A reticular variant of elastolytic giant cell granuloma

An 80-year-old man presented with a distinctive reticular form of elastolytic giant cell granuloma (EGCG). This represents a rare subset of EGCG, thus belonging to a larger group of granulomatous skin diseases with poorly understood pathogenesis. The patient exhibited numerous erythematous to brownish, sharply demarcated patches of reticulate appearance with partial central atrophy and nonelevated margins, which involved the trunk and especially chest, shoulders, upper back and arms. Skin biopsy revealed a granulomatous infiltrate with multinucleate histiocytes containing remnants of elastic fibres in conjunction with a significant loss of elastic fibres throughout the dermis. There is little published information on treatment, which remains unsatisfactory.

Sublethal toxicity of two wastewater treatment polymers to lake trout fry (Salvelinus namaycush)

Lake trout fry (Salvelinus namaycush) were exposed in laboratory experiments to two wastewater treatment polymers, one anionic (MagnaFloc 156) and one cationic (MagnaFloc 368; Ciba Speciality Chemical), to determine if these chemicals which are used and discharged by mining operations in Canada's North pose a significant hazard to juvenile fishes. The cationic polymer was substantially more toxic to lake trout fry than the anionic polymer, with 96-h LC50 estimates of 2.08 and >600 mg/l, respectively. Separate 30-d exposure experiments yielded no observed and lowest observed effect concentrations, respectively, of 0.25 and 0.5mg/l for MagnaFloc 368, and 75 and 150 mg/l for MagnaFloc 156. In both cases, behavioural responses, especially startle response, were the most sensitive test endpoints. Histopathological assessment revealed that gill pathology appeared within a few days of exposure to both polymers, apparently as a result of localized hypoxia. Acute (4 d) effects included cloudy swelling of epithelial cells, increased gill vascularization, and thickening and shortening of the gill lamella. Chronic (30 d) polymer exposure produced only slightly greater pathological effects than acute exposure, with comparable responses observed only at >1.0mg/l MagnaFloc 368 and 150 mg/l MagnaFloc 156, suggesting that the fish displayed some level of both behavioural and physiological adaptation to the respiratory stress imposed by the two polymers.

Leukoencephalopathy with ataxia, hypodontia, and hypomyelination

The authors describe four unrelated girls with a distinctive neurologic disorder with early-onset progressive ataxia and hypodontia with a characteristic pattern of delayed dentition. Cerebral MRI shows hypomyelinated white matter and cerebellar atrophy; 1H-MRS of white matter reveals a marked elevation of myo-inositol.

Comparison of dose calculation algorithms in phantoms with lung equivalent heterogeneities under conditions of lateral electronic disequilibrium

An extensive set of benchmark measurement of PDDs and beam profiles was performed in a heterogeneous layer phantom, including a lung equivalent heterogeneity, by means of several detectors and compared against the predicted dose values by different calculation algorithms in two treatment planning systems. PDDs were measured with TLDs, plane parallel and cylindrical ionization chambers and beam profiles with films. Additionally, Monte Carlo simulations by means of the PENELOPE code were performed. Four different field sizes (10 x 10, 5 x 5, 2 x 2, and 1 x 1 cm2) and two lung equivalent materials (CIRS, p(w)e=0.195 and St. Bartholomew Hospital, London, p(w)e=0.244-0.322) were studied. The performance of four correction-based algorithms and one based on convolution-superposition was analyzed. The correction-based algorithms were the Batho, the Modified Batho, and the Equivalent TAR implemented in the Cadplan (Varian) treatment planning system and the TMS Pencil Beam from the Helax-TMS (Nucletron) treatment planning system. The convolution-superposition algorithm was the Collapsed Cone implemented in the Helax-TMS. The only studied calculation methods that correlated successfully with the measured values with a 2% average inside all media were the Collapsed Cone and the Monte Carlo simulation. The biggest difference between the predicted and the delivered dose in the beam axis was found for the EqTAR algorithm inside the CIRS lung equivalent material in a 2 x 2 cm2 18 MV x-ray beam. In these conditions, average and maximum difference against the TLD measurements were 32% and 39%, respectively. In the water equivalent part of the phantom every algorithm correctly predicted the dose (within 2%) everywhere except very close to the interfaces where differences up to 24% were found for 2 x 2 cm2 18 MV photon beams. Consistent values were found between the reference detector (ionization chamber in water and TLD in lung) and Monte Carlo simulations, yielding minimal differences (0.4%+/-1.2%). The penumbra broadening effect in low density media was not predicted by any of the correction-based algorithms, and the only one that matched the experimental values and the Monte Carlo simulations within the estimated uncertainties was the Collapsed Cone Algorithm.

Cutaneous leukaemic infiltrations in a patient with previously undiagnosed myelodysplastic syndrome

We report the rare case of a patient with leukaemia cutis first presenting only on the hand and fingers and then subsequently spreading over the trunk and face. The lesions heralded the transformation of a previously undiagnosed myelodysplastic syndrome type RAEB (refractory anaemia with blast excess) into frank myeloid leukaemia. The haematological disease was first detected by the dermatohistopathologist. This case underlines the need to look meticulously for skin changes and perform early skin biopsies in haematological patients, as the skin can reveal the first clinical signs of an otherwise not evident bone marrow disorder. Leukaemia cutis as the initial clinical presentation of a transforming myelodysplastic syndrome type RAEB into acute myeloid leukaemia has been reported only very rarely.

[Allergic contact dermatitis to common ivy (Hedera helix L.)]

Common ivy (Hedera helix L.) is a ubiquitous plant in Europe whose major allergen falcarinol has moderate allergic potential. It is not related to poison ivy (Toxicodendron spp.). There are no cross reactions between the allergens of common ivy (falcarinol) and poison ivy (urushiol). Contact with common ivy or falcarinol may lead to sensitization and then a delayed hypersensitivity reaction. There are only few cases described in the literature. We report on a male hobby gardener with appropriate clinical history and positive patch test. The pathogenic mechanism is a type IV reaction following a sensitization exposure. Gardeners and landscape architects with frequent exposure to common ivy and thus a high risk of sensitization should wear appropriate protective clothing.

A teledermatological approach to enhance diagnostic accuracy in dermatohistopathology

We determined whether digital photographs of skin lesions could enhance diagnostic accuracy in dermatohistological evaluations. Two dermatohistopathologists examined 375 unsorted consecutive cases. On a standardized questionnaire they recorded whether the final diagnostic interpretation would be improved by the availability of digital images of the skin lesions. In 101 cases (27%) they said that digital photographs would be helpful. Subsequently, 30 histological analyses were performed with and without digital photographs of the skin lesions. Presentation of digital photographs reduced the number of differential diagnoses significantly, from a median of 3 to 2. Ratings of ability to make a single definitive diagnosis increased significantly with the presentation of digital photographs. Enhancement of information given by the digital images was scored a median of 6 (on a scale of 0-10, with higher scores reflecting greater enhancement). Digital photographs of skin lesions are likely to refine diagnostic accuracy in histopathology.

Transmitted light microscopy of a fibre reinforced metal

A method is presented for studying fibre damage in continuous fibre reinforced composites. It is based on contrasting the transmission of light through intact translucent fibres with the light through fractured or dead-ended fibres. The method is applied in order to detect processing-induced fibre fractures in aluminium reinforced with continuous alumina fibres.

Childhood epidermolysis bullosa acquisita: a novel variant with reactivity to all three structural domains of type VII collagen

Most patients with epidermolysis bullosa acquisita develop an autoimmune response to the non-collagenous (NC) 1 domain of type VII collagen. We report a 4-year-old girl of white European descent presenting with widespread blistering disease involving the face, hands, genital area and oral mucosa. Histopathology revealed subepidermal blisters, and linear deposits of IgG and C3 were seen along the dermal-epidermal junction on direct immunofluorescence (IF) microscopy of a perilesional skin biopsy. On indirect IF microscopy, circulating autoantibodies exclusively stained the dermal side of 1 mol L-1 NaCl-split skin. The patient's IgG autoantibodies labelled a 290-kDa protein on Western blotting of dermal extracts, and reacted with the NC1, NC2 and triple helical domains of type VII collagen on immunoblotting of recombinant and cell-derived fragments obtained by pepsin and collagenase digestion of the full-length protein. Oral methylprednisolone and dapsone led to clearance of lesions, which healed with mild scarring and milia formation. Treatment was discontinued after 1 year and the patient has now been in remission for more than 3 years.

Intracranial Nocardia dissemination during minocycline therapy

Nocardia species is a well-known pathogen in immunocompromised hosts, including renal transplant recipients. Primary pulmonary infection can disseminate to other organs and recommended first-line therapy is high-dose trimethoprim/sulfamethoxazole (TMP/SMX). We report two cases of primary pulmonary Nocardia sp. in immunosuppressed patients who were treated with minocycline, a second-line drug. During treatment with minocycline, both patients developed central nervous system (CNS) lesions of Nocardia sp. and were then treated with TMP/SMX with resolution of disease. The literature on Nocardia and treatment with minocycline is reviewed. Treatment of pulmonary Nocardia sp. with 200 mg minocycline daily is not adequate to prevent disseminated CNS disease.

Reactivity of the inversely polarized phosphaalkenes RP=C(NMe2)2 (R = tBu, Me3Si, H) towards arylcarbene complexes [(CO)5M=C(oEt)Ar] (Ar= Ph, M = Cr, W; Ar = 2-MeC6H4, 2-MeOC6H4, M = W)

The reaction of the arylated Fischer carbene complexes [(CO)5M=C(OEt)Ar] (Ar=Ph; M = Cr, W; 2-MeC6H4; 2-MeOC6H; M = W) with the phosphaalkenes RP=C(NMe2), (R=tBu, SiMe3) afforded the novel phosphaalkene complexes [[RP=C(OEt)Ar]M(CO)5] in addition to the compounds [(RP=C(NMe2)2]M(CO)5]. Only in the case of the R = SiMe3 (E/Z) mixtures of the metathesis products were obtained. The bis(dimethylamino)methylene unit of the phosphaalkene precursor was incorporated in olefins of the type (Me2N)2C=C(OEt)(Ar). Treatment of [(CO)5W=C(OEt)(2-MeOC6H4)] with HP=C(NMe2)2 gave rise to the formation of an E/Z mixture of [[(Me2N)2CH-P=C(OEt)(2-MeOC6H4)]W(CO)5] the organophosphorus ligand of which formally results from a combination of the carbene ligand and the phosphanediyl [P-CH(NMe2)2]. The reactions reported here strongly depend on an inverse distribution of alpha-electron density in the phosphaalkene precursors (Pdelta Cdelta+), which renders these molecules powerfu] nucleophiles.

Efficacy of ultrasound B-scan compared with physical examination in follow-up of melanoma patients

BACKGROUND

The value of ultrasound B-scan for routine follow-up of melanoma patients still is not generally accepted. Therefore, the authors compared the efficacy of physical examination (PE) with ultrasound B-scan (UBS) for detection of regional tumor recurrence in melanoma patients. The aim of the current study was to evaluate whether early detection of metastases improves relapse-free and overall survival.

METHODS

For a period of 4 years, 829 consecutive melanoma patients were followed prospectively. Physical examination of 3011 patients and concomitant UBS of in-transit routes and regional lymph node basins were performed. Suspicious lesions were diagnosed by fine-needle aspiration cytology and pathology.

RESULTS

During the study period, 242 (90.6%) of 267 patients with melanoma recurrences were first recognized by PE or UBS within the routine follow-up program. The sensitivities of both methods differed significantly (P = 0.001). Metastases were detected by PE in only 61 of 242 recurrences (25.2%, 95% confidence interval [CI]: 19.9-31.2%), whereas UBS revealed 240 recurrences (99.2%, 95% CI: 97.3-99.6%). The specificity was 98.4% (95% CI: 97.8-98.8%) and 98.3% (95% CI: 97.7-98.7%), respectively. Survival of 103 patients who presented with a first nodal melanoma recurrence was followed and analyzed by multiple Cox regression. Overall survival was affected by the diameter of the largest metastasis (P = 0.001) and the number of metastatic lesions (P = 0.012).

CONCLUSION

The study found that ultrasound B-scan was highly effective in the early detection of regional melanoma metastases compared with physical examination. Earlier detection of such metastases seemed to result in improved overall survival.

Competitive polymerase chain reaction used to diagnose cutaneous leishmaniasis in German soldiers infected during military exercises in French Guiana

A competitive polymerase chain reaction (PCR) followed by enzyme-linked-immunoassay-based verification of PCR products has been developed, which facilitated the diagnosis of leishmaniasis in two German soldiers who underwent survival training in the jungle of French Guiana and returned with therapy-resistant pyoderma-like lesions. After treatment with liposomal amphotericin B, the skin manifestations disappeared, and leishmania DNA could no longer be detected by PCR. In the context of growing military involvement in areas where leishmaniasis is prevalent, this assay may help detect or, due to its internal controls, exclude cases of infection with this parasite.