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Competing Interests: Conflicts of interest None disclosed.

Background: Immunocompromised patients, including those with human immunodeficiency virus (HIV), have been observed to have verrucae that are more extensive and treatment-resistant compared to those in immunocompetent patients. However, there is a critical lack of data in the current literature on the characteristics of verruca vulgaris in individuals with HIV., Methods: This retrospective chart review included a cohort of HIV-positive individuals and a control group of immunocompetent individuals presenting to an outpatient, county hospital-based dermatology clinic for evaluation of verruca vulgaris between the years of 2016 and 2018. Clinical characteristics, including gender, age, last CD4 count, viral load, antiretroviral therapy adherence, and total number and location of lesions were recorded., Results: A total of 66 patients (33 HIV-positive, 33 immunocompetent) were included in the study. HIV-positive status was significantly associated with a higher total number of lesions (42% of immunocompromised patients versus 21% of immunocompetent patients presented with four or more lesions, P=0.04) as well as location of lesions on the face, scalp, and neck (51.5% versus 9.1%, P<0.001)., Conclusions: HIV-positive status may be associated not only with a higher burden of verruca vulgaris lesions but also a higher number of lesions in locations at or above the neck.

Condyloma lata, a cutaneous manifestation of secondary syphilis, typically presents as verrucous papules or plaques in the anogenital area. Here, we present a case of secondary syphilis presenting in a 38-year-old man as condyloma latum of the plantar foot in the absence of other cutaneous findings of secondary syphilis. The plantar foot is an unusual location for condyloma lata which has not previously been reported in the medical literature. Histopathology was essential to diagnosis in this case and demonstrated verrucous epidermal hyperplasia with a plasma cell-rich infiltrate in the dermis and innumerable spirochetes in the epidermis. The patient was successfully treated with intramuscular penicillin benzathine G. Given the recent rise in the incidence of primary and secondary syphilis, it is essential for clinicians to be aware of atypical presentations of secondary syphilis to avoid delays in treatment and decrease the risk of transmission to sexual partners.

Competing Interests: The authors declare no conflicts of interest.

Nodular secondary syphilis is an uncommon variant of secondary syphilis. We identified three cases of nodular secondary syphilis at our institution. The first patient presented with a diffuse nodular rash that included his scrotum and penis. The second patient had disseminated skin-colored nodules with serosanguinous crust on his face, trunk, and extremities. The third patient had a pruritic papular and nodular rash with overlying crust. All three patients had a reactive rapid plasma reagin and tested positive for fluorescent treponemal antibody absorption. All were eventually confirmed to be human immunodeficiency virus-positive. Histopathological examination demonstrated inflammatory infiltrate in the dermis composed of lymphocytes, histiocytes, and plasma cells, and treponemal staining highlighted spirochetes in the dermis. The patients were successfully treated with intramuscular penicillin benzathine G. Physicians should be aware of nodular syphilis as a less common cutaneous manifestation of secondary syphilis. Prompt diagnosis of secondary syphilis can expedite resolution of the infection and avoid progression to tertiary syphilis.

Postoperative inflammation and the formation of fibrotic tissue around the intracochlear electrode array are often held responsible for negative outcomes in cochlear implant recipients. Here we test the effectiveness of intracochlear delivery of dexamethasone via a drug-eluting electrode array in reducing fibrotic tissue formation, assessed via measurement of both monopolar and four-point electrode impedance. Adult guinea pigs were bilaterally implanted with a dexamethasone-eluting array (left ear) and a standard non-eluting array (right ear). Arrays were electrically stimulated daily for 4 weeks, commencing 1 week after implantation, and impedance measured both before and after stimulation. Histological assessment of the tissue was made at the end of the 5-week period. The dexamethasone-eluting array did not reduce monopolar (MP1 + 2) electrode impedance over the course of 5 weeks, and no significant difference was observed in fibrotic tissue, new bone growth, or spiral ganglion neuron density between array types. However, four-point impedance, which provides an indication of the local environment at the neural-tissue interface, was significantly lower in the presence of dexamethasone. A strong relationship was seen between four-point and monopolar impedance for individual electrode arrays, with the exception of the standard array after daily electrical stimulation. This group instead showed a significant correlation between the final four-point impedance measure and percentage of fibrous tissue and new bone growth. In conclusion, this study demonstrated that dexamethasone influences four-point electrode impedance as well as the relationship between fibrotic tissue and impedance, and that both outcomes are shaped by daily electrical stimulation. These results suggest a change occurs at the local tissue-electrode interface in the presence of sustained, intracochlear release of dexamethasone.

Verrucous venous malformation, also known as verrucous hemangioma, is a superficial vascular malformation with a variable degree of hyperkeratosis that is composed of capillaries and veins in the dermis and sometimes subcutaneous tissue. We describe a 53-year-old man who presented with a large hyperkeratotic plaque of the left dorsal and plantar foot. Biopsy revealed verrucous acanthosis of the epidermis and a proliferation of thin-walled vessels in the dermis. We provide a brief review of the clinical and histopathologic presentation, differential diagnosis, and management of this rare entity.

Follicular porokeratosis is a rare variant of porokeratosis in which the coronoid lamellae are confined to hair follicles. It classically presents with annular plaques with a surrounding keratotic ridge. However, the clinical presentation has shown significant variation in reported cases. We present the case of a 26-year-old man with chronic diffuse follicular spicules associated with alopecia. Clinical findings were suggestive of trichodysplasia spinulosa, but multiple biopsies showed findings consistent with follicular porokeratosis. Diffusely spiculated presentation as present in our patient has not been previously reported in the literature. It is important to recognize the necessity of histopathologic confirmation in a diagnostically challenging condition such as follicular porokeratosis.

Nocardia is a ubiquitous environmental pathogen that causes infection primarily following inhalation into the lungs. It is generally thought to cause infection primarily in immunocompromised patients, but nonimmunocompromised individuals are also at risk of infection. We sought to compare risk factors, clinical manifestations, diagnostic approach, treatment, and mortality in immunocompromised and nonimmunocompromised adults with nocardiosis.We studied all adults with culture-proven Nocardia infection at a tertiary care hospital from 1994 to 2015 and compared immunocompromised with nonimmunocompromised patients. The immunocompromised group included patients who had a solid organ transplant, hematopoietic cell transplant (HCT), hematological or solid tumor malignancy treated with chemotherapy in the preceding 90 days, inherited immunodeficiency, autoimmune/inflammatory disorders treated with immunosuppressive agents, or high-dose corticosteroid therapy for at least 3 weeks before the diagnosis of nocardiosis.There were 112 patients, mean age 55 ± 17 years; 54 (48%) were women. Sixty-seven (60%) were immunocompromised, and 45 (40%) were nonimmunocompromised. The lung was the site of infection in 54 (81%) immunocompromised and 25 (55%) nonimmunocompromised patients. Pulmonary nocardiosis in immunocompromised patients was associated with high-dose corticosteroids, P = .002 and allogeneic HCT, P = .01, and in nonimmunocompromised patients with cigarette smoking, bronchiectasis, and other chronic lung diseases, P = .002.Cavitation occurred only in the immunocompromised group, P < .001. Disseminated infection was more common in the immunocompromised, P = .01, and was highest in solid organ transplant recipients, P = .007. Eye infection was more common in nonimmunocompromised patients, P = .009. Clinical signs and symptoms did not differ significantly between the 2 groups. The initial treatment for most patients in both groups was trimethoprim-sulfamethoxazole with or without a carbapenem. All-cause 1-year mortality was 19%; 18 (27%) immunocompromised and 3 (7%) nonimmunocompromised patients died, P = .01.Immunocompromised patients with nocardiosis had more severe disease and significantly higher mortality than nonimmunocompromised patients, but clinical presentations did not differ.

Purpose: Following successful clinical outcomes of the prototype suprachoroidal retinal prosthesis, Bionic Vision Australia has developed an upgraded 44-channel suprachoroidal retinal prosthesis to provide a wider field of view and more phosphenes. The aim was to evaluate the preclinical passive safety characteristics of the upgraded electrode array., Methods: Ten normal-sighted felines were unilaterally implanted with an array containing platinum electrodes (44 stimulating and 2 returns) on a silicone carrier near the area centralis. Clinical assessments (color fundus photos, optical coherence tomography, full-field electroretinography, intraocular pressure) were performed under anesthesia prior to surgery, and longitudinally for up to 20 weeks. Histopathology grading of fibrosis and inflammation was performed in two animals at 13 to 15 weeks., Results: Eight animals showed safe electrode array insertion (good retinal health) and good conformability of the array to the retinal curvature. Eight animals demonstrated good mechanical stability of the array with only minor (<2 disc diameters) lateral movement. Four cases of surgical or stability complications occurred due to (1) bulged choroid during surgery, (2) hemorrhage from a systemic bleeding disorder, (3) infection, and (4) partial erosion of thin posterior sclera. There was no change in retinal structure or function (other than that seen at surgery) at endpoint. Histopathology showed a mild foreign body response. Electrodes were intact on electrode array removal., Conclusions: The 44-channel suprachoroidal electrode array has an acceptable passive safety profile to proceed to clinical trial. The safety profile is expected to improve in human studies, as the complications seen are specific to limitations (anatomic differences) with the feline model.

Cochlear implant systems are used in diverse environments and should function during work, exercise and play as people go about their daily lives. This is a demanding requirement, with exposure to liquid and other contaminant ingress from many sources. For reliability, it is desirable that the speech processor withstands these exposures. This design challenge has been addressed in the Nucleus(R) Freedom(TM) speech processor. The Nucleus Freedom speech processor complies with International Standard IEC 60529, as independently certified. Tests include spraying the processor with water followed by immediate verification of functionality including microphone response, radio frequency link and processor controls. The processor has met level IP44 of the Standard.

Background: Ischemic preconditioning (IPC) and pharmacological preconditioning (PPC) have both been shown to confer cardioprotective effects. However, the role of protein synthesis in preconditioning is unclear., Methods and Results: Isolated rabbit hearts were treated with cycloheximide (CHx, 10 micromol/L), a protein synthesis inhibitor at the translational level, before 2 cycles of IPC (5 minutes of global ischemia/5 minutes of reperfusion, n=6) or PPC by pinacidil (PIN, 10 micromol/L; n=6), an ATP-sensitive potassium channel opener. Six rabbit hearts received actinomycin D (Act D, 20 micromol/L; n=6), a protein synthesis inhibitor at the transcriptional level, before IPC. The left anterior descending coronary artery was then occluded for 60 minutes and reperfused for 120 minutes. Control hearts received no treatment before prolonged ischemia (n=6). Left ventricular pressure, action potential duration, and coronary flow were measured. Infarct size is expressed as a percentage of the area at risk. IPC (n=6) and PIN (n=8) hearts experienced reduced infarct size compared with control hearts (22+/-3% and 27+/-2% versus 46+/-3%, IPC and PIN versus control; P:<0.01). Translational blockade (CHx) reversed the IPC infarct size reduction effect (22+/-3% versus 48+/-4%, IPC versus CHx+IPC; P:<0.01) but not the effects of pinacidil (27+/-2% versus 29+/-3%, PIN versus CHx+PIN; P:=NS). Transcriptional blockade (Act D) did not abolish the IPC effect (23+/-5% versus 22+/-3%, Act D+IPC versus IPC; P:=NS). There were no significant differences in electromechanical function consequent to CHx and Act D treatment., Conclusions: These findings suggest an important role for protein synthesis in the mechanism for IPC-mediated protection at the translational level, which may be different from PPC.