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Letters to the Editor

A case report of dysthymia, resulting from

disfigurement related erratic perception
of systemic sclerosis
Sir,
Systemic sclerosis is a disorder that involves multiple
organ systems and follows a long course with poor
clinical outcome.[1] Dermatological changes are frequently
seen patients of systemic sclerosis. Contracture of the
joints of the extremities and degenerative or erosive
arthropathy are also reported.[1] These changes lead to
cosmetic disfigurement and often embarrassing for the
patients. Disability and disfigurement due to systemic
sclerosis leads to significant self-image dissatisfaction
and distress. [2,3] The cumulative effects of disability,
self-perception, pain and disfigurement are responsible
for anxiety and depressive manifestations in systemic
sclerosis.[4] In this case report, we highlighted the impact Figure 1: The figure shows hypopigmentation of the skin over the digits,
of degenerative cutaneous and skeletal changes in the tightness of the skin giving the glistening appearance, pitting of nails
hands of a patient with systemic sclerosis that attribute and degeneration and absorption of the distal phalanges in both hands
to psychological distress.
the patient had revealed — depressed affect, pessimistic
A 50-year-old housewife was referred for psychiatric view toward the future, somatic preoccupation, death
consultation for her complaints of poor appetite, weight wishes, preoccupation with a negative self-image. Based
loss and disturbed sleep. Her husband had also reported on the history and mental status examination findings, a
about change in her behavior in past 4 years in the form of diagnosis of “Dysthymia” was made as per International
remaining withdrawn to self, decreased interest in interaction Classification of Diseases-10, diagnostic criteria. [5] She
with family members and friends, avoiding going outside was prescribed antidepressant sertraline at a dose of
home and death wishes. She was suffering from systemic 50 mg/day, which was later increased to 100 mg/day.
sclerosis since 1996 and was on treatment for the same. Over Benzodiazepine — clonazepam was prescribed at a dose of
past 10 years, she had developed Raynaud’s phenomenon 0.25 mg, as and when needed basis for anxiety and zolpidem
and thickening of the skin all over her body with prominent
10 mg at bed time was prescribed for insomnia. Supportive
changes on face, neck and extremities. She was having severe
psychotherapy was given, and relaxation exercises were
gastro-esophageal reflux symptoms. She was on calcium
taught. With this treatment, patient had shown an adequate
channel blocker (nifedipine) for the symptoms of vasospasm
response over next 4 months, on follow-up. The patient
(due to Raynaud’s phenomenon) and anti-reflux agents
initially believed these changes in her fingers (ulceration,
(pantoprazole and domperidone) for gastro-esophageal reflux.
hypopigmentation and erosive arthropathic changes) as
There was an increase in disfigurement of the face with Hansen’s disease that is not uncommon in India. Hansen’s
decrease in mouth opening and cutaneous changes in disease is a chronic debilitating illness with a stigma attached
last 4 years. She also had contracture in joints of upper to it and patients poor knowledge and misinterpretation led
extremity with digital ulceration and degeneration [Figure to her psychological distress.
1], which temporally correlated with onset of psychiatric
symptoms. There was no other significant medical or Supportive psychotherapy, relaxation exercises,
surgical illness in the patient. There was no past history antidepressant treatment and proper health education
or family history of psychiatric illness. Premorbidly, she (explaining about systemic sclerosis) were helpful in
was well adjusted to life. Mental status examination of reducing her distress.

Medical Journal of Dr. D.Y. Patil University | May-June 2016 | Vol 9 | Issue 3 415
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Letters to the Editor
In the above case it is fair to conclude that misinterpretation
of the bodily changes and identifying them with more
stigmatizing illnesses is more likely to produce psychological
distress, which is often out of proportion to the underlying
illness, itself.
Sujita Kumar Kar, Aditya Somani
Department of Psychiatry, King George’s Medical University,
Lucknow, Uttar Pradesh, India
Address for correspondence:
Dr. Sujita Kumar Kar,
Department of Psychiatry, King George’s Medical University,
Lucknow, Uttar Pradesh, India.
E-mail: skkar1981@yahoo.com
References
1. Generini S, Fiori G, Moggi Pignone A, Matucci Cerinic M,
Cagnoni M. Systemic sclerosis. A clinical overview. Adv Exp
Med Biol 1999;455:73-83.
Poroid hidradenoma: An unusual presentation
Sir,
The term “poroma” refers to a group of benign cutaneous
adnexal neoplasms with “poroid” or terminal ductal
differentiation. Four histopathologic variants have been
identified depending on location of the tumor cells:
Hidradenoma simplex, eccrine poroma, dermal duct tumor
and poroid hidradenoma.[1-3] Recent studies have shown a
common histogenesis for all these variants.[4]
A 45-year-old male presented to the surgical outpatient
department with a gradually increasing swelling of 1-year
duration, over right lower anterior abdominal wall. There
were no other associated symptoms. On examination, there
was a 3 cm × 3 cm, mobile, nontender, erythematous lump
arising from anterior abdominal wall of right iliac fossa.
His past medical and family history were unremarkable.
A clinical diagnosis of infected sebaceous cyst was made.
The nodular swelling was excised under local anesthesia
and was sent for histopathological examination.
Macroscopic examination showed a skin covered soft tissue
mass measuring 3 cm × 2.5 cm × 1.5 cm. Cut surface showed
a sub-epidermal, well-circumscribed, solid grayish white
tumor with multiple small cystic foci [Figure 1]. Microscopic
examination revealed a well-circumscribed, lobulated, intra-
dermal, solid-cystic tumor, with no apparent connection to
416 Medical Journal of Dr. D.Y. Patil University | May-June 2016 | Vol 9 | Issue 3
2. Benrud-Larson LM, Heinberg LJ, Boling C, Reed J, White B,
Wigley FM, et al. Body image dissatisfaction among women
with scleroderma: Extent and relationship to psychosocial
function. Health Psychol 2003;22:130-9.
3. Haythornthwaite JA, Heinberg LJ, McGuire L. Psychologic
factors in scleroderma. Rheum Dis Clin North Am
2003;29:427-39.
4. Müller H, Rehberger P, Günther C, Schmitt J. Determinants of
disability, quality of life and depression in dermatological patients
with systemic scleroderma. Br J Dermatol 2012;166:343-53.
5. The ICD-10 Classification of Mental and Behavioural Disorders.
Clinical descriptions and diagnostic guidelines. Geneva: World
Health Organization; 1992. Available from: http://www.who.
int/classifiations/icd/en/bluebook.pdf. [Last assessed on 2014
Jun 6].
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10.4103/0975-2870.167999
the overlying epidermis [Figure 2]. The tumor was composed
of, small and dark staining poroid cells having round to oval
nuclei, indistinct nucleoli with scant eosinophilic cytoplasm
[Figure 3] and cuticular cells having round nuclei, distinct
nucleoli with abundant eosinophilic cytoplasm. Cuticular
cells showed evidence of ductal differentiation at places
[Figure 4]. Focal areas showed glandular structures lined
by columnar to cuboidal cells with clear cell change at
places, cystic spaces filled with eosinophilic material,
[Figure 1] irregular ectatic vessels and stromal infiltration
by lymphocytes and plasma cells. Histomorphological
findings were compatible with poroid hidradenoma. The
postoperative period was uneventful and the patient was
doing well after 2 months of surgery.
Poroid hidradenoma is an uncommon variant of
Poromas described by Abenoza and Ackerman in
1990,[1-3] occurring over a wide age range from 17 to 91
years,[2] with a peak in the seventh decade. It presents
clinically as a solitary, circumscribed, intra-dermal
nodule. Histopathologically, these are hybrid lesions,
showing cytological characteristics of poromas with
poroid and cuticular cells[3] and architectural features
of hidradenoma, which is an intra-dermal, solid-cystic
tumor.[1] Some reports have stressed on the role of fine
needle aspiration cytology in the diagnosis of these solid-