with bone metastases. Regular postoperative monitoring after resection by conventional imaging techniques and carcinoembryonic antigen levels aids physicians in identifying such tumor recurrences. However, some recurrences might elude detection by bone scan, computed tomography, and magnetic resonance imaging, and newer tests such as immunoscintigraphy using radioimmune-tagged monoclonal antibodies may be more diagnostic. Here we report a case, presenting with delayed recurrence at a rare bony site, in which application of immunoscintigraphy helped in the definitive detection of the tumor recurrence.

INTRODUCTION: Oral chemotherapy with Vismodegib for locally advanced Basal Cell Carcinoma (BCC) is widely used by dermatologists. In several isolated case reports, rare hepatotoxicity has been reported, but no consumer safety notifications have been issued by the manufacturer or the FDA to date. CASE DESCRIPTION/METHODS: A 62-year-old Caucasian female presented to emergency room with profound jaundice of her skin and scleral icterus that began two weeks after completion of Vismodegib oral chemotherapy for BCC of the left lateral forehead (Figure 1). Her past medical history was only significant for hypertension and pyrosis. The patient reports that she did not take any prescription or over-the-counter medications, herbal supplements, and had no history of alcohol use. Admission labs revealed AST of 37, ALT of 287, alkaline phosphatase of 522, total bilirubin 11.2, direct bilirubin 6.9, and indirect bilirubin of 4.3. A prompt liver biopsy revealed findings consistent with drug-related injury, including bile ductular reaction associated with portal inflammation consisting of lymphocytes, eosinophils, and neutrophils (Figure 2). She was stabilized and discharged with a plan for weekly outpatient monitoring. However, she presented two weeks later with complaints of right upper quadrant pain and melanotic stools for two days. Admission labs revealed a hemoglobin of 8.4, decreased from 12.0 on previous discharge. She was transfused appropriately and an upper endoscopy (EGD) revealed bleeding from the papillary orifice, indicative of hemobilia (Figure 3), warranting selective angiography and coil embolization for successful hemostasis. Jaundice resolved fully in four weeks and hemoglobin and liver function tests (LFTs) normalized in two months at follow-up. DISCUSSION: As noted in our case, gastroenterologists are bound to see an array of iatrogenic life-threatening complications from outpatient oral therapy for cosmetic lesions. Our case involved not only the hepatotoxic effects from Vismodegib, but a rare iatrogenic complication from the biopsy with bleeding requiring further interventions. Fatalities have been reported with this drug. Therefore, heightened awareness in medical community and mandated patient safety notifications by the manufacturer and the FDA are necessary to improve outcomes.

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