In diabetic patients with normal coronary and ejection fraction, segmental and global end-systolic longitudinal ST decreased and differences between Ts among LV segments increased irrespective of diastolic dysfunction at early stage. These results suggest that there might be early detectable changes in systolic function in the natural course of diabetes mellitus by STE study.

Among tissue Doppler and deformation indices, overall peak systolic strain was the strongest correlate of the LV hypertrophy grade. Therefore, in hypertensive patients with normal cardiac systolic function, a reduction in overall strain in the 6 basal LV segments may be a good indicator of progression of the LV hypertrophy grade and systolic dysfunction.

Toxic epidermal necrolysis (TEN) and cutaneous mucormycosis are dermatological emergencies. Both present with cutaneous necrosis that warrant prompt management, which is mutually exclusive. We report a case of TEN complicated by invasion of Apophysomyces variabilis species of Mucor that ended in a fatal outcome. A 45-year-old bipolar affective disorder patient developed itchy maculopapular rash due to carbamazepine. He was treated with 60 mg prednisolone from a local hospital without stopping the causal drug. Mucocutaneous examination revealed intact blisters at the periphery of eroded skin along with atypical target lesions on the face, trunk, and proximal extremities. Haemorrhagic crusting of lips, oral erosions, and mucoid exudates from eyes were noted. Deep ulcers with irregular borders covered with blackish eschar were noted on the trunk and both arms (Figure 1). In addition to stopping carbamazepine, he was treated with intravenous vancomycin for Staphylococcus aureus sepsis. High-dose intravenous immunoglobulin was also administered since he had new necrotic areas coming up. The erythema and atypical target lesions responded rapidly to the treatment, although deep necrotic ulcers persisted. Punch biopsy was taken from the margin of a necrotic ulcer, and he was put on empirical intravenous amphotericin-B. Histopathology showed features of toxic epidermal necrolysis with mucormycosis (Figure 2). Although there was initial improvement in ulcers, the patient developed septic encephalopathy on the fourth week of admission. Eventually, the patient died of multiorgan dysfunction syndrome. Polymerase chain reaction of the biopsy specimen was performed using panfungal primers ITS1 5′-TCCGTAGG-TGAACCTGCGG-3′ and ITS2 5′-GCTGCGTTCTTCATC-GATGC-3′ targeting the partial internal transcribed spacer region (ITS-1) of the nuclear ribosomal DNA. Subsequent sequencing of the amplicon was performed using the Big Dye Terminator Sequencing ready reaction kit in an automated ABI 3130 genetic analyzer (Applied Biosystems, Foster City, California). The sequence obtained showed 99% to 100% identity with A. variabilis in the NCBI database. In the current patient, the possibility of a necrotizing angioinvasive fungal infection was overlooked initially due Medical Letter 679827C MSXXX10.

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