HIV combined with skin infection of Nocardia brasiliensis: A rare case report
Introduction. The HIV virus can attack and gradually damage the human immune system causing the host to be unprotected when infected. Nocardia is a type of opportunistic pathogenic bacteria that can easily cause infections in patients with chronic wasting diseases immune dysfunction and the use of immunosuppressants. Nocardia can invade various tissues and parts of the body causing corresponding clinical symptoms. There are few reports of HIV patients being infected with Brazilian Nocardia.
Case presentation. This article reports a case of an HIV patient with concurrent infection with Brazilian Nocardia. A patient with HIV developed a lump on the surface of their left skin without any obvious cause. Due to improper disinfection and treatment methods the condition worsened and they subsequently sought medical attention at our hospital. A series of laboratory related tests are conducted clinically based on the patient's medical history symptoms and signs. Based on the test results a reasonable treatment plan was adopted clinically ultimately achieving satisfactory treatment outcomes for patients.
Conclusion. HIV patients are prone to various types of infections even rare bacteria as their immune function decreases. With the popularity of new identification methods such as mass spectrometry laboratories should pay attention to traditional staining methods and use microscopes to detect pathogens.
Brief Report: Nasal colonization with Staphylococcus aureus and Methicillin resistant Staphylococcus aureus among community-dwelling older adults with comorbidities seeking follow-up medical care in Central Sri Lanka.
Older adults are more severely affected by infections caused by drug-resistant bacteria including Methicillin-Resistant Staphylococcus aureus (MRSA). We aimed to identify the MRSA colonization rates and associated factors among older adults aged more than 65-years-old. Among the 309 recruited 152 (49.2%) were males. Self-collected nasal swabs were used to isolate Staphylococcus aureus and MRSA with routine microbiological methods. Staphylococcus aureus was isolated from 36 (11.7%) participants while 11 (3.6%) were colonized with MRSA. We identified a significant association between the male sex and MRSA colonization (p=0.028 Chi-square test). However this needs careful interpretation given the smaller number of outcome events. Other factors studied had no statistically significant association with MRSA colonization.
Title of Manuscript: Prevalence of SARS- CoV-2 virus in saliva, stool, and urine samples of COVID-19 patients in Bihar, India
Introduction: The coronavirus illness caused by SARS- CoV-2 can cause multiple organ involvement with varying degrees of severity. Besides inhalation as a route for transmission feco-oral has also been proposed. Its transmission to sewage systems is a growing public health issue.
Objective: To detect SARS-CoV-2 RNA in non-respiratory samples (saliva urine and stool) collected from COVID-19 cases in Bihar.
Materials and methods: This Cross-Sectional observational study was conducted from January 2021 to March 2022 on human non-respiratory samples. A total of 345 samples including saliva (116) stool (97) and urine (132) were collected from 143 covid-19 cases. Samples were analyzed for SARS-CoV-2 by multiplex RT-PCR targeted against E ORF 1ab and RdRp gene.
Results: In this study out of 143 cases a total of 107(74.8%) were positive for SARS-CoV-2 RNA in at least one of the non-respiratory samples.
Conclusion: There is a high prevalence of SARS-CoV-2 virus in non-respiratory samples.
Genome sequence of the plant-growth-promoting bacterium Bacillus velezensis EU07
Many Gram-positive spore-forming rhizobacteria of the genus Bacillus show potential as biocontrol biopesticides that promise improved sustainability and ecological safety in agriculture. Here we present a draft-quality genome sequence for Bacillus velezensis EU07 which shows growth-promotion in tomato plants and biocontrol against Fusarium head blight. We found that the genome of EU07 is almost identical to that of the commercially used strain QST713 but identified 46 single-nucleotide differences that distinguish these strains from each other. The availability of this genome sequence will facilitate future efforts to unravel the genetic and molecular basis for its beneficial properties.
Development of Recombinant Proteins for Vaccine Candidates Against Serotype O and A of Foot and Mouth Disease Virus in Bangladesh
Frequent vaccine failure leading to recurrent outbreaks of Foot-and-Mouth Disease (FMD) in livestock populations necessitates the development of a customizable vaccine platform comprising potential antigenic determinants of circulating lineages of FMD viruses. Artificially designed chimeric peptide-based recombinant vaccines are novel approaches to combat the phylogenetically diverse FMD Virus (FMDV) strains. Among seven recognized serotypes only serotypes O and A are dominantly circulating in Bangladesh and neighboring countries of Asia where transboundary transmission recurrent outbreaks and emergence of novel lineages of FMDV are highly prevalent. The objective of this study was to develop multi-epitope recombinant peptides procuring immunogenicity against circulating diverse genotypes of FMDV serotypes O and A. Two chimeric peptides named B1 (41.0 kDa) and B3 (39.3 kDa) have been designed to incorporate potential B-cell and T-cell epitopes selected from multiple FMDV strains including previously reported and newly emerged sub-lineages. After expression characterization and immunization of guineapigs with considerable antigen load of B1 and B3 followed by the serological assays revealed the significant protective immunogenicity developed from the higher (100 µg) doses of both antigens against most of the currently prevalent serotype O and A strains of FMDV. The efficient expression antigenic stability and multivalent immunogenic potency of the chimeric peptides strongly indicate their credibility as novel vaccine candidates for existing serotypes O and A of FMDV in Bangladesh and surrounding territories.
Deciphering the interaction surface between the West Nile virus NS3 and NS5 proteins
West Nile virus (WNV) is the most prevalent mosquito-borne disease and the leading cause of viral encephalitis in the continental United States. It belongs to the Flavivirus family which includes other important human pathogens such as dengue virus (DENV) Japanese encephalitis virus (JEV) and Zika viruses (ZIKV). Despite several decades of research no specific antiviral drugs are available to treat Flavivirus infections. The present study characterizes the interaction between the WNV NS3 and NS5 proteins for the purpose of identifying hotspots in the protein-protein interaction which could be targeted for the development of antiviral therapeutics. We previously developed an interaction model in silico based on data available in the literature. Here potential interacting residues on NS3 and NS5 were mutated in a WNV replicon and seven mutations in the NS3 protein were found to drastically reduce viral replication. In addition to being well conserved among mosquito-borne Flaviviruses these residues are located on the protein’s surface in two clusters which might be interesting new targets for future drug development.
An Evaluation of ChatGPT and Bard (Gemini) in the Context of Biological Knowledge Retrieval
ChatGPT and Bard (now called Gemini) two conversational AI models developed by OpenAI and Google AI respectively have garnered considerable attention for their ability to engage in natural language conversations and perform various language-related tasks. While the versatility of these chatbots in generating text and simulating human-like conversations is undeniable we wanted to evaluate their effectiveness in retrieving biological knowledge for curation and research purposes. To do so we asked each chatbot a series of questions and scored their answers based on their quality. Out of a maximal score of 24 ChatGPT scored 5 and Bard scored 13. The encountered issues included missing information incorrect answers and instances where responses combine accurate and inaccurate details. Notably both tools tend to fabricate references to scientific papers undermining their usability.
In light of these findings we recommend that biologists continue to rely on traditional sources while periodically assessing the reliability of ChatGPT and Bard. As ChatGPT aptly suggested for specific and up-to-date scientific information established scientific journals databases and subject-matter experts remain the preferred avenues for trustworthy data.
Detection and significance of anti-Mycobacterium tuberculosis specific IgG antibody response for the diagnosis of pulmonary tuberculosis using enzyme-linked immunosorbent assay
Objective: Evaluation of an ELISA test for detection of IgG antibody response using in-house prepared Mycobacterium tuberculosis H37Rv soluble extract (MTSE) as antigen for rapid diagnosis of pulmonary tuberculosis and its clinical usefulness.
Methods: In this study a total of 758 pulmonary tuberculosis (TB) patients (652 AFB-positive and 106 AFB-negative) 276 healthy controls and 43 pulmonary infectious disease controls other than TB were recruited. IgG antibody level against MTB soluble extract was measured in sera samples of all study groups using an ELISA test. The level of IgG antibody responses was compared among groups by the Kruskal-Wallis test. The pairwise comparison was made by the Mann-Whitney test A positive score was represented by optical density above the cut–off value which was calculated from OD values of healthy controls by adding 2SD to the mean OD value. The evaluation of diagnostic value was considered based on sensitivity and specificity.
Results: Significantly higher levels of IgG antibody response were observed in PTB patients compared to healthy control and non-TB other pulmonary infectious disease control groups (p value<0.0001). The percent positivity for the IgG antibody response was higher in AFB-positive 574/652 (88.04%) and 79/106 (74.53%) AFB-negative PTB patients as compared to healthy control 9/276 (3.26%) and non-TB other pulmonary infectious disease control 3/43 (6.97%). The sensitivity of the test in PTB patients (AFB-positive and AFB-negative) was 86.15% (95% CI; 83.48-88.53) and the specificity was 96.74% (95% CI; 93.90-98.50).
Conclusion: This developed immunological test could be an efficient test in detecting IgG antibody response in PTB patients. Further this test could be useful for diagnosing AFB-negative presumptive TB cases.
Xanthomonas citri pv. eucalyptorum 4866-2_S43 strain (formerly X. axonopodis pv. eucalyptorum): Causal agent of bacterial leaf blight on eucalypt recovered in Argentina
We report here a draft genome assembly of strain 4866-2_S43 isolated from a eucalyptus lesion in Argentina and what until recently was caused by Xanthomonas axonopodis pv. eucalyptorum (Xae). The genome size is 5188607 bp with a G+C content of 64.66%. Comparative analysis reveals that the closest relative of strain 4866-2_S43 is Xae LPF 602 isolated in Brazil. Comparison of the whole genome sequences revealed an average nucleotide identity (ANI) of 99.96%. between the two strains. ANIs were determined between the whole genome sequence of strain 4866-2_S43 and the genomes of all currently validated Xanthomonas spp. These results revealed that strain 4866-2_S43 had greater than 95% with X. citri pv. citri and X. citri pv. phaseoli and less than 95% with X. euvesicatoria pv. alfalfae X. perforans and X. euvesicatoria pathovars euvesicatoria and eucalyptii.
PATHOGENECITY AND ENZYME SCREENING OF SOME SELECTED NON-DERMATOPHYTIC MOLDS
A total of 10 non-dermatophytic molds isolated from both symptomatic and asymptomatic cattle skin which includes Penicillum citrinum Aspergillus welwitschiae Aspergillus aculeatus Curvularia kusanol Cladosporium teniussmum Pestalotiopsis microspora Fusarium oxysporum Fusarium linchenicola Absidia sp. and Aspergillus fumigatuswere subjected to a pathogenicity test using albino mice. These isolates were also screened for five enzymes using standard plate method. Result from pathogenicity test showed that Absidia sp C. tenuissimum and Aspergillus welwitschiae were able to elicit discoloration lesion production and alopecia on the albino mice skin respectively which are evidences of clinical symptoms associated of cutaneous mycoses. The enzyme screening results revealed the highest zone of activity for keratinase (65mm) amylase (86mm) protease (60mm) lipase (60mm) and cellulase (86mm) which were observed on P. microspora A. welwitschiae C. tenuissimum A. welwitschiae and A. welwitschiae respectively. Pathogenicity test from this study shows that some of these molds may be virulent and that can be attributed to their ability to possess some virulent factors which includes secretion of hydrolytic enzymes.
Inducible clindamycin resistance among clinical Gram-positive cocci in a tertiary hospital in Niger Republic
Background. Macrolide-induced resistance to clindamycin is a well-described mechanism leading to treatment failure. Herein we determined the frequency and associated factors of inducible clindamycin resistance in Gram-positive cocci in a tertiary care hospital.
Methods. A cross-sectional descriptive study was carried out between January and December 2022. D tests were performed as recommended by EUCAST 2021 guidelines on 100 non-duplicate clinical isolates of Gram-positive cocci to determine the prevalence of methicillin resistance and inducible clindamycin resistance among the collected isolates.
Results. Of the 100 Gram-positive cocci isolates 56 (56.0 %) 17 (17.0 %) and 27 (27.0 %) were respectively coagulase-negative staphylococci Staphylococcus aureus and Streptococcus spp. Among Streptococcus spp. Group D Streptococci (15.0%) were the most isolated. Methicillin-resistant Staphylococcus aureus (MRSA) represented 9 (53.0 %) of S.aureus isolates. Constitutive (cMLSb) and inducible clindamycin resistance (iMLSb) phenotypes were detected in 36 (36.0%) and 14 (140%) of the isolates respectively. S. aureus exhibited 38.4% of cMLSb and 13.7% of iMLSb. The result of multivariate analysis showed that age groups gender type of samples provenance and bacteria were not significantly associated with Gram-positive cocci iMLSb phenotype.
Conclusion. The study reported for the first time a high prevalence of inducible resistance of Gram-positive cocci strains to clindamycin in Niger Republic. This suggests the urgent need for the implementation of regular screening of these isolates and the wise use of clindamycin in clinical practice.
Erysipelothrix spp. and other Erysipelotrichales detected by 16S rRNA microbial community profiling in samples from healthy conventionally reared chickens and their environment
Outbreaks of erysipelas a disease caused by infection with Erysipelothrix rhusiopathiae (ER) is a re-emerging problem in cage-free laying hen flocks. The source of ER infection in hens is usually unknown and serological evidence has indicated the presence of ER or other antigenically related bacteria also in healthy flocks. The aim of the present study was to evaluate sample collection culture methods and DNA-based methodology to detect ER and other Erysipelotrichales in samples from healthy chickens and their environment.
We used samples from a research facility with conventionally reared chickens with no history of erysipelas outbreaks where hens with high titers of IgY recognising ER previously have been observed. Microbial DNA was extracted from samples either directly or after pre-culture in nonselective or ER-selective medium. Real-time PCR was used for detection of Erysipelothrix spp. and high-throughput amplicon sequencing of 16S rRNA sequencing was used for detection of Erysipelotrichales. A pilot serological analysis of some Erysipelotrichales members with IgY from unvaccinated and ER vaccinated high biosecurity-chickens as well as conventionally reared chickens was also performed.
All samples were negative for ER E. tonsillarum and E. piscisicarius by PCR analysis. However 16S rRNA community profiling indicated the presence of several Erysipelotrichales genera in both environmental samples and chicken intestinal samples including Erysipelothrix spp. that were detected in environmental samples. Sequences from Erysipelothrix spp. were most frequently detected in samples pre-cultured in ER-selective medium. On species level the presence of E. anatis and/or E. aquatica was indicated. Serological results indicated that IgY raised to ER showed some cross-reactivity with E. anatis. Hence environmental samples pre-cultured in selective medium and analysis by 16S rRNA sequencing proved a useful method for detection of Erysipelotrichales including Erysipelothrix spp. in chicken flocks. The observation of such bacteria in environmental samples offers a possible explanation for the observation of high antibody titres to ER in flocks without a history of clinical erysipelas.
Galleria mellonella as a superficial model for Malassezia globosa and its treatment
Introduction. Malassezia globosa is a yeast species that belongs to the mycobiota of humans and animals associated with dermatological disorders such as dandruff. This is a chronic scalp skin disorder characterized by flaking and itching. Treatments include commercial shampoo with different formulations that contain antifungal activities like Zinc pyrithione or Piroctone Olamine. The effectiveness of these formulations have been evaluated for decades for dandruff symptom relief of volunteers. To date non-mammalian in-vivo methods exist to test formulations of these actives.
Aim. To evaluate in vivo in Galleria mellonella larva two commercial antifungal shampoos (Shampoo with 1% ZPT & 1.6% Zinc Carbonate and shampoo with 0.5% PO) against this species.
Methodology. G. mellonella larvae were inoculated with M. globosa on abraded cuticular surface. Then integument cell viability histological changes and fungal burden were evaluated.
Results. Larvae inoculated with M. globosa showed higher lesion melanization and tissue damage. In addition M. globosa population showed to increase over time. Concerning the shampoo’s effectiveness both formulations significantly reduced M. globosa burden and tissue damage.
Conclusion. G. mellonella larvae were allowed to evaluate M. globosa superficial infection and antifungal effectiveness. Shampoos with ZPT and PO showed a positive effect on inoculated larvae.
Retrospective analysis of Acinetobacter baumannii bacteraemia risk factors, complications, and mortality in a tertiary university hospital in Saudi Arabia
Introduction. Acinetobacter baumannii is a nosocomial pathogen of which many isolates are multidrug resistant. A. baumannii is a major cause of healthcare-acquired infections in patients who are critically ill and A. baumannii bacteraemia (ABB) is associated with high mortality. Several factors are known to play a role in A. baumannii transmission and the emergence of resistance.
Aim. This study aimed to retrospectively analyse ABB cases in Saudi Arabia where little is known about the prevalence risk factors clinical disease treatment outcomes and mortality associated with this infection.
Methods. A retrospective chart review was performed from January 1 2015 until December 31 2022 to identify all patients 14 years and above with ABB. Demographic and clinical data as well as results from laboratory analyses were collected from patients’ electronic charts. Statistical analyses were performed on the data to identify factors associated with 90-day mortality.
Results. In total 112 ABB cases were identified with a mean age of 58.0 years of which 66.1% were males. Of these cases 71 (63.4%) died. The factors that were found to be associated with 90-day mortality were the Charlson comorbidity score Pitt bacteraemia score quick Sequential Organ Failure Assessment (qSOFA) score (p < 0.001 for each) hospital ward (p < 0.02) short duration of antibiotic treatment (p < 0.01) and higher age (p < 0.05). The most common source of infection was Central Line-associated Bloodstream Infection in 52.7%. Also associated with mortality were inappropriate antimicrobial therapy (p < 0.02) and empirical use of colistin (p < 0.05). In many patients ABB was caused by carbapenem-resistant A. baumannii (CRAB) (69.6%) and 74.4% of those patients died.
Conclusion. CRAB is a growing threat in hospitals in Saudi Arabia especially in the critical care setting and carries a very high risk of mortality. Future studies should focus on novel ways of preventing CRAB infections and on the assessment of promising new antimicrobials such as cefiderocol or sulbactam-durlobactam and other treatment options such as bacteriophages.
Fatal Clostridium septicum gas gangrene complicating ECMO : case report and review of literature
Clostridium septicum gas gangrene is a severe and deadly infection caused by an anaerobic spore-forming Gram-positive bacillus. As previously described two entities are observed: traumatic and spontaneous (or non-traumatic) forms. In this report we aim to describe the case of a fulminant and ultimately fatal C. septicum myonecrosis occurring in a patient who was first admitted for refractory cardiac arrest and placed on veino-arterial extracorporeal membrane oxygenation (ECMO). Building upon prior studies that have documented cases of spontaneous gas gangrene caused by C. septicum we provide an updated compilation focusing on microbiological characteristics of C. septicum along with the diagnostic and therapeutic challenges associated with spontaneous gas gangrene. Additionally the specific clinical situation of our case illustrates the seriousness of this infectious complication that combined both spontaneous and traumatic gas gangrene risk factors. We thus discuss the antibiotic coverage prior to the initiation of ECMO procedure.
Isolation of Bioactive Compounds from Low-cost Agricultural Resources and its Utilization in Daily Life.
The ethanolic (80%) methanolic (80%) and aqueous decoction (100% distilled water) of whole plant of Oxalis corniculata Linn (Indian Sorrel) was evaluated for its anti‐microbial and antioxidant properties by in vitro methods. Methanolic (80%) and ethanolic (80%) decoctions showed significant antibacterial property against Staphylococcus aureus Bacillus subtilis Escherichia coli Salmonella typhi bacterial strains. In comparison to Chloramphenicol (C30) against bacteria 80% ethanolic decoctions showed significant effect among the decoctions. Nowadays though the standard soap is in a huge demand but it’s also facing major backlashes due to the presence of synthetic compounds in it which over long use may cause harmful effects on the skin health. Therefore the organic soaps which are made up of natural ingredients herbs or any sort ayurvedic compound have less side effects on the human skin and are much safer than standard daily soap. The formulated therapeutic soap exhibits significant amount of reducing potential (high FRAP and TAC values) and antioxidant activity (DPPH ABTS assay).
Identification of anaerobic and aerobic bacteria that can be associated with DFI and their therapeutic in Elnaw teaching hospital
Diabetic foot infection (DFI) is one of the commonest diabetic complications which considered a major public health concern around the world with the rising prevalence especially in developing countries. Globally adults with diabetes accounted for 463 million in 2019 according to the International Diabetes Federation.
The aim of this study was to identify the anaerobic and aerobic bacteria that causing DFI and their therapeutic regimen on diabetic patients in diabetic clinic room in Elnaw teaching hospital - Khartoum state.
The study showed that there was no infection by anaerobic organism and the most frequently isolated organisms were gram negative rods (70%) which represents (65%) on diabetic patients. The commonest isolated organism was S.aureus (30%) followed by E.coli (25%) in control group (non-diabetic) while Klebsiella.spp and S.aureus with (20%) for each; were isolated from the clinic room swabs.
Early diagnosis optimal management and effective antibiotic therapy are necessary to prevent DFI and amputation.
ELISA for leptospiral 3-hydroxyacyl-CoA dehydrogenase in urine is a promising screening tool for acute leptospirosis
Introduction: Leptospirosis is a zoonotic disease that is prevalent worldwide. The leptospiral 3-hydroxyacyl-CoA dehydrogenase (3-HADH) is excreted in the urine of infected individuals. However the potential use of 3-HADH as a biomarker for the diagnosis of leptospirosis using enzyme-linked immunosorbent assay (ELISA) has not been investigated. A technique that identifies Leptospira in a patient in urine sample will be valuable in regular diagnostics and epidemic scenarios as opposed to existing serological approaches. This study aimed to develop and evaluate an ELISA that can detect 3-HADH in the urine of patients with confirmed acute leptospirosis and to assess its potential as a screening test for leptospirosis.
Methods: Laboratory confirmation of acute leptospirosis was done by flaB-nested polymerase chain reaction (PCR) of plasma samples from suspected patients. ELISA-based determination of the presence of 3-HADH in the urine of PCR-positive patients versus PCR-negative patients matched for fever date was performed by coating ELISA plates with urine supernatants and using rabbit anti-3-HADH as the primary antibody. Receiver operating characteristic curve analysis was used to determine the cutoff values for the ELISA. The diagnostic measures between the PCR-positive and PCR-negative patients were compared using the Mann-Whitney U test.
Results: In total 158 febrile patients were assessed of whom 121 (76.6%) were male. Of the 15 flaB-nested PCR-positive patients 12 were in the acute phase of the febrile illness. The best cutoff was an average optical density (ODav) value of 0.2200 for febrile patients. Sensitivity and specificity were 83.33% (95% confidence interval [CI] 51.59–97.91%) and 83.33% (95% CI 76.05–89.13%) respectively. The ODav values for PCR-positive patients in the acute phase of the disease (≤7 days of fever) were significantly higher than those for PCR-negative patients (p<0.001 U=114.0 z= -4.946).
Conclusion: Detection of 3-HADH in urine by ELISA appears promising for the screening of acute leptospirosis in suspected patients.
A Case of Persistent Pasteurella Multocida Cellulitis Complicated with Large Endocarditis Vegetation
Introduction: A distinct and infrequent player emerges in the realm of infective endocarditis Pasteurella multocida now warranting careful consideration in this unique case report. Disseminated P.multocida infection seeded into the heart valve has only been reported in about one case per year worldwide with only 42 cases were found in the literature and only 5 cases reported to have underlying liver cirrhosis as in our case.
Case Presentation: A 73-year-old female with past medical history of liver cirrhosis secondary to primary biliary cholangitis with splenomegaly and pancytopenia presented to hospital with weakness fever and leg rash. She had recent admission with lower extremity cellulitis and P.multocida bacteremia treated with 14 days high dose oral amoxicillin-clavulanate after negative blood culture prior to discharge. The repeat blood culture showed P.multocida. Echocardiogram showed a 1.9 cm x 1 cm mobile mass attached to the mitral valve. She was not a suitable candidate for valve surgery due to her comorbidities. She was ultimately discharged with a two-week course of ceftriaxone continued with levofloxacin to complete six weeks of total treatment and followed by long-term penicillin.
Conclusion: In this case report we delve into a rare clinical presentation of Pasteurella multocida case. Our patient is the second reported case which showed complication of native mitral valve endocarditis even in the setting of bacteremia resolution. This report sheds light on the challenging diagnosis and management of this uncommon yet clinically significant condition highlighting the importance of vigilant and prompt intervention in endocarditis cases with atypical agents.
Cutaneous tuberculosis an unusual localization: A case report
Tuberculosis is a major public health concern. Morocco is a tuberculosis endemic country; nearly 30000 cases are recorded each year. Pulmonary tuberculosis accounts for 57% extrapulmonary tuberculosis 43%. Cutaneous localization is exceptional; it accounts for 0.5% to 2% of cases of tuberculosis. It is very difficult to diagnose given the variability of clinical presentation. We report a rare case of cutaneous tuberculosis in a patient with a history of pulmonary and cutaneous sarcoidosis.