Prayer-marks Heralding Acute Coronary Syndrome

We read, with interest, the case report on extension of prayer-marks by Cangiano et al. and its association with worsening of the underlying chronic disease (1). We report a case where the occurrence of a similar skin lesion preceded an episode of acute coronary syndrome. A 45-year old man presented with sudden onset of severe retrosternal chest pain radiating to the found to be associated with lichenification, acan-thosis, basal cell hyperpigmentation, hyperkerato-sis, hypergranulosis, and dermal papillary fibrosis (2). Our report emphasizes the association of the prayer sign (Namaaj sign) with acute conditions in addition to chronic conditions as suggested by Cang-iano et al. However, further studies are needed to Fig. 1. Hyperpigmented area over the middle of forehead Fig. 2. Hyperpigmented areas of knees prove a statistically significant link between the two entities.