Poster Impact of Acne Vulgaris Severity on Quality of Life No.1 and Psychological Health in Hospital Tuanku Jaa’far, Seremban, Malaysia Zi Ling Hun 1, Najeeb Ahmad B. Mohd. Safdar 2, Chen Hsiung Liang 3, Vaani Valerie A/P Visuvanathan 2, Prakash A/L Balasubramaniam 2, Khar Weoi Low 3 1 International Medical University Clinical School, Seremban, Malaysia 2 Department of Dermatology, Hospital Tuanku Ja'afar Hospital, Seremban, Malaysia 3 Klinik Kesihatan Kahang Batu 22, Kluang, Johor, Malaysia INTRODUCTION RESULTS Acne is a common dermatological condition that • There was no significant difference between gender impacts approximately 85 percent of those between and acne severity (p= 0.242), as well as between ages of 12 and 24¹ . However, it is often viewed as a ethnic and acne severity (p= 0.369). cosmetic condition. Treatment of acne is often sidelined  The mean DLQI score was 9.60 ± 5.16. There was no by health care administrators resulting in poor resource significant difference between acne severity and the allocations in the treatment of acne. DLQI score (p= 0.104).  The mean for PHQ-4 score was 4.14 ± 3.63. There was no significant difference between acne severity OBJECTIVE and psychological health. (p= 0.425). To determine the impact of severity of acne on quality  No significant difference between gender and of life and psychological health among acne patients in dermatology life quality index (p= 0.866), as well as Hospital Seremban. psychological health ( p= 0.215). No significant difference between ethnic and dermatology life quality index (p= 0.208), as well as with psychological health MATERIALS AND METHOD ( p= 0.792).  A cross-sectional study on acne patients visiting Dermatology clinic in Hospital Tuanku Jaa’far, Seremban, Malaysia from August 2016 to January 2017 DISCUSSION was carried out. All patients with acne vulgaris aged 13  A higher prevalence of males (55%) having years and above were invited to participate in this study. moderate-severe acne than females, similar as had  Data was collected with standardized questionnaire been demonstrated in other studies². forms namely Global Acne Grading System (GAGS),  Mean DLQI score of 9.60 indicates patients in Dermatology Life Quality Index (DLQI) and Patient Seremban Hospital experienced moderate Health Questionnaire for Depression and Anxiety (PHQ- impairment in quality of life due to their acne. 4).  Mean PHQ-4 score was 4.14, indicating mild  The data was analyzed with T test, using statistical symptoms of depression and/or anxiety in the past analysis IBM SPSS. two weeks.  No significant difference between acne severity and dermatology life quality index (p= 0.104). This implies RESULTS that effect on quality of life should not be judged Table 1: Socio-demographic data and clinical based on acne severity alone. Lack of coping characteristics of patients strategies, for example, increased cosmetics usage and hairstyles to partly conceal the presence of acne, Characteristics N=40 (%) are other factors which may influence the quality of Gender life in patients, besides the severity of acne. Male 22 (55%) Female 18 (45%) LIMITATIONS Ethnicity  Small sample size Malay 27 (67.5%)  Cross sectional design Chinese 7 (17.5%) Indian 3 (7.5%) Others 3 (7.5%) CONCLUSION Acne severity using Global Acne Grading System (GAGS) Acne has a profound effect on quality of life and the Mild 21 (52.5%) psychological well being of patients. However these Moderate 17 (42.5%) effects are not related to the severity of acne per se. Severe 2 (5%) Quality of life and psychological health issues must be addressed in all patients with acne vulgaris regardless of acne severity. Table 2: Quality of life and psychological health of acne patients REFERENCES Quality of life and psychological N=40 (%) health 1. Bhate K, Williams H. Epidemiology of acne vulgaris. Br. J. Dermatol. 2013;168(3):474-485. Quality of life measured with 2. Aktan S, Ozmen E, S B. Anxiety, depression, and Dermatology Life Quality Index (DLQI) nature of acne vulgaris in adolescents. Int J Dermatol. No effect 1 (2.5%) 2000;39(5):354-357. Mild effect 8 (20%) 3. Yap F. The impact of acne vulgaris on the quality of Moderate effect 15 (37.5%) life in Sarawak, Malaysia. SSDDS. 2012;16(2):57-60. Very large effect 15 (37.5%) 4. Hanisah A, Omar K, Shah SA. Prevalence of acne Extremely large effect 1 (2.5%) and its impact on the quality of life in school-aged adolescents in Malaysia. J Prim Health Care. Psychological Health measured using 2009;1:20-5. Patient Health Questionnaire for 5. Tanghetti, E. A., Kawata, A. K., Daniels, S. R. Depression and Anxiety (PHQ-4) Yeomans, K., Burk, C. T., Callender, V. None 16 (40%) D.Understanding the Burden of Adult Female Acne. J Mild 9 (22.5%) Clin Aesthet Dermatol. 2014:7(2):22-30. Moderate 9 (22.5%) Severe 6 (15%) 2 Zulaiha A. Jalil, Siti Khalijah M. Zulkefli, Rajalingam Ramalingam Department of Dermatology, Hospital Tengku Ampuan Afzan, Kuantan INTRODUCTION There are many types of cutaneous adverse drug reactions (CADR), from mild pruritus to severe life-threatening conditions such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), with significant morbidity and mortality. Awareness of local epidemiology of CADR may play a vital role in future clinical management protocols. METHODOLOGY A retrospective review of all patients referred to the Department of Dermatology of Hospital Tengku Ampuan Afzan (HTAA), Kuantan, Pahang with CADR from 2013 to 2016 was carried out to determine the epidemiology of CADR in the local population. RESULTS Rates of CADR among both genders • A total of 62 CADR involving 59 patients • More females (80.0%) had SJS than males and various ethnic groups were seen among 7,353 new patients, (20.0%), while TEN showed a reverse No. of new No. with CADR yielding an incidence rate of 0.80% (yearly pattern (83.3% males vs 16.7% females) patients CADR rate CADR rate range: 0.16 – 1.89%) • Allopurinol was the commonest culprit N (%) N (%) (%) • The highest CADR rate was seen among drug causing SJS (7/15) and TEN (2/6) Gender indigenous peoples • Cotrimoxazole and Cloxacillin were the two Male 3567 (48.5) 37 (62.7) 1.04 • Two-thirds of patients with CADR were Female 3786 (51.5) 22 (37.3) 0.58 commonest antimicrobials implicated in between 21 and 60 years old, with a mean CADR, while the commonest analgesic was Ethnicity age of 47.3 years (range: 3 – 92) Malay 5697 (77.5) 41 (69.5) 0.72 Celecoxib Chinese 1176 (16.0) 11 (18.6) 0.94 • Two patients died, one each from dapsone • One-third of our patients only took a single Indian 322 (4.4) 3 (5.1) 0.93 hypersensitivity syndrome and TEN, drug, while the average number of drugs Indigenous 158 (2.1) 4 (6.8) 2.53 resulting in a mortality rate of 3.39% taken by a patient was three. Total 7353 59 0.80 Type of CADR (n=62) Culprit Group of Drug Stevens-Johnson syndrome 2% Antibiotics 2% Maculopapular Eruption 2% 2% 8% Toxic Epidermal Necrolysis 11% Allopurinol 2% Photodermatitis 5% 2% 24% Analgesics 3% Urticaria/Angioedema 3% Acute Generalized Exanthematous Pustulosis Antiepileptics 3% Exfoliative Dermatitis 3% 3% 48% Antimitotics Erythema Multiforme 3% 3% Fixed Drug Eruption Traditional & 21% Complimentary Medicine Erythroderma 10% 8% Antiretroviral Therapy Drug-related Eosinophilia with Systemic Symptoms 8% Lichenoid Drug Eruption 15% Unknown 10% Bullous Drug Eruption Others/Miscellaneous Dapsone Hypersensitivity syndrome No Data DISCUSSION A comparison of clinicoepidemiological studies on CADR in Malaysia and various Asian countries Huang HY, et al1 ChoonSE, et al2 TalibNH, et al3 Garg HK, et al4 MokhtariF, et al5 Janardhan B, et al6 Our Study (2004-2008) (2001-2010) (2009-2010) (2010-2012) (2006-2013) (2013-2014) (2013-2016) Shanghai, China JohorBahru, Malaysia KualaLumpur, Malaysia Ajman, UAE Isfahan, Iran Hyderabad, India Kuantan, Malaysia N=734 N=362 N=134 N=43 N=282 N=481 N=62 Male:Femaleratio 1:1.97 1.14:1 1.1:1 1:1.15 1:1.55 1.78:1 1.68:1 Mean age(years) 43.9 (8-93) 39.6 (1-98) 47.0 (14-91) 30.0 29.48 (0.4-90) 42 (1-64) 47.2 (3-92) Median latency (days) 7.64±8.32 NA NA 5.63±0.5 NA 4 (1-120) 6 Incidence/ NA Incidence: 0.86 Prevalence: 0.2 NA NA Prevalence: 1.08 Incidence: 0.8 Prevalence (%) Commonest CADR (%) 1. EM (34.7) 1. MPE (42.3) 1. MPE (22.4) 1. MPE (48.8) 1. SJS (31.9) 1. MPE (35.6) 1. SJS (24.2) 2. Urticaria(26.2) 2. SJS (24.3) 2. SJS (9.7) 2. Erythroderma 2. MPE (24.5) 2. Urticaria (26.2) 2. MPE (21.0) 3. MPE (21.7) 3. DRESS (9.4) 3. FDE (8.9) (18.6) 3. TEN (11.0) 3. FDE (17.9) 3. TEN (9.7) 3. Urticaria(11.7) Commonest Groupsof 1. Antimicrobials 1. Antimicrobials 1. Antimicrobials 1. Antimicrobials 1. AEDs (51.8) 1. Antimicrobials 1. Antimicrobials Culprit Drugs (48.3) (40.3) (36.6) (48.8) 2. Antimicrobials (56.3) (48.4) 2. Allopurinol (6.0) 2. AEDs (22.4) 2. TCM (17.9) 2. Analgesics (32.5) (33.7) 2. NSAIDs (19.5) 2. Allopurinol (14.5) 3. Allopurinol (13.8) 3. Analgesics (13.4) 3. TCM (4.6) 3. Analgesics (5.7) 3. AEDs (16.6) 3. Analgesics (9.7) EM: erythema multiforme; MPE: maculopapular exanthem; SJS: Stevens-Johnson syndrome; DRESS: drug-related eosinophilia with systemic symptoms; FDE: fixed drug eruption; TEN: toxic epidermal necrolysis; AEDs: anti-epileptic drugs; TCM: traditional and complimentary medicine; NSAIDs: non-steroidal anti-inflammatory drugs; NA: not available • Severe CADR, namely SJS and TEN, were among the commonest CADRs observed in the Malaysian hospitals above, including ours. This could be due to a referral bias, being dermatology referral centers accepting serious CADRs. This could also explain the lower CADR rate in our cohort compared to 1.38% and 1.5% of dermatology referrals in Denmark7 and Tunisia8, respectively. • We now know that there are specific genetic markers for carbamazepine- and phenytoin-induced CADRs9,10, and that these alleleic markers occur with varying frequency in different ethnic populations. Whether this holds true for the indigenous peoples of the state of Pahang resulting in higher CADR rates among them, requires further pharmacogenomic studies. • Antimicrobials being the predominant culprit group in almost all of the studies above not only reflects the high infectious diseases burden in tropical and subtropical Asia, but also serves to remind us of more judicious prescriptions of these agents in the future. CONCLUSION SJS was the commonest CADR encountered in our center, while the commonest culprit drug was allopurinol. Antibiotics as a group caused the most CADR. REFERENCES 1.HuangH.Y.,etal.Clin&ExpDermatol2010;36:135-1412.ChoonS.E.,etal.IndJDermatolVenereolLeprol2012;78(6):734-7393.TalibN.H.,etal.SAfrFamPract2015;57(4):227-2304.GargH.K.,etal.IntJMed ResProf2016; 2(5): 45-495. Mokhtari F.,et al. JResMedSci2014; 19: 720-5 6.JanardhanB., et al.Int JResDermatol 2017; 3(1): 74-78 7. BorchJ. E., et al. ActaDerm Venereol 2006; 86: 523-527 8. ZaraaI., et al.IntJ Dermatol2011;50:877-8809.LimK.S.etal.NeurolAsia2008;13:15-2110.ChangC.C.,etal.IntJDermatol2011;50:221-4 ACKNOWLEDGEMENT We would like to thank the Director General of Health, Malaysia for permission granted to present this report. * There is no conflict of interest for all authors * 3 INTRODUCTION Fungal infections of the skin is one the most common diseases encountered in dermatology. As a tertiary referral center in the state of Pahang, we sought to determine the clinicoepidemiology pattern of patients with cutaneous fungal infections. METHODS A retrospective review of all cutaneous specimens sent for fungal culture from the Department of Dermatology of Hospital Tengku Ampuan Afzan (HTAA), Kuantan, Pahang between 2011 to 2016 was carried out to determine the local pattern of cutaneous mycology. RESULTS A total of 496 samples from 413 patients were sent, out of which 62.9% were nail clipping, 19.0% skin scraping, 12.9% hair and 5.2% skin biopsy tissue. Cultures were positive in 226 (45.6%) samples from 193 patients. Overall, non-dermatophyte molds were the predominant fungus isolated (74.0%), followed by yeasts (14.7%) and dermatophytes (11.3%). Skin scraping Nail 14% 15% Feet Fingernail 9% Scalp Toenail 1% 15% Trunk Fingernail & 58% 76% Toenail Groin 10% Not specified Not specified 2% Positive Cultures Nail Skin Scraping Hair Skin Biopsy Patients N 135 31 19 8 Male : Female 1 : 1.33 1.21 : 1 1.7 : 1 1.67 : 1 Malay 82 (60.7%) 24 (77.4%) 18 (94.7%) 5 (62.5%) Chinese 33 (24.4%) 5 (16.1%) 0 3 (37.5%) Indian 19 (14.1%) 2 (6.4%) 0 0 Indigenous 1 (0.7%) 0 1 (5.3%) 0 Mean age (years) 53.5 (2 – 90) 47.9 (2 – 80) 8.9 (3 – 28) 66.1 (27 – 83) Samples N 150 40 27 9 Commonest A. niger: 62 (41.3%) M. canis: (6 (15.0%) M. canis: 20 (74.1%) S. schenckii: 3 (33.3%) fungus isolated T. rubrum: 10 (6.7%) T. rubrum: 5 (12.5%) M. audouinii: 5 (18.5%) C. cladosporioides: 1 (11.1%) Penicillium sp: 9 (6.0%) T. interdigitale: 3 (7.5%) E. floccosum: 1 (3.7%) Penicillium sp: 1 (11.1%) A. niger: Aspergillus niger; T. rubrum: Trichophytonrubrum; T. interdigitale: Trichophytoninterdigitale; M. canis: Microsporumcanis; M. audouinii: Microsporumaudouinii; E. floccosum: Epidermophytonfloccosum; S. schenckii: Sporothrixschenckii; C. cladosporioides: Cladosporumcladosporioides DISCUSSION • More than half of all samples did not isolate any fungus despite a clinical diagnosis of cutaneous mycosis. This could be due to several possible factors: i. a wrong diagnosis of cutaneous mycosis ii. delayed specimen transportation to the lab; it is recommended that specimens for fungal culture should be transported to the lab preferably within 2 hours to ensure optimum recovery of fungi1 iii. improper sampling methods without the aid of direct microscopy using potassium hydroxide (KOH) or Wood’s lamp examination, especially for onychomycosis and superficial mycoses • Ideally, as described in previous studies, micro-drilling, proximal sampling and subungual curettage2 yield better results than simple nail clipping for nail fungal cultures. A recent meta-analysis concluded that the accuracy of KOH and cultures was lower compared to nail biopsy with Periodic Acid-Schiff (PAS)-staining3, something worth considering in patients with recalcitrant onychomycosis. • For suspected tinea capitis, hair root and scalp skin scraping should be obtained by vigorously rubbing over the erythematous, scaly or alopecic region with a moistened cotton swab or gently rubbing with a sterile toothbrush4. • While skin biopsy and tissue culture remains the gold standard in diagnosing subcutaneous and deep fungal infection, occasional specimens can be difficult to culture either due to low fungal burden or heavy secondary infections, and may require multiple sampling, subcultures and/or extended incubation5. Furthermore, there may be histopathologic identification of fungal elements despite skin tissue culture failing to show fungal growth6. As such, future studies may want to look at the discrepancy rate between both methods of fungal identification. • We advocate proper prospective studies in the future addressing mycological patterns of cutaneous fungal infection with important associated factors such as comorbidities, immunosuppression, occupation, social habits and chronic medication usage in addition to improved sampling techniques. • The utilization of polymerase chain reaction (PCR) or matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF)7 for a more accurate identification of fungal species should also be considered in future clinicoepidemiological studies. CONCLUSION The predominant fungi isolated from nail samples were non-dermatophyte molds, whereas samples of skin scraping and hair mainly isolated dermatophytes. Apart from onychomycosis, both superficial and subcutaneous mycoses of the skin and hair showed a male preponderance. REFERENCES 1. ChayaA.K., et al. IndJ DermatolVenereolLeprol2007; 73(3): 2002-2005 2. ShemerA., et al. JDermatol2009; 36: 410-414 3. Velasquez-Agudelo V., et al. BMCInfectiousDiseases 2017; 17(166): 2- 11 4. Friedlander S. F., et al. Pediatrics 1999; 104(2): 276-279 5. Barros M. B., et al. ClinMicrobiol Rev 2011; 24(4): 633-654 6. Gonzalez Santiago T. M., et al. J AmAcad Dermatol 2014; 71: 293-301 7. ChalupováJ.,etal.BiotechnolAdv2013;1-12 ACKNOWLEDGEMENT We would like to thank the Director General of Health, Malaysia for permission granted to present this report. * There is no conflict of interest for all authors * Poster Syringocystadenoma papilliferum No. 4 arising in a naevus sebaceous Nik Aimee Azizah Faheem MB BCh BAO1, Zhenli Kwan Adv M Derm1, Adrian Sze Wai Yong MRCP (Dermatology)1, Chin Chwen Ch’ng Adv M Derm1, Leng Leng Tan Adv M Derm1, Jayalakshmi Pailoor FRCPath2, Kim Kwan Tan MBBS2, Manimalar Naicker MPath2 1 Division of Dermatology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia 2 Department of Pathology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia Introduction Naevus sebaceous is a cutaneous hamartoma with hyperplasia of the epidermis, sebaceous glands and apocrine glands. It usually occurs in the head and neck region and is present since birth. Naevus sebaceous has been well documented to have the potential of developing into both benign and malignant neoplasms. 18.9% of patients with naevus sebaceous have secondary benign neoplasms while another 2.5% have malignant neoplasms.1 We report a case of syringocystadenoma papilleferum (SCAP) arising Figure 2: Syringocystadenoma papilliferum (H&E. stain, x4) from a naevus sebaceous. Case Report A 56-year-old Malay lady with underlying type 2 diabetes mellitus, hypertension and gout was referred to our Dermatology clinic by her local government clinic with a lesion over her right temporal scalp. This lesion had been present since birth but increasing in size with intermittent bleeding over the past two months. She was initially treated with oral antibiotics and dressings without improvement. On physical examination, there was a fleshy Figure 3: Apocrine metaplasia (blue arrow), a feature of papillomatous exophytic mass measuring 3 cm x 2 naevus sebaceous (H&E. stain, x10) cm over her right temporal scalp with surrounding maceration and pus discharge. There was no Discussion palpable lymphadenopathy. An excisional biopsy SCAP is a hamartoma derived from apocrine eccrine was performed. glands. It is the second commonest benign neoplasm arising from a pre-existing naevus sebaceous after trichoblastoma.1 However in Taiwan, SCAP is more common in patients with naevus sebaceous compared to trichoblastoma.2 Katoulis and Bozi have described 3 types of SCAP. 3 Our patient had the first type, namely the plaque type, which presents as a hairless lesion on the scalp and is often associated with naevus sebaceous. It is generally apparent at birth and gradually enlarges after puberty. The other types are the linear and solitary nodule types. Malignant transformation of SCAP to basal cell carcinoma, squamous cell carcinoma, or syringocystadenocarcinoma papilliferum may occur. The treatment options for SCAP include surgical excision, Mohs micrographic Figure 1: Fleshy papillomatous mass on temporal surgery and carbon dioxide laser excision.3 For scalp, measuring 3 x 2 cm naevus sebaceous, surgical excision may be delayed till after adolescence as risk of malignancy is low.4 Histopathological examination revealed papillomatosis with cystic invaginations extending References downwards from the epidermis. Numerous papillary 1. Idriss MH, Elston DM. Secondary neoplasms associated with nevus projections were extending into the lumina of these sebaceus of Jadassohn: A study of 707 cases. J Am Acad Dermatol 2014; invaginations. The invaginations and papillary 70: 332-7. 2. Hsu MC, Liau JY, Hong JL, et al. Secondary neoplasms arising from nevus projections were lined by glandular epithelium sebaceus: A retrospective study of 450 cases in Taiwan. J Dermatol consisting of an outer layer of small cuboidal cells 2016;43:175-80. 3. Chandramouli M, Sarma D, Tejaswy K, Rodrigues G. Syringocystadenoma and inner layer of tall columnar cells. Underlying papilliferum of the scalp arising from a nevus sebaceous. J Cutan Aesthet apocrine metaplasia was also seen, suggesting the Surg 2016;9:204-6. presence of a naevus sebaceous. 4. Lowell G, Katz S, Gilchrest B, Paller A, LeffellD, Wolff K. Fitzpatrick’s Dermatology in General Medicine, 8th ed. United States of America: McGraw-Hill; 2012. Ichthyosis and fragile hair: What say you? Poster 1Voo SYM, 1Yusof DSY, 2Leong KF 5 1Department of Dermatology, Hospital Queen Elizabeth 2Department of Pediatrics, Pediatric Institute Hospital Kuala Lumpur Introduction Netherton syndrome (NS) is a rare autosomal recessive ichthyosiform disorder characterized by ichthyosis, atopic diathesis and hair shaft abnormalities1. Here, we present a family of NS. Case report The index case was referred at the age of 13 years for management of erythroderma. He had generalized scaling and desquamation since day 3 of life and was follow-up at a district hospital however defaulted review since 10 years ago. Both his parents were distant cousins. He was refused for schooling because of his skin condition. His eldest sister, one aunt (Fig 1b) and two of his uncles had similar skin changes at newborn. However, except his aunt, they passed away during early infancy. His family tree is shown in Figure 4. Clinically his hair was sparse with loss of eyebrow and mild ectropian (Fig 1). He was erythrodermic with polycyclic erythematous serpiginous patches with double edge scales at his trunk (Fig 2a). His weight and height were below 95% centile. Dermoscopic examination of his hair showed bamboo hair (Fig 2b). Histopathological examination of the skin biopsy showed psoriasiform hyperplasia, hyperkeratosis with focal parakeratosis with lack of granular layer (Fig 3b and 3c). There was almost absence of lymphoepithelial kazal-type related inhibitor (LEKTI) staining at the granular layer the epithelium(Fig 3a). His total Ig E was > 5000 kU/L.The diagnosis of NS was made based on clinical signs and symptoms as well as immunofluorescence staining results. His aunt’s skin biopsy for LEKTI staining is still pending. The index patient’s skin and symptoms improved after started acitretin and he plans to start schooling. Fig 1a Fig 1b Fig 2a Fig 3a Fig 4 Fig 2b Fig 3b Discussion Near to one fifth of a study of newborn with erythroderma had NS2. The clinical hallmark of NS are non bullous ichthyosiform erythroderma, ic hthyosis linearis circumflexa (ILC) and hair shaft abnormalities3 which in clude trichorrhexis invaginata (TI). The challenge of the diagnosis is that the characteristic hair may appear late due to delayed hair growth. It is not uncommon for hundreds of hair samples to be examined before TI is found. Furthermore ILC is Fig 3c intermittent and may not be present during examination. NS is due to mutation in SPINK5 gene located in chromosome 5q31-32 which encodes for serine protease inhibitor LEKTI. As a result of loss of function of LEKTI, there is increased skin proteolytic activity affecting skin barrier function. This syndrome is also associated with metabolic disturbance (for example aminoaciduria), immunological disorders and growth retardation. Fig 4 Conclusion Netherton syndrome should be considered in any neonate presenting with erythroderma or ichthyosis, growth failure and recurrent infection and prompt us to look for additional clues. The most important period is the neonatal period whereby supportive therapy is the mainstay of treatment as mortality is high due to intercurrent infection4. R eferences 1.Emre S et al. Two siblings with Netherton Syndrome. Turk J Med Sci 2010; 40(5): 819-23 2.Pruszkowski A et al. Neonatal and infantile erythrodermas: a retrospective study of 51 patients. Arch Dermatol. 2000; 136: 875-80 3.Bittencourt MdeJ et al. Trichoscopy as a diagnostic tool in trichorrhexis invaginata and Netherton Syndrome. An Bras Dermatol 2015 Jan Feb; 90(1): 114-6 4.Craiglow BG. Icthyosis in newborn. Semin Perinatal 2013 Feb; 37(1): 26-1 Acknowledgement The authors would like to thank Dr Lee Bang Rom for interpreting and providing the images of the skin histopathology, Dr Dwi for performing and providing the images of the LEKTI staining as well as the Director General of Health for giving the permission to present this case report. Clinical pattern and treatment response of Syphilis among 6 Human Immunodeficiency Virus (HIV)-infected Men Who Have Sex with Men (MSM) in Malaysia: a 5-year Multi-centre retrospective study (2011-2015) Ministry of Health Siaw Yen Ong*, Min Moon Tang*, IzzatyDalawi¥, Vijayaletchumi Krishnasamy*, Wooi Chiang Tan§, Chin Aun Yeoh§, Wee Meng Kho†, Malaysia Pubalan Muniandy†, Pui Li Wong#, Rukumani Devi Velayuthan¶, Zhenli Kwan‡, Chin Chwen Ch’ng‡, Norli Marwyne Mohd Noor¤, Asmah Johar* *Department of Dermatology, Hospital Kuala Lumpur; ¥Clinical Research Centre, Hospital Kuala Lumpur; §Department of Dermatology, Hospital Sultanah Bahiyah; †Department of Dermatology, Hospital Umum Sarawak; #Infectious Disease Unit, University Malaya Medical Center; ¶Department of Medical Microbiology, University Malaya Medical Centre; ‡Dermatology Unit, University Malaya Medical Centre ¤Department of Dermatology, Hospital Sungai Buloh INTRODUCTION METHODOLOGY High rates of syphilis have been reported worldwide among men who This is a retrospective study on all HIV-infected MSM with syphilis have sex with men (MSM). Co-infections between human between 2011 and 2015. Data was collected from five centres which immunodeficiency virus (HIV) and other sexually transmitted infections included Department of Dermatology Hospital Kuala Lumpur; Department (STI) are common due to shared routes of sexual transmission. As a of Dermatology Hospital Sultanah Bahiyah; Department of Dermatology notifiable disease in Malaysia, the data of syphilis among MSM and Hospital Umum Sarawak; Dermatology Unit and Infectious Disease Unit among those infected with HIV is lacking. This study aims to describe University Malaya Medical Centre; and Department of Dermatology the clinical pattern and treatment response of syphilis among HIV- Hospital Sungai Buloh. infected MSM. RESULTS • A total of 294 HIV seropositive MSM with the mean age of 31.2 • The characteristics of syphilis and the type of treatment received are years (range 16-66) were confirmed to have syphilis. Nearly half shown in Table 2. (47.6%) were in the age group of 20-29 years. The demography is • The number of early and late syphilis in our cohort were almost equal. shown in Table 1. However about 2/3 of the patients (66.3%) had latent syphilis. The pre- • Less than 10% was documented to have substance abuse. Only treatment non-treponemal antibody titre (VDRL or RPR) for early about 13% was documented to use condom consistently. syphilis was significantly higher than the late syphilis. The median CD4 • About a quarter was previously infected with syphilis. counts and the number of patients with CD4 <200/μl in early syphilis • The most frequent concomitant sexually transmitted infection was were comparable to late syphilis. genital wart. • The treatment outcome is shown in Table 3. Excluding those who were • More than half (55%) were diagnosed to have syphilis and HIV re-infected and defaulted follow up or died, the rate of treatment concurrently. failure were 12.1% and 8.8% for early and late syphilis respectively (p=0.582). Table 1. Demography of 294 HIV seropositive MSM with syphilis Characteristics n=294 Table 2 Characteristics of Syphilis in 294 HIV-infected MSM Mean age in years (range) 31.2 (16-66) Characteristics] n=294 p Age group in years, n (%) <20 10 (3.4%) Type of syphilis Early syphilis Primary 8 (2.7%) 0.861 20-29 140 (47.6%) (n=149) Secondary 83 (28.2%) (early vs 30-39 95 (32.3%) Early Latent 58 (19.7%) late) 40-49 37 (12.6%) Late syphilis Late latent 65 (22.1%) 50-59 10 (3.4%) (n=145) Latent of unknown 72 (24.5%) duration 60-69 2 (0.7%) Tertiary 8 (2.7%) Ethnicity, n (%) Malay 165 (56.7%) Median Pre-treatment Early syphilis 1:64 (0-1:2048) <0.0001 Chinese 100 (34.0%) VDRL/RPR titer (range) Late syphilis 1:8 (1:1-1:1024) Indian 9 (3.1%) Median CD4 count Early syphilis 341 (2-998) 0.315 Bumiputra (Iban, Bidayuh, Bajau, Melanau) 18 (6.1%) (range), cell/μl Late syphilis 312 (3-978) Foreigner (Philippines & Indonesian) 2 (0.7%) Number of patients with Early syphilis 30 (20.1%) 0.402 Number with documented substance abuse, n (%) 25 (8.5%) CD4 < 200/μl (%) Late syphilis 36 (24.3%) Number of bisexual, n (%) 75 (25.5%) Type of treatment, n (%) Early syphilis Benzathine penicillin 131 (44.6%) - Type of partners, n (%) Casual 164 (55.8%) Doxycycline 41 (13.9%) Steady 96 (32.7%) Crystalline penicillin 2 (0.7%) Commercial 16 (5.4%) Procaine penicillin G 3 (1%) Number of patients with 2 or more partners in the past 6 months, n (%) 164 (55.8%) Late syphilis Benzathine penicillin 135 (45.9%) Number with documented consistent use of condom in the past 6 39 (13.3%) Doxycycline 11 (3.7%) months, n (%) Crystalline penicillin 3 (1%) Number with previous history of sexually transmitted infections, n (%) 184 (62.6%) Procaine penicillin G 1 (0.3%) Type of previous Syphilis 71 (24.1%) Ceftriaxone 1 (0.3%) sexually transmitted Gonorrhoea 26 (8.8%) Table 3. The treatment outcomes with serological responses at one year after treatment infection (STI), Genital warts 19 (6.5%) Treatment outcome with serological response Early syphilis Late Total n (%) Herpes genitalis 18 (6.1%) syphilis Hepatitis B 8 (2.7%) n=149 n=145 n=294 Non-gonococcal urethritis 4 (1.4%) Responded 4-fold drop at 1 year 8 10 18 (6.1%) Number with other concomitant STI, n (%) 80 (27.5%) to Serology non-reactive 15 15 30 (10.2%) Concomitant STI apart Genital warts 50 (17.0%) treatment Serofast(1:8 or less) 35 37 72 (24.5%) from syphilis, n (%) Herpes genitalis 24 (8.2%) Fail treatment 8 6 14 (4.8%) Four fold drop at 6 months but re-infected 17 11 28 (9.5%) Gonorrhoea 12 (4.1%) Treated and Defaulted right after treatment 36 46 82 (27.9%) Hepatitis B 10 (3.4%) Defaulted Treated with 4-fold drop at 6 months & defaulted 23 14 37 (12.5%) Chlamydia 3 (1.0%) Treated with no 4-fold drop at 6 months & 7 3 10 (3.4%) Non-gonococcal urethritis 1 (0.3%) defaulted Median CD4 count (range) 334 (2 – 998) Died before completed treatment 0 3 3 (1%) DISCUSSION • Syphilis and HIV co-infection has been labelled as a dangerous • The treatment and the response rate of early syphilis in our cohort were duo1,2. Syphilis enhances the risk of contracting HIV infection comparable to other studies. and HIV may alter the natural course of syphilis3. • Future prospective study is needed to describe the effect of HAART on the • HIV may result in higher rate of asymptomatic primary syphilis natural history and treatment outcome of syphilis in HIV-infected MSM. or more aggressive disease manifestations in early syphilis4,5. Table 4. The characteristics and treatment outcome of syphilis among HIV-infected MSM reported in other countries Neurosyphilis may occur more frequently, at a much earlier Author, year Country n % Early syphilis (%) Late syphilis (%) % responded stage and progress more rapidly in the presence of HIV MSM Primary Secondary Early Late Latent of Tertiary to treatment latent latent Unknown at 1 year* infection6,7. Treatment failure is noted to be higher and duration serological cure has been shown to be slower in HIV-infected Manaviet al, 200712 UK 129 82 31 21 - - - - 70 48 undetermined stage patients with syphilis8-10. Jinnoet al, 201313 US 560 96.7 14 26 60 - - - 90.9 • The burden of syphilis among the MSM is known to be Tsai et al, 201414 Taiwan 349 94.9 8.9 55.3 35.8 - - - 67.8 Yang et al, 201415 Taiwan 573 94.1 8.9 57.8 33.3 - - - 70.9 inexplicably high worldwide11. Nishijimaet al, 201616 Japan 112# 100 62 unspecified 4 18 - - - • The clinical characteristics and treatment outcome of syphilis Current study 2017 Malaysia 294 100 2.7 28.2 19.7 22.1 24.5 8 Early syphilis - 87.9 among HIV-infected MSM have been described in a few studies Overall-89.6 as shown in Table 4. Most papers did not study late syphilis. * Excluding patients who re-infected with syphilis, defaulted after treatment and died; #-incident syphilis infection CONCLUSION The most common subtype of syphilis among MSM with HIV was latent syphilis. Approximately 43.8% of the patients defaulted after treatment. About 8.5% failed treatment at 1-year follow up. REFERENCES ACKNOWLEDGEMENT 1. Lynn et al. Lancet Infect Dis 2004;4:456-66 6. Flood et al, J Infect Dis 1998;177:931-40 12.Manaviet al. IntJ STD AIDS 2007; 18: 814–818 We would like to thank the Director General of Health, 2. Karumudiet al. Expert Rev Anti Infect Ther2005;3:825- 7. Marraet al. ClinInfect Dis 2004;38:1001-6. 13.Jinnoet al. BMC Infect Dis. 2013;13:605 Malaysia for permission to present this report. 31 8. Ghanemet al. Sex TransmInfect 2007;83:97-101 14.Tsai et al. PLoSOne 2014;9: e109813 3. Kenyon et al. BMC Infect Dis 2017;17:111 9. Malone et al. Am J Med 1995:55-63 15.Yang et al. PLoSOne 2014;9:e109667 4. Kassuttoet al. EmergInfect Dis 2004;10:1471-3 10.Smith et al. South Med J 2004;97:379-82 16.Nishijimaet al. PLoSONE. 2016;11(12):e0168642 5. Schoferet al. GenitourinMed 1996;72:176-81 11.Abaraet al. PLoSOne 2016;11:e0159309 Prevalence of Co-infection of Gonorrhoea and Non Gonococcal Urethritis in Males with Urethral Discharge Poster at Genitourinary Clinic, Hospital Kuala Lumpur: No :07 a 5-year study between 2011 - 2015 Vijayaletchumi Krishnasamy, Asmah Johar Department of Dermatology, Hospital Kuala Lumpur Table 2 . The etiology of urethritis in 307 men with urethral discharge Introduction Age group Neisseria Non gonococcal Nisseria Total Dual infection with Neisseria gonorrhoeae and chlamydia has been reported in gonorrhoea only urethritis gonorrhoea & several studies worldwide in men presenting with urethral discharge. The rates Chlamydia of co-infection have been reported to be 1.5-51%5-11. In Malaysia there is limited trachomatis data on the prevalence of gonorrhoea, non gonococcal urethritis and its co- N=204 N=75 N=28 N=307 infection. This study aims to determine the demographic characteristics and <20 27(8.7%) 4(1.3%) 6(1.9%) 37 behavior traits of men diagnosed to have the above infections. 20-29 132(28%) 54(8.7%) 12(1.0%) 198 Methodology 30-39 32(7.8%) 11(2.6%) 8(1.9%) 51 40-49 5(1.0%) 5(1.6%) 1(0.3%) 11 This is a retrospective study was done at GUM clinic, HKL. All case notes of men 50-59 8(1.6%) 1(0.3%) 1(0.32%) 10 who had presented with urethral discharge and diagnosed to have gonococcal and non gonococcal urethritis from the year 2011 to 2015 were retrieved and Discussions reviewed. • According to the WHO1, the estimates global incidence of Nisseria gonorrhoea and Results Chlamydia trachomatis were 106.1 and 105.7 millions cases respectively in 2008. The number of reported cases were in increasing trend from the 2005 report for both. • There were a total of 307 men who had attended the GUM clinic with urethral • Nesseria gonorrhoea infection is a notifiable in Malaysia. The incidence of gonorrhoea for discharge. The demographic data is shown in Table 1. Malaysia was 4.7 per 100,000 population in 20112, increasing over the years to 7.53 per • The mean age of the patients was 26.4 years(range 16-57). Majority of the 100,000 in 20153. Nevertheless, NGU is not in the list of notifiable infections in patients (64.5%) were in the age group between 20-29 years. Malaysia. The rise of incidence of gonorrhoea could be consistent with the global rise or • About 95% were Malaysian and of these about 80% were Malay. it could due to the increase in the awareness of notification among the clinicians. • Thirty-seven patients (12%) completed their tertiary education. • Non-gonoccocal urethritis (NGU) may be caused by Chlamydia trachomatis, Mycoplasma sp, Ureaplasma sp and others4. NGU is diagnosed when staining of urethral secretion in • There were 24 patients (8%) documented to have substance abuse. a symptomatic man shows inflammation without gram negative diplococcic. All men who • Majority (78%) were heterosexual. About 36% of patients had 2 or more are confirmed to have NGU need to be tested further for the etiology. However, the partners (range 2-10) 6 months before the symptoms developed. diagnostic tests for Mycoplasma sp and Ureaplasma sp are not available in our setting. • The most common cause of urethritis was gonococcal urethritis (66.4%), • Co-infection of gonococcal and non-gonococcal urethritis especially Chlamydia followed by non-gonococcal urethritis (NGU; 24.4%). trachomatis has been observed in different countries5-11 as shown in Table 3. The rates of • Among the NGU, nine were detected to have Chlamydia sp infection (12%). co-infection were reported to be between 1.5-51%. • Co-infection of Neisseria gonorrhoeae and Chlamydia sp were detected in 28 • In our cohort of gonococcal urethritis, about 12% was also infected with Chlamydia men (9.1%). trachomatis. This may not justify the policy of epidemiological treatment of chlamydia in all cases of gonococcal urethritis in Malaysia. Future prospective study is needed to • Seven (2.3%) were HIV seropositive. determine other aetiology of NGU in order to characterize better the rate of co-infection in this country. Table 1. The demographic data and sexual history of 307 men with urethritis Table 3 . The reported rate of co-infection of gonococcal and NGU urethritis in Characteristics n=307 different countries Mean age in years (range) 26.4 (16-56) Author, year Countries Age (yrs) Sexual behaviour NG (%) NGU (%) CT(%) NG and CT Age group in years (%) <20 37 (%) (%) 20-29 198 (47.8%) Sarah et al UK 22.4 - 3.8 - 8.1 1.5 30-39 51 (32.6%) 20035 (mean) 40-49 11 (12.0%) Khan et al US 15-16 - 1.3 - 5.9 51 50-59 10 (3.4%) 20056 Ethnicity Malay 245 (79.8%) Satyajit et al UK 20-25 1 partner 43.7% - - - 16.1 20057 2 partners 32.3% Chinese 13 (33.7%) ≥3 28.7% Indian 30 (9.8%) Donati. et al Italy 33.7 - - - 74.5 30.1 Bumiputra 3 (1%) 20098 (mean) Foreigner 16 (5.2%) Barbosa et al Brazil 26.5 1partner 85.4% 18.4 13.1 4.4 Highest education level Primary 45 (14.7%) 20109 (mean) Secondary 222 (72.3%) Tongtoyai et Thailand MSM 4.6 11.6 2.9 Tertiary 37 (12.0%) al, 201510 Missing data 3 (1.0%) Lim et al, Singapore 14-19 Heterosexual 33.1 23.6 10.2 201511 male with STI Employment history Student 43 (14.0%) Krishnasamy HKL 26.4 > 2 Partners - 66.4 24.4 3 9.1 Unemployed 26 (8.5%) et al 2017 Malaysia (mean) 36.2% Employed 238 (77.5%) NG – Neisseria gonorrhoea; NGU- non gonococcal urethritis; CT – Chlamydia trachomatis; MSM- man having sex with man; STI – sexually transmitted infections Number with documented substance abuse (%) 24 (7.8%) Conclusion Sexual orientation Heterosexual 242 (78.8%) Majority of males diagnosed with urethritis were heterosexual. Two third of the Bisexual 35 (11.4%) urethritis were gonorrhea. About 10% had co-infection with Neisseria Homosexual 30 (9.8%) gonorrhoea and Chlamydia trachomatis. Type of partners Casual 182 (59.3%) Steady 92 (30.0%) References Commercial 31 (10.1%) 1. WHO 2012. ISBN: 978 92 4 150383 9 Number of patients with 2 or more partners in the past 6 months (%) 111 (36.2%) 2. MOH Malaysia. Health Fact 2012. 3. MOH Malaysia. Health Fact 2015. Number with other concomitant sexually transmitted infections (%) 18 (5.9%) 4. CDC. MMWR 2015;64:51-52 Concomitant sexually Syphilis 4 (1.3%) 5. Sarah et al. Int J STD AIDS 2003;14:109-113 6. Khan et al. Sex Transm Dis 2005;32:255-259 transmitted infections apart Genital warts 3 (1.0%) 7. Satyajit et al. Int J STD AIDS 2005;16:318-322 from Urethritis Herpes genitalis 2 (4.1%) 8. Donati et al. Eur J Clin Microbiol Infect Dis 2009;28:523-526 9. Barbosa et al. Rev Soc Bras Med Trop 2010;43:500-503 Hepatitis B 2 (3.4%) 10. Tongtoyai et al. Sex Transm Dis 2015;42:440-449 Hepatitis C 1 (0.3%) 11. Lim et al. Sex Transm Dis 2015;42:450-456 Acknowledgement Human immunodeficiency virus 7 (2.3%) We would like to thank the doctors and allied health personals from GUM clinic for their contribution to this study. We would also like to thank the Director of Health Malaysia for the permission to present the poster 08 PATTERN OF SEXUALLY TRANSMITTED INFECTIONS (STI) AMONG PATIENTS WITH HIV IN GENITOURINARY MEDICINE (GUM) CLINIC, HOSPITAL KUALA LUMPUR (HKL) Shir Nee Tan, Swee Kuan Heah, Azura Mohd Affandi, Asmah Johar Department of Dermatology, Hospital Kuala Lumpur BACKGROUND Figure 2 : Number of concomitant sexually transmitted infections The latest WHO update in August 2016 reported more than 1 million 1.1 % sexually transmitted infections (STIs) acquired every day worldwide. 0.7 % Each year, there is an estimated 357 million new infections with either 1 of these 4 STIs: chlamydia, gonorrhoea, syphilis and trichomoniasis. HIV patients are high risk group for STIs. However, data regarding the current 1 type of STI trend of STIs among HIV patients in Malaysia is limited . 27.9 % OBJECTIVE 2 types of STIs To describe the pattern of STIs and profile of patients with HIV in GUM 70.3 % 3 types of STIs clinic, HKL. 4 types of STIs METHODOLOGY This was a retrospective study carried out from 2011 until 2015 in GUM clinic, HKL. Case notes of patients with HIV positive were retrieved and reviewed. Demographic data such as: gender, ethnicity, age, occupation and sexual orientation were analysed. Clinical presentations and types of Figure 3 : Types of sexually transmitted infections in STIs were identified. patients with HIV RESULTS 44.2 SYPHILIS GENITAL WART 34.4 There were a total of 276 HIV seropositive patients, which were confirmed to have STIs and have sought treatment at the GUM clinic HERPES 11.2 between 2011 - 2015. Most of the patients were males (267, 96.7%) and the remaining were females (3, 3.3%). As for ethnic distribution, the GONORRHEA 3.3 Malays accounted for 55.8%, followed by Chinese (30.8%), Indians (8.0%) and 5.4% belong to the other groups. 46.4% of patients’ CHLAMYDIA 0.7 occupation were blue collar, followed by white collar (21.0%), students OTHERS 6.2 (12.7%) and there were no available data for 19.9%. The mean age of patients that was diagnosed to have STIs was 31.1 ± 0 10 20 30 40 50 9.9 years. More than half were homosexual (55.8%), followed by heterosexual (22.1% ) and bisexual (13.8%). There were 147 valid CD4 Percentage, % count and 129 missing data, of which 20.4% patients had a CD4 count of >500 cells/μL, 55.7% patients with CD4 count between 200-500 cells/μL and 22.4% patients with CD4 < 200 cells/μL. Almost half of patients presented with warts (40.1%), with the remaining presenting with rash Figure 4 : Types of syphilis in patients with HIV (Figure 1) (19.6%), ulcer (16.3%), discharge (7.2%) and pruritus (0.4%) . 70.3% patients had 1 type of STI, 27.9% had 2 types of STIs, 1.1% had 3 5.0 types of STIs and 0.7 % had 4 types of STIs during the follow up period PRIMARY SYPHILIS (Figure 2) of 5 years . SECONDARY SYPHILIS 44.6 The most common STIs among HIV patients were syphilis (139, 44.2%), followed by genital wart (95, 34.4%), herpes (31, 11.2%), gonorrhea (9, EARLY LATENT… 23.0 3.3%), chlamydia (2, 0.7%), others (17, 6.2%) being non specific (Figure 3) urethritis and chancroid . Among the patients with syphilis, the 12.9 LATE LATENT… most common presentations were secondary syphilis (44.6%), followed by early latent (23.0%), late latent (12.9%), primary (5%) and tertiary 2.2 TERTIARY SYPHILIS (Figure 4) (2.2%). . 12.2 NOT SPECIFIED Figure 1 : Clinical presentation of sexually transmitted 0 10 20 30 40 50 infections in 276 HIV seropositive patients Percentage, % WARTS 40.6 19.6 RASH CONCLUSION ULCER 16.3 DISCHARGE 7.2 PRURITIS 0.4 Based on the data from GUM, HKL, STIs were commonly seen in males suffering from HIV. Almost half of the patients were in the blue collar OTHER 14.1 occupation. More than half of the patients were homosexuals. Syphilis 1.8 NOT AVAILABLE was the commonest type of STI in HIV patients and secondary syphilis was the most common presentation. It was noted that 29.3% of patients 0 10 20 30 40 50 Percentage, % suffered from 2 or more types of STIs. ACKNOWLEDGEMENT We would like to extend our sincere gratitude to the doctors, allied health personnels from GUM,HKL for their contributions in this study and as well as Nooraishah Ngah Saaya for helping to compose the data. We would also like to thank Director General of Heath Malaysia for permission to present this poster. Prevalence of Sexually Transmitted Infections (STI) in Poster Genito-Urinar y Medicine Clinic (GUM), Hospital Kuala Lumpur No.9 HR Hariyadurai, SR Syed Nong Chek, A Johar Department of Dermatology, Hospital Kuala Lumpur Figure 1:SexuallyTransmitted Infections according to Age Group BACKGROUND 250 Efforts by the Ministry of Health and non-governmental organisations (NGOs) has seen the incidence of human immunodeficiency virus (HIV) on the downtrend. 200 Nevertheless, the opposite can be said with syphilis and gonorrhea1-3. Earlier age of 0-12 s t 13-19 sexually debut and lack of sexual education exposure has led to STIs further n e 20-29 i150 spreading to others as patients fail to realise that they are disease carriers resulting t a p 30-39 in complications such as infertility and spread of HIV4-5. f o 40-49 r100 e 50-59 b m 60-69 OBJECTIVES u N 50 70 > To determine the prevalence of reported STIs within the Genitourinary Medicine (GUM) 0 Clinic, HKL between 2015-2016. METHODS This is a retrospective study of patients age more than 10 years attending the GUM Clinic, HKL between 2015-2016. Data was obtained by reviewing patients’ case notes and further analysed using SPSS version 18.0. RESULTS Figure 2:Sexually Transmitted Infections presented to GUM Clinic Hospital Kuala Lumpur A total of 1361 patients had attended the clinic of which 1296 (95.2%) diagnosis of STDS were made. The most common age group attending the clinic are between 20-29. This consisted 472 (48.3%) males and 182 (47.5%) females. 14.9% Warts • Table 1 represents the demographic characteristics of the patients. 30.2% 7.9% • Figure 1 constitutes age group versus type of STIs. Syphilis • Figure 2 depicts top 5 STIs in our study. HIV screening was performed in all the patients Gonorrhea presenting to the clinic. There were 129 (9.5%) patients diagnosed with HIV although the Primary Herpes 11.4% data for the mode of transmission is not available NSU Others Table1: Demographic characteristics GUM Clinic attendees 21.7% 13.8% Characteristics n=1361 % Gender Male 978 71.9 Female 383 28.1 Table2: Literature review on the Prevalence of Sexually Transmitted Infections in other Mean age in years (range) regions Age group in years (%) <20 78 5.7 Region Country Author/Year Number (subjects) Top 5 STI 20-29 654 48.1 Asia Thailand Rugpao et al, 195 Chlamydia, gonorrhea, warts, 30-39 366 26.9 1997 molluscum contagiosum, 40-49 118 8.7 trichomoniasis 50-59 84 6.2 Malaysia Rohani et 435 Gonorrhea, syphilis, al,2002 non specific urethritis (NSU), 60-69 40 2.9 Other STDs, Herpes genitalis >70 21 1.5 Indonesia Hamzah et al, 278 NSU, gonorrhea, warts, Ethnicity Malay 801 58.9 2009 vulvovaginal candidiasis, bartholinitis Chinese 234 17.2 Malaysia Hariyadurai et al, 1361 Warts, latent syphilis, Indian 216 15.9 2017 gonorrhea, Others 82 6.0 primary herpes, non specific urethritis Foreigner 28 2.1 WHO Americas, African Rowley et al, Trichomoniasis -276.4 million Trichomoniasis, gonorrhea, Sexual orientation Heterosexual 1059 77.8 regions, European 2008 Gonorrhea-106.1 million chlamydia, syphilis Bisexual 245 18.0 regions, Eastern Chlamydia-105.7 million Mediterranean, Western Syphilis-10.6 million Homosexual 57 4.2 Pacific, South East Asia Source of referrals Government Hospital 586 43.1 North US Satterwhite 2013 19.7 million Warts, Chlamydia, Government Clinic 311 22.9 America Trichomoniasis, Gonorrhea, Herpes Genitalis Self referred 209 15.4 General Practioner 116 8.5 CONCLUSION Pusat Darah Negara 83 6.1 Emergency Department 39 2.9 The three commonest STI presented to GUM clinic were genital wart, syphilis and Others 17 1.2 gonorrhoea. Reason for visits Symptomatic 968 71.1 REFERENCES Positive VDRL 176 12.9 Contact 117 8.6 1. Cheng et al. Sexually Transmitted Disease (STD). WebmedCentral INFECTIOUS DISEASE 2011;2:WMC002611 STI Check Up 98 7.2 2. Anwar et al. BMC Public Health 2010;10:47. Negative VDRL 1 0.1 3. Planning Division, Health Informatics Centres, MOH. Sexually Transmitted Diseases. Others 1 0.1 4. Incidence Rate & Mortality Rate of Communicable Diseases,Health Facts 2012-2016 Diagnosis Sexually Transmitted Infections (STIs) 1296 95.2 5. Low WY. JUMMEC 2009;12:3-14. Non STI 65 4.8 6. Zulkifli et al. J Adolesc Health 2000;27:276-80. ACKNOWLEDGEMENT We would like to thank all doctors and allied health personnel from the GUM Clinic, Hospital Kuala Lumpur. We also acknowledge the support of Ministry of Health Malaysia and Director General of Health, Malaysia. Cutaneous manifestations in patients infected with 10 Human Immunodeficiency Virus: An audit in Hospital Kuala Lumpur Meena Nithianandan, Anisha Bhullar, Suganthi Thevarajah, Min Moon Tang Department of Dermatology, Hospital Kuala Lumpur Figure 2. Infective causes (n=103) skin lesions among HIV infected BACKGROUND patients Infection Type (number) Individuals infected with human immunodeficiency virus (HIV) may Viral Genital wart (31) suffer from various cutaneous diseases. Local surveillance data 1.9 Herpes genitalis (11) 16.5% Herpes zoster (6) demonstrate that HIV is still confined within the key populations1, and Molluscum contangiosum (2) that the prevalence among relatively low risk populations is between 29.1% Herpes labialis (1) Common wart (1) 0.02 to 0.11%2. This audit aims to describe the pattern of cutaneous Hairy leukoplakia (1) manifestations of patients infected with HIV, whom were referred to Bacterial Syphilis (20) Gonorrhea (4) the Department of Dermatology, Hospital Kuala Lumpur. Cellulitis (3) 52.4% Abscess (2) Folliculitis (1) METHODS Lupus Vulgaris (1) Fungal Oral candidiasis (6) This is a retrospective study on all newly referred HIV-infected patients Bacterial infections Penicilliosis (4) Viral infections Histoplasmosis (2) who presented to the Department of Dermatology, Hospital Kuala Fungal infections Arthropod Infestation Onychomycosis (1) Lumpur in year 2016. Patients case notes were retrieved and reviewed. Tinea corporis (1) Tinea pedis (1) Arthropod Scabies (2) RESULTS Figure 3. Non-Infective causes (n=49) skin lesions among HIV • There were a total of 110 new HIV-infected patients referred to us infected patients with skin diseases. The demographic characteristics are shown in 8.2% Non infective Type (number) Table 1. Inflammatory Psoriasis (15) • The mean age of the patients was 33.6 years (range 15-72). Majority dermatoses Pruritic papular eruptions in HIV (7) Contact dermatitis (4) of the patients (43.6%) were from the 20-29 years age category. Photodermatitis (4) 12.2% • About a third (31.8%) of cases were in-patient referrals. Papular urticaria (1) Eosinophilic folliculitis (1) • Fifty-nine patients (53.6%) were men who had sex with men (MSM). Discoid eczema (1) • Nine patients (8.2%) were documented to have substance abuse. Nodular prurigo (1) Papular eczema (1) • Majority (59%) had CD4+ counts of more than 200/μL. About 80% of Xerosis (1) 79.6% in-patient cases had CD4+ counts of less than 200/μL whereas about Hydradenitis suppurativa (1) three-quarters of out-patient cases had CD4+ counts of more than Cutaneous Severe cutaneous adverse drug adverse drug reactions (6) 200/μL. Adverse cutaneous drug reaction reactions Maculopapular (2) • There were 46 patients (41.8%) who were on HAART. Non-infective dermatoses Malignancy Kaposi sarcoma (4) Malignancy • A total of 152 skin diagnosis were made. Of these, 103 were infective DISCUSSION & CONCLUSION and 49 were non infective diseases. • The commonest infection observed was viral infections (52.4%) with • The pattern of HIV transmission in Malaysia has changed genital human papilloma virus infection being the most frequently significantly from primarily via Intravenous Drug-Use (IVDU), to encountered. transmission via sexual routes. • The most common non-infective skin disease was papulosquamous • IVDU to sexual transmission ratio declined from 4 in year 2000 to 0.2 disorders such as psoriasis (44.7%) followed by pruritic papular in 2015, owing to efforts made in opioid-replacement therapy and eruption of HIV (21.1%). needle exchange programme2. • Six patients had severe adverse cutaneous drug reactions i.e. Stevens- • However, HIV prevalence among the MSM population has since increased2. Johnson Syndrome (SJS)/SJS-Toxic Epidermal Necrolysis overlap • While the majority of referrals were from outpatient sources, syndrome to Co-trimoxazole, carbamazepine, Akurit-4 and low CD4+ counts complicated with opportunistic infections levofloxacin. incurred a greater need for inpatient treatment. Table 1. Demographic Data of 110 HIV infected patients in 2016 • The types of dermatoses among the HIV infected patients in Characteristics n = 110 (%) various Asian countries were shown in Table 2. Mean Age in Years (range) 33.62 (15-72) • Interestingly, psoriasis was encountered more often than Age (years) 11-20 4 (3.6) seborrheic dermatitis in our cohort similar to an Indian study3. 21-30 51 (46.4) The latter being more commonly seen in other similar studies4,6 31-40 28 (25.5) along with xerosis. 41-50 16 (14.5) • Seborrheic dermatitis in HIV infected patients may be more Above 50 11 (10.0) commonly managed by primary care doctors in our setting. Gender Male 104 (94.5) • Our cohort showed that 9.5% of patients with kaposi sarcoma Female 6 (5.5) among those with CD4+ counts less than 200 similar to a report Sexual Orientation Heterosexual 26 (23.6) from Taiwan Homosexual 51 (46.4) Bisexual 8 (7.3) • Lower threshold to perform skin biopsy is advocated Ethnicity Malay 65 (59.1) • Oral candidiasis which is commonly encountered in HIV cohorts Chinese 32 (29.1) as demonstrated by other studies in Asia6 (up to 70%), showed a Indian 8 (7.3) much lower prevalence in this study (5.5%). Others 5 (4.5) • Most patients had received treatment for oral candidiasis at primary Concomitant Illness Pulmonary tuberculosis 23 (20.9) care, dental clinics as well as from their ID physicians. Fungal infections 7 (6.4) • In conclusion, majority of HIV infected patients in our cohort Hepatitis B 2 (1.8) presented with infective skin diseases, of which, viral causes Hepatitis C 3 (2.7) were most frequently encountered. Bipolar Mood Disorder 1 (0.9) • The results of this study, add to the increasing evidence of Asthma 2 (1.8) cutaneous manifestations in HIV. Further local studies are Diabetes mellitus 1 (0.9) needed to analyse the evolution of skin disease through the Referral Category Inpatient referral 35 (31.8) Outpatient referral 75 (68.2) different stages of HIV and their treatment outcome. Mode of HIV Transmission Heterosexual 26 (23.6) Homosexual 51 (46.4) Table 2. Cutaneous diseases among HIV infected subjects in Bisexual 8 (7.3) different Asian countries IVDU 9 (8.2) Country India3 Indonesia4 Thailand5 Taiwan6 Current Blood Transfusion 1 (0.9) study Not available 15 (13.6) No of Cases (n) 150 121 96 45 110 Figure 1. CD4+ Count versus referral category Total Diagnosis 473 195 322 158 152 90 Infective (%) 46.5 31.8 32.9 62.0 67.8 Inpatient referral Outpatient referral Non-Infective (%) 53.5 68.2 67.1 38.0 32.2 80 % of CD4+<200 59.3 71.7 37.5 79 38.2 70 s t n 60 ACKNOWLEDGEMENT e i t a 50 We would like to thank all doctors and allied health personnel from the Department of Dermatology, p f Hospital Kuala Lumpur. We would also like to thank the Director of Health Malaysia for the permission o 40 r to present the poster. e b 30 m REFERENCES u 20 N 1. MOH. Malaysia Global AIDS Response Progress Report 2016 10 2. MOH. Malaysia National Strategic Plan for Ending AIDS 2016-2030 (2015) 3. Sud et at. Int J STD AIDS 2009;20:771-4 0 4. Dwiyana et al. Acta Med Indones 2009;41 Suppl 1:18-22 < 200 200 - 500 > 500 5. Wiwanitkit V. Int J Dermatol 2004;43: 265-8. CD4 Count 6. Tzung et al. Kaohsiung J Med Sci 2004;20:216-24