Publications by authors named "Jesse J Keller"

17 Publications

  • Page 1 of 1

Long-term Physical and Psychological Outcomes of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis.

JAMA Dermatol 2021 May 5. Epub 2021 May 5.

Hennepin Healthcare, University of Minnesota Medical School, Minneapolis.

Importance: Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is known to cause multiple end-organ complications in its acute phase, but less is known about the long-term association with patients' mental health and quality of life.

Objective: To examine the chronic physical and psychological sequelae affecting patients with SJS/TEN.

Design, Setting, And Participants: A survey study conducted at 11 academic health centers in the US evaluated 121 adults diagnosed with SJS/TEN by inpatient consultive dermatologists between January 1, 2009, and September 30, 2019.

Interventions: Patients completed a survey that included the following validated questionnaires: Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Primary Care Post-Traumatic Stress Disorder Screen (PC-PTSD), and the 12-item Short Form Health Survey (SF-12). The survey also included questions created by the study team regarding fear, patient education, and long-term sequelae relevant to SJS/TEN.

Main Outcomes And Measures: Primary outcome measures were the percentage of patients reporting long-term physical sequelae; the percentage of patients with positive results on PHQ-9, GAD-7, and PC-PTSD screening; and the numeric score on the SF-12 (score of 50 defined as average physical and mental well-being).

Results: A total of 121 individuals (73 women [60.3%]; mean [SD] age, 52.5 [17.1] years) completed the survey (response rate, 29.2%). The most common long-term physical sequelae reported were cutaneous problems (102 of 121 [84.3%]), ocular problems (72 of 121 [59.5%]), and oral mucosal problems (61 of 120 [50.8%]). A total of 53.3% (64 of 120) of the respondents had results indicating depression on the PHQ-9, 43.3% (52 of 120) showed signs of anxiety on the GAD-7, and 19.5% had results indicating PTSD on the PC-PTSD. The mean (SD) SF-12 Physical Component Summary score was 42.4 (22.8), and the mean Mental Component Summary score was 46.1 (20.9). A total of 28.2% (33 of 117) of the respondents were unable to work, 68.1% (81 of 119) were fearful of taking new medications, and 30.0% (36 of 120) avoided taking prescribed medications for a diagnosed medical condition.

Conclusions And Relevance: This survey study found that long-term physical sequelae, depression, and anxiety appear to be common in patients with SJS/TEN, with implications for health and well-being. Improved awareness of these complications may assist health professionals in offering medical care, counseling, and support to patients with SJS/TEN.
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http://dx.doi.org/10.1001/jamadermatol.2021.1136DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8100906PMC
May 2021

Atypical Pyoderma Gangrenosum in the Setting of Venous and Arterial Insufficiency.

Int J Low Extrem Wounds 2021 Apr 29:15347346211002334. Epub 2021 Apr 29.

6684Oregon Health & Science University, Portland, OR, USA.

Ulcers of mixed etiology are diagnostically elusive and challenging to treat, especially when rare conditions are superimposed. Pyoderma gangrenosum (PG) is an autoinflammatory, ulcerative skin disease that is difficult to diagnose. Diagnostic criteria exist but there are no specific clinical tests to identify it. We discuss a case of PG initially diagnosed as venous ulcer in the setting of peripheral artery disease, complicated by superinfection, refractory to standard wound care, multiple surgical debridements, revascularization, negative pressure therapy, and parenteral antibiotics. Findings differentiating PG from other wound etiologies are explored, with the aim of improving clinical recognition of this condition.
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http://dx.doi.org/10.1177/15347346211002334DOI Listing
April 2021

Use of teledermatology by dermatology hospitalists is effective in the diagnosis and management of inpatient disease.

J Am Acad Dermatol 2021 Jun 7;84(6):1547-1553. Epub 2020 May 7.

Department of Dermatology, Mayo Clinic, Rochester, Minnesota.

Background: Patient outcomes are improved when dermatologists provide inpatient consultations. Inpatient access to dermatologists is limited, illustrating an opportunity to use teledermatology. Little is known about the ability of dermatologists to accurately diagnose disease and manage inpatients with teledermatology, particularly when using nondermatologist-generated clinical data.

Methods: This prospective study assessed the ability of teledermatology to diagnose disease and manage 41 dermatology consultations from a large urban tertiary care center, using internal medicine referral documentation and photographs. Twenty-seven dermatology hospitalists were surveyed. Interrater agreement was assessed by the κ statistic.

Results: There was substantial agreement between in-person and teledermatology assessment of the diagnosis with differential diagnosis (median κ = 0.83), substantial agreement in laboratory evaluation decisions (median κ = 0.67), almost perfect agreement in imaging decisions (median κ = 1.0), and moderate agreement in biopsy decisions (median κ = 0.43). There was almost perfect agreement in treatment (median κ = 1.0), but no agreement in follow-up planning (median κ = 0.0). There was no association between raw photograph quality and the primary plus differential diagnosis or primary diagnosis alone.

Limitations: Selection bias and single-center nature.

Conclusions: Teledermatology may be effective in the inpatient setting, with concordant diagnosis, evaluation, and management decisions.
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http://dx.doi.org/10.1016/j.jaad.2020.04.171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7204758PMC
June 2021

Ulcerative C2 neurocutaneous dysesthesia (trigeminal trophic syndrome in an alternative distribution).

Dermatol Online J 2020 Jan 15;26(1). Epub 2020 Jan 15.

Department of Dermatology, Oregon Health & Science University, Portland, OR.

Trigeminal trophic syndrome is an uncommon condition characterized by paresthesia, itch, and self-inflicted wounds following the trigeminal dermatome(s). Similar processes adhering to cervical nerve distributions have been reported, calling into question the specificity of trigeminal trophic syndrome for the trigeminal network. Herein, we report patient with trigeminal trophic syndrome adhering to the C2 dermatome, a previously unreported distribution.
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January 2020

Inpatient teledermatology: Diagnostic and therapeutic concordance among a hospitalist, dermatologist, and teledermatologist using store-and-forward teledermatology.

J Am Acad Dermatol 2020 May 20;82(5):1262-1267. Epub 2020 Jan 20.

Biostatistics Shared Resource, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon.

Background: Inpatient dermatology has been shown to improve patient outcomes at a reduced cost. Few hospitals have dermatologists available. Teledermatology may allow dermatologists to assess hospitalized patients remotely.

Objective: To examine the diagnostic concordance between a hospitalist, dermatologist, and teledermatologist using store-and-forward teledermatology.

Methods: For 100 consecutive patients requiring inpatient dermatology consultation, a survey was conducted by all 3 raters to convey diagnostic impressions and therapeutic recommendations. Complete and partial agreements were assessed using the Cohen kappa statistic.

Results: Inpatient dermatology consultation often resulted in a change in diagnosis (50.9%) and a change in systemic therapy (41.5%). Likewise, virtual teledermatology consultation would have resulted in a change in diagnosis (54.7%) and a change in systemic therapy (47.2%) at similar rates. Comparing the dermatologist and teledermatologists, diagnostic complete and partial agreement were 52.8% and 84.9%, respectively. Systemic therapy agreement was 77.4%. Teledermatologists recommended biopsy more often (68.5% vs 43.5%).

Limitations: Small sample size, tertiary academic medical center, single rater for inpatient teledermatology with specific inpatient niche.

Conclusion: Teledermatologists performed comparably to an in-person dermatologist for the diagnosis and management of hospitalized patients with skin conditions. Teledermatology may be a suitable alternative for delivery of inpatient care if no dermatologist is available.
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http://dx.doi.org/10.1016/j.jaad.2020.01.030DOI Listing
May 2020

Characterisation and diagnosis of ulcers in inpatient dermatology consultation services: A multi-centre study.

Int Wound J 2019 Dec 2;16(6):1440-1444. Epub 2019 Sep 2.

Oregon Health & Science University, Department of Dermatology, Portland, Oregon.

Accurate and prompt diagnosis of skin ulcers is critical to optimise management; however, studies in hospitalised patients are limited. This retrospective review of dermatologic consultations included 272 inpatients with skin ulcers between July 2015 and July 2018 in four U.S. academic hospitals. The median age was 54 years and 45% were male. In 49.3% of the patients, skin ulcers were considered the primary reason for admission. Ulcers of 62% were chronic and 49.6% were located on the lower extremities. Pyoderma gangrenosum (17.3%), infection (12.5%), and exogenous causes (11.8%) were the leading aetiologies; 12% remained diagnostically inconclusive after consultation. Diagnostic agreements pre-dermatology and post-dermatology consult ranged from 0.104 (n = 77, 95% CI 0.051-0.194) to 0.553 (n = 76, 95% CI 0.440-0.659), indicating poor-modest agreement. This study highlights the diagnostic complexity and relative incidences of skin ulcers in the inpatient setting.
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http://dx.doi.org/10.1111/iwj.13211DOI Listing
December 2019

Dermatology in the Diagnosis of Noncutaneous Malignancy: Paraneoplastic Diseases.

Dermatol Clin 2019 Oct 10;37(4):537-544. Epub 2019 Jul 10.

Oregon Health & Science University, 3303 Southwest Bond Avenue CH16D, Portland, OR 97239, USA.

It is important to recognize paraneoplastic dermatoses because they allow the practitioner to begin an early, directed workup to detect an underlying malignant neoplasm. In this review, several paraneoplastic dermatoses are outlined using existing data to detail each one's association with underlying malignancy, demographics, prognosis, and treatment considerations.
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http://dx.doi.org/10.1016/j.det.2019.05.011DOI Listing
October 2019

Do I Have Calciphylaxis?

JAMA Dermatol 2019 07;155(7):872

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http://dx.doi.org/10.1001/jamadermatol.2019.0458DOI Listing
July 2019

Clinical factors influencing the response to intravenous immunoglobulin treatment in cases of treatment-resistant pyoderma gangrenosum.

J Dermatolog Treat 2020 Nov 6;31(7):723-726. Epub 2019 May 6.

Department of Dermatology, Oregon Health & Science University, Center for Health & Healing, Portland, OR, USA.

Pyoderma gangrenosum (PG) is a neutrophilic disorder which classically presents as chronic, painful ulcers on the lower extremities. There is evidence supporting a potential role for intravenous immunoglobulin (IVIG) as adjuvant therapy for treatment-resistant cases; however, it is unclear which patients will most benefit from this modality of treatment - an especially important consideration given the cost per infusion ($5000-$10,000). Thus, we sought to identify the clinical characteristics of patients with refractory PG lesions who demonstrated complete healing when IVIG was incorporated into the therapeutic plan. We performed a literature search of PubMed/MEDLINE and Embase using the keywords 'pyoderma gangrenosum' and 'IVIG'. We also added four institutional cases. Descriptive statistics were used to analyze the data. Significance was set at  < .05. We discovered a total of 45 cases. Twenty-three patients with treatment-resistant PG had complete healing, 22 had partial or unhealed PG ulcers. Patients with one ulcer were 4.1 (95% CI: 1.1-18.5) times more likely to achieve complete healing than patients with more than one ulcer, when IVIG was added ( = .041). There is increased efficacy of IVIG as a treatment for patients with a solitary treatment-resistant PG lesion compared to patients with multiple refractory lesions.
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http://dx.doi.org/10.1080/09546634.2019.1606888DOI Listing
November 2020

Herpes zoster presenting as unilateral vasculitis.

Dermatol Online J 2018 Nov 15;24(11). Epub 2018 Nov 15.

Department of Dermatology, Oregon Health and Science University, Portland, Oregon.

Vasculitis can be a primary disorder or a cutaneous manifestation of a viral infection. The present case describes an atypical localized cutaneous varicella-zoster virus infection inducing a small vessel vasculitis in a patient with multisystem sarcoidosis. Additionally, we discuss the differential diagnoses and treatment options. Varicella-Zoster infection occurs more frequently in immunosuppressed populations and can present with uncharacteristic clinical manifestations complicating the diagnosis as in the present case.
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November 2018

Clinical Features of Neutrophilic Dermatosis Variants Resembling Necrotizing Fasciitis.

JAMA Dermatol 2019 01;155(1):79-84

Department of Dermatology, University of California San Francisco, San Francisco.

Importance: Pyoderma gangrenosum and necrotizing Sweet syndrome are diagnostically challenging variants of neutrophilic dermatosis that can clinically mimic the cutaneous and systemic features of necrotizing fasciitis. Improved characterization of these rare variants is needed, as improper diagnosis may lead to inappropriate or delayed treatment and the potential for morbidity.

Objective: To determine the characteristics of necrotizing neutrophilic dermatosis to improve diagnostic accuracy and distinguish from infection.

Design, Setting, And Participants: A case series of patients with necrotizing neutrophilic dermatosis treated at 3 academic hospitals (University of California San Francisco, Oregon Health and Science University, and University of Minnesota) from January 1, 2015, to December 31, 2017, was performed along with a literature review of related articles published between January 1, 1980, and December 31, 2017. Data were obtained from medical records as well as Medline and Embase databases. All patients had signs resembling necrotizing infection and had a final diagnosis of pyoderma gangrenosum with systemic features or necrotizing Sweet syndrome. Patients were excluded if a diagnosis other than neutrophilic dermatosis was made, if key clinical information was missing, and if reported in a non-English language.

Main Outcomes And Measures: Description of key characteristics of necrotizing neutrophilic dermatosis.

Results: Overall, 54 patients with necrotizing neutrophilic dermatosis were included, of which 40 had pyoderma gangrenosum with systemic features and 14 had necrotizing Sweet syndrome. Of the 54 patients, 29 (54%) were male and 25 (46%) were female, with a mean (SD) age of 51 (19) years. Skin lesions commonly occurred on the lower (19 [35%]) and upper (13 [24%]) extremities and developed after a surgical procedure (22 [41%]) or skin trauma (10 [19%]). Shock was reported in 14 patients (26%), and leukemoid reaction was seen in 15 patients (28%). Of the patients with necrotizing neutrophilic dermatosis, 51 (94%) were initially misdiagnosed as necrotizing fasciitis and subsequently received inappropriate treatment. Debridement was performed in 42 patients (78%), with a mean (SD) of 2 (2 [range, 1-12]) debridements per patient. Four amputations (7%) were performed. Forty-nine patients (91%) received antibiotics when necrotizing neutrophilic dermatosis was misdiagnosed as an infection, and 50 patients (93%) received systemic corticosteroids; all patients responded to immunosuppressants.

Conclusions And Relevance: A complex spectrum of clinical findings of pyoderma gangrenosum and Sweet syndrome with prominent systemic inflammation exists that defines a new subset of neutrophilic dermatoses, termed necrotizing neutrophilic dermatoses; recognizing the difference between this variant and severe infection may prevent unnecessary surgical procedures and prolonged disease morbidity associated with a misdiagnosis and may expedite appropriate medical management.
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http://dx.doi.org/10.1001/jamadermatol.2018.3890DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6439570PMC
January 2019

Bone morphogenetic protein 4 antagonizes hair cell regeneration in the avian auditory epithelium.

Hear Res 2018 07 2;364:1-11. Epub 2018 May 2.

University of Washington School of Medicine and the Virginia Merrill Bloedel Hearing Research Center, Seattle, WA, United States. Electronic address:

Permanent hearing loss is often a result of damage to cochlear hair cells, which mammals are unable to regenerate. Non-mammalian vertebrates such as birds replace damaged hair cells and restore hearing function, but mechanisms controlling regeneration are not understood. The secreted protein bone morphogenetic protein 4 (BMP4) regulates inner ear morphogenesis and hair cell development. To investigate mechanisms controlling hair cell regeneration in birds, we examined expression and function of BMP4 in the auditory epithelia (basilar papillae) of chickens of either sex after hair cell destruction by ototoxic antibiotics. In mature basilar papillae, BMP4 mRNA is highly expressed in hair cells, but not in hair cell progenitors (supporting cells). Supporting cells transcribe genes encoding receptors for BMP4 (BMPR1A, BMPR1B, and BMPR2) and effectors of BMP4 signaling (ID transcription factors). Following hair cell destruction, BMP4 transcripts are lost from the sensory epithelium. Using organotypic cultures, we demonstrate that treatments with BMP4 during hair cell destruction prevent supporting cells from upregulating expression of the pro-hair cell transcription factor ATOH1, entering the cell cycle, and fully transdifferentiating into hair cells, but they do not induce cell death. By contrast, noggin, a BMP4 inhibitor, increases numbers of regenerated hair cells. These findings demonstrate that BMP4 antagonizes hair cell regeneration in the chicken basilar papilla, at least in part by preventing accumulation of ATOH1 in hair cell precursors.
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http://dx.doi.org/10.1016/j.heares.2018.04.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5984193PMC
July 2018

Evaluation of ELISA testing for BP180 and BP230 as a diagnostic modality for bullous pemphigoid: a clinical experience.

Arch Dermatol Res 2016 May 19;308(4):269-72. Epub 2016 Feb 19.

Department of Dermatology, UH Case Medical Center, 11100 Euclid Ave, Lakeside Building 3500, Cleveland, OH, 44106, USA.

Bullous pemphigoid (BP) is a common autoimmune blistering disorder of the elderly. Several diagnostic modalities are available, including clinical impression, histopathology, direct and indirect immunofluorescence, and enzyme-linked immunosorbent assay (ELISA) detection of pathogenic antibodies. In this study, we aim to examine the utility of the newest test, ELISA, in comparison to the constellation of other tests. We describe our clinical experience in which 170 patients diagnosed with bullous pemphigoid had multiple tests performed. BP180 alone showed a sensitivity of 54 % and specificity of 94 %. The positive predictive value (PPV) is 95 % while the negative predictive value (NPV) is 52 %. BP230 alone yielded a sensitivity of 48 % and specificity of 94 %. The PPV is 94 % and the NPV is 49 %. Using both tests in combination yielded a sensitivity of 66 % and specificity of 89 %. The PPV of at least one of two tests returning positive is 92 % while the NPV of dual negative tests is 58 %. Use of ELISAs for suspected cases of BP are an inadequate standalone test, and are only helpful in making the diagnosis should they return positive. However, they would appear to miss about one-third of cases.
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http://dx.doi.org/10.1007/s00403-016-1631-1DOI Listing
May 2016

A systematic review and meta-analysis of animal-type melanoma.

J Am Acad Dermatol 2015 Dec 26;73(6):1031-9. Epub 2015 Sep 26.

Department of Dermatology, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio. Electronic address:

Background: Animal-type melanoma is a rare subtype of melanoma with heavily pigmented dermal epithelioid and spindled melanocytes. Its classification as a subtype of melanoma versus a borderline melanocytic tumor is debated.

Objectives: Our primary objective was to characterize the demographics, clinical presentation, histopathology, management, and outcomes of patients with animal-type melanoma.

Methods: We performed a systematic review and meta-analysis of the English-language literature on animal-type melanoma.

Results: We identified 190 cases of animal-type melanoma. They occurred equally in men and women, with Caucasians (53.7%) most commonly affected. The median Breslow depth was 3.8 mm; ulceration was reported present in 15.8%; and dermal mitoses greater than or equal to 1/mm(2) was reported in 27.4%. The most common initial management was wide local excision with sentinel lymph node biopsy (55.7%). In all, 78 patients underwent sentinel lymph node biopsy with 41.0% positivity rate. A total of 32 patients underwent completion lymph node dissection with 34.4% positivity rate. Locoregional recurrence was reported in 15 patients, recurrence with distant metastases in 6 patients, and death in 5 patients.

Limitations: Data were obtained from small studies with limited follow-up. There is no universally accepted definition of animal-type melanoma.

Conclusion: Prospective studies with complete staging information and molecular profiling may allow further characterization of this tumor.
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http://dx.doi.org/10.1016/j.jaad.2015.08.016DOI Listing
December 2015

Germline mutation in MSH6 associated with multiple malignant neoplasms in a patient With Muir-Torre syndrome.

J Clin Oncol 2012 Aug 25;30(22):e195-8. Epub 2012 Jun 25.

University of Washington Division of Dermatology, Box 358056, Seattle, WA 98195-8056, USA.

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http://dx.doi.org/10.1200/JCO.2011.41.5562DOI Listing
August 2012

Rare and deadly.

Am J Med 2011 Jan;124(1):32-4

Division of Dermatology, Department of Medicine, University of Washington, Seatle, Wash., USA.

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http://dx.doi.org/10.1016/j.amjmed.2010.09.006DOI Listing
January 2011

Wnt and related signaling pathways in melanomagenesis.

Cancers (Basel) 2010 May 26;2(2):1000-12. Epub 2010 May 26.

University of Washington School of Medicine, Seattle, WA 98195, USA.

Given the pivotal roles of morphogen pathways including Wnt, Notch, Hedgehog, and BMP pathways in the development of the neural crest lineage, it is not surprising that these signaling networks have also been implicated in the biology of malignant melanoma. Understanding the mechanisms by which these pathways can alter cell fate and other biological properties in tumor cells will be essential for determining whether the therapeutic targeting of these pathways has a potential role in melanoma treatment. This review highlights some of the recent findings with regards to how morphogen signaling may regulate melanoma cell biology.
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http://dx.doi.org/10.3390/cancers2021000DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3835115PMC
May 2010