Therapeutic options for erythroderma

In this work we will discuss some of the dilemmas and therapeutic options in the treatment of patients with erythroderma. We will mention treatment modalities for psoriatic erythroderma and review briefly one illustrative case in which a new experimental approach was utilized.

Vasculitis in the antiphospholipid syndrome. A cause of ischemia responding to corticosteroids

A 63-year-old woman with atherosclerotic peripheral vascular disease and the lupus anticoagulant developed ischemia of the right lower extremity, requiring progressive amputations. Pathologic specimens revealed inflammatory vasculitis in multiple arteries. Her serum showed anticardiolipin antibodies in high titer. Treatment with high-dose corticosteroids reversed the ischemic process. In patients with antiphospholipid antibodies, thrombosis is the most common pathologic finding associated with cutaneous lesions and/or gangrene. Vasculitis, although uncommon, is known to occur and may respond to corticosteroid therapy.

Lymphocytoma cutis: a series of five patients successfully treated with cryosurgery

BACKGROUND

Lymphocytoma cutis is a rare cutaneous eruption that may possess clinical and histologic features resembling malignant lymphoma.

OBJECTIVE

Our purpose was to find a good method to treat patients with lymphocytoma cutis.

METHODS

Five patients with lymphocytoma cutis were seen; each agreed to cryosurgery.

RESULTS

In each patient the lesions responded well to cryosurgery.

CONCLUSION

Cryosurgery appears to be an excellent therapeutic option for patients with lymphocytoma cutis. To our knowledge this is the first time liquid nitrogen has been used to eradicate these lesions.

Color Doppler ultrasound imaging in iatrogenic arterial injuries

Pulsatile masses following arterial puncture for diagnostic or therapeutic procedures may represent false aneurysms or noncommunicating periarterial hematomas with transmitted arterial pulsation. Color Doppler ultrasound imaging was used in 27 patients with pulsatile groin masses. Of these 27 patients, 23 were diagnosed as having pseudoaneurysms and 5 as having periarterial hematomas. The pseudoaneurysms were confirmed at surgical exploration, and the periarterial hematomas were all observed longitudinally with spontaneous resolution. With a sensitivity of 100% and a specificity of 100% in this clinical study, color Doppler ultrasound imaging appears to be the diagnostic modality of choice for detecting false aneurysms following transarterial procedures, obviating the need for additional invasive diagnostic procedures.

The treatment of atypical lipoma with liposuction

Large lipomas may best be treated with liposuction. Once a lipoma enlarges to 4 cm or more, liposuction has several advantages over conventional surgery. A well-demarcated lipoma 15 cm in diameter and deep to muscle was treated by liposuction. Biopsy showed an atypical lipoma. Because the entire tumor was removed by liposuction, we feel that the prognosis is excellent. The cosmesis and morbidity results were far superior to those anticipated with conventional excisional surgery. Small superficial lipomas may be treated by suction lipectomy and the surrounding area can be contoured symmetrically at the same time, whereas large ones can be liposuctioned completely without extensive surgical extirpation and morbidity. Because such big lesions may represent atypical lipomas or liposarcomas, care must be taken to remove the entire tumor.

Detection of anti-basement membrane zone antibodies in bullous systemic lupus erythematosus

We describe a 42-year-old black woman with long-standing systemic lupus erythematosus in whom vesiculobullous lesions developed. Routine histologic and immunologic studies fulfilled the criteria for the diagnosis of bullous systemic lupus erythematosus. Indirect immunofluorescence showed antinuclear antibodies without basement membrane zone fluorescence. We destroyed the nuclear antigens of the indirect immunofluorescence substrate with 2 mol/L sodium chloride, which unmasked basement membrane zone linear IgG staining. We also confirmed anti-basement membrane zone antibodies by employing a new technique of direct immunofluorescence on sodium chloride-split skin. Our finding prove that a thorough search for anti-basement membrane zone antibodies can be revealing. Our results support the idea that a subset of bullous systemic lupus erythematosus has the staining characteristics of epidermolysis acquisita, with the dermal side of the split skin showing linear immunoglobulin deposition.

Sign of Leser-Trélat with a metastatic mucinous adenocarcinoma

We describe a middle-aged woman with the sudden onset of multiple seborrheic keratoses in association with a metastatic mucinous adenocarcinoma to the liver from an unknown primary neoplasm. This case illustrates the significance of the sign of Leser-Trélat and its association with cancer.

Epidermolytic hyperkeratosis treated with etretinate

Epidermolytic hyperkeratosis is an unusual type of ichthyosis that may be characterized in extreme cases by massive cutaneous involvement resembling a porcupine. We present such a patient who had a remarkable response to treatment with oral etretinate.

Buschke-Löwenstein tumor: verrucous carcinoma of the anogenitalia

Buschke-Löwenstein tumor is a rare type of anogenital squamous cell carcinoma with a distinctive clinical appearance. We present the case of a thirty-four-year-old man with this tumor, which was excised surgically. Human papillomavirus was detected in formalin-fixed, paraffin-embedded sections with a human papillomavirus 6/11 probe, but not with a human papillomavirus 16 or a human papillomavirus 18 probe.

Diagnosing Lyme disease: often simple, often difficult

Lyme disease has as its hallmark erythema migrans. However, it is only present in about one half of the patients who contract this disease. In its absence, the diagnosis of Lyme disease may be difficult. It depends upon a compatible history of exposure and clinical signs and symptoms together with positive results of serologic testing. Unfortunately, seronegativity for antibody to the pathogen may occur both during the first six weeks of infection and be chronic due to the reactive antibody being bound in immune complexes. The selective use of new diagnostic tests may be required to confirm the diagnosis. These tests include assays for antibody or antigen analysis of immune complex components, as well as polymerase chain reactions.

Sweet's syndrome with acute leukemia

Sweet's syndrome presenting with malignancy or acute neutrophilic dermatosis is an unusual cutaneous disorder associated most commonly with acute myelogenous leukemia. Although other cancers may be linked to acute neutrophilic dermatosis, a large majority of patients have associated neoplasms of hematopoietic, plasma cell, or lymphoid nature. We report a patient with aplastic anemia who showed acute neutrophilic dermatosis and, ultimately, acute leukemia. The individual lesions responded to carbon dioxide laser surgery.

Lyme disease during pregnancy

Lyme disease, caused by infection with Borrelia burgdorferi, can affect those exposed to a vector tick. Pregnant women are no exception, and such infection places the fetus at risk. It is particularly important to recognize the disease early so that effective therapy may be instituted. Although the present patient had a favorable outcome, not all do. Clinical diagnosis is especially important since conventional laboratory tests may be inadequate or require lengthy periods of time before a positive result occurs. The dermatologic sign of Lyme disease, erythema migrans, although occurring in only 50 percent of cases, is likely to be the most important diagnostic sign.

Florid cutaneous papillomatosis, malignant acanthosis nigricans, and pulmonary squamous cell carcinoma

A 72-year-old man had florid cutaneous papillomatosis (FCP), which is an obligatory paraneoplastic syndrome always associated with an internal malignancy. The cancer, which is usually intraabdominal and most often gastric in origin, evolves parallel to the FCP. This patient is the first case of FCP occurring in association with a lung malignancy. An association of FCP with other signs of internal cancer is common, with malignant acanthosis nigricans usually appearing many times with the sign of Leser-Trélat. FCP, malignant acanthosis nigricans, and the sign of Leser-Trélat are part of a continuum, developing by a common or similar pathogenic pathway due to an underlying malignancy producing a factor possibly similar to human epidermal growth factor.

Bowenoid papulosis

Bowenoid papulosis is an uncommon genital dysplasia induced by human papillomavirus infection. Clinically, it usually resembles persistent warts, but histologically it may be suggestive of squamous cell carcinoma in situ. This unusual disorder and recent advances in our understanding of it are reviewed.

Erythroderma as the initial presentation of the acquired immunodeficiency syndrome

A 32-year-old black homosexual man, seronegative for human immunodeficiency virus antibody, presented with erythroderma. His peripheral blood was significant for circulating Sézary-like cells bearing the CD8(+) phenotype. Eighty-eight percent of his lymphocytes were CD8(+) as well. He seroconverted 3 months after the initial presentation. We conclude that erythroderma was the presenting sign of the acquired immunodeficiency syndrome.

Verrucous carcinoma of a leg amputation stump

Verrucous carcinoma of the skin is a rare cancer which tends to appear on the soles of the feet, although it can appear elsewhere on the cutaneous surface. It has not, to our knowledge, been previously reported on a leg amputation stump.

Does the end-to-end venous anastomosis offer a functional advantage over the end-to-side venous anastomosis in high-output arteriovenous grafts?

This study explores the hemodynamics, mechanics, and biologic response of end-to-end versus end-to-side venous anastomoses in a canine arteriovenous graft model. Femoral polytetrafluoroethylene grafts were implanted bilaterally in a paired fashion (n = 22). Detailed local hemodynamic measurements were made by use of color Doppler ultrasound imaging at 1, 4, 8, and 12 weeks after implant. Measurements included volumetric flow rate and Doppler-derived spectral window (percent window) as a measure of turbulence. Amplitude and velocity of vessel wall movement were also measured. Volume of perivascular tissue vibration quantitated kinetic energy transfer through the vessel wall. Volumetric flow rate (end to end, 1013 +/- 70 ml/min; end to side, 1015 +/- 72 ml/min), percent window (end to end, 6.6% +/- 0.6%, end to side, 5.6% +/- 0.4%) and volume of perivascular tissue vibration (end to end, 19.6 +/- 1.2 ml, end to side, 16.3 +/- 1.8 ml) were statistically equivalent in the two graft types (end to end vs end to side p greater than 0.05). Both graft types developed venous intimal-medial thickening of a similar magnitude: end to end, 0.35 +/- 0.05 mm, end to side, 0.43 +/- 0.09 mm, normal vein 0.070 +/- 0.004 mm (analysis of variance [ANOVA] p less than 0.001, p less than 0.01 for end to end or end to side vs control, end to end vs end to side p greater than 0.05 by Student-Newman-Keuls test). The best correlations with venous intimal-medial thickening were obtained from inverse percent window (r = 0.84, p less than 0.001) and volume of perivascular tissue vibration (r = 0.68, p less than 0.001). In the end to end configuration the relative amplitude of venous wall movement decreased, and the relative velocity of wall motion increased over time. We conclude that in the circumstances of this high flow arteriovenous graft model the end-to-end venous anastomosis does not significantly differ from the end-to-side venous anastomosis in terms of flow stability, turbulence, or kinetic energy transfer. The magnitude of the hyperplastic response is statistically equivalent for the two anastomotic types, but the pattern is somewhat different, possibly providing evidence for differences in stress distribution. Differences in the relative amplitude and velocity of vessel wall movement suggest that anastomotic geometry may affect the way in which kinetic energy is dissipated at the graft/vessel interface.

Buschke-Loewenstein tumor: verrucous carcinoma of the penis

The Buschke-Loewenstein tumor is an anogenital tumor of characteristic clinical and histologic pattern best considered as a low-grade, well-differentiated squamous cell carcinoma. This remarkable neoplasm and its features are reviewed in detail, stressing salient advances in our understanding of it.

Histoid lepromas of lepromatous leprosy

Histoid lepromas are a rare eruption in patients with lepromatous leprosy. A 59-year-old man from India with lepromatous leprosy who developed histoid lepromas and who was dapsone resistant was studied. These tumors resembled cutaneous metastases. This Indian man is to our knowledge the first patient to be reported with this rare disorder in the continental United States.

Dermatopathia pigmentosa reticularis

Dermatopathia pigmentosa reticularis is a rare disorder that presents as reticulate pigmentation distributed widely all over the cutaneous surface. Only nine patients with this disease have been described previously. Our patient had no fingernail and toenail prints, a striking finding also noted in some, but not all, of the other nine patients. Our patient also had a history of a seizure disorder and had two cutaneous neurofibromas, unlike the other patients with this disorder. However, there were no other findings, such as Lisch nodules of the iris, to suggest a diagnosis of von Recklinghausen's disease.

Graft geometry and venous intimal-medial hyperplasia in arteriovenous loop grafts

This study explores graft geometry and hemodynamics in a reproducible canine arteriovenous loop graft model of intimal-medial hyperplasia. Untapered 6 mm diameter polytetrafluoroethylene grafts (n = 10) were paired with 4 to 7 mm taper (n = 5) or 7 to 4 mm taper (n = 5) grafts for a 12-week period. Several hemodynamic variables were assessed at multiple locations, and venous intimal-medial thickness was measured at locations corresponding to the hemodynamic measurements. Color Doppler imaging demonstrated energy transfer out of the vessel in the form of perivascular tissue vibration. This was quantitated by the distance required for Doppler signal attenuation or volume of the detected vibration signal. Differences among graft types were noted for pressure, flow velocity, tissue vibration, and venous intimal-medial thickness. Hyperplasia was significantly decreased in 4 to 7 mm taper grafts. Stepwise deletion regression indicated volume of the vibration signal had a better correlation with venous intimal-medial thickness than any other variable (r 0.9, p less than 0.001). We conclude that graft geometry can have a significant impact on hemodynamic factors and venous intimal-medial hyperplasia in arteriovenous loop grafts. Flow disturbances appear to cause energy transfer through the vessel wall and into perivascular tissue. Kinetic energy transfer in the form of perivascular tissue vibration was quantitated in vivo and correlates strongly with venous intimal-medial thickness.

Adult linear IgA bullous dermatosis: a polymorphic disorder

We report on two patients with unusual forms of adult linear IgA bullous dermatosis. One was a middle-aged woman who had targetoid lesions and bullae on her trunk and extremities. This patient first presented with lesions that clinically resembled erythema multiforme, but these evolved into a widespread eruption with bulging, elongated bullae. Examination of a biopsy specimen showed changes compatible with dermatitis herpetiformis and bullous pemphigoid. Findings on immunofluorescence studies showed deposition of linear IgA at the basement membrane zone. The second patient was an elderly woman with intensely pruritic vesicles whom we classified as having vesicular pemphigoid, until the linear IgA band on direct immunofluorescent test results became the predominant immunofluorescent finding. These cases are reported because of their unusual clinical presentations. The mechanism for the targetoid lesions in the first patient is discussed.

Intimal fibroplasia: an unusual etiology of stroke

Individuals with arterial intimal fibroplasia represent a rare subset of patients with proliferative disorders of the arterial wall. This case describes the successful antemortem management of intimal fibroplasia of the internal carotid artery which had caused ipsilateral cerebral infarction. The noninvasive and invasive imaging characteristics of the lesion are also described.

Beneficial effects of banding on venous intimal-medial hyperplasia in arteriovenous loop grafts

Local hemodynamics were modified in a canine arteriovenous loop graft model by placing a flow-limiting band on femoral polytetrafluoroethylene (PTFE) grafts. Banded and unbanded grafts were implanted in a paired fashion. Hemodynamic studies included Reynolds number and phonoangiography as measures of turbulence. Intimal-medial thickness was measured 8 weeks after implantation. Reduction of the volumetric flow rate by 50 percent resulted in significant changes in flow velocity, flow pulsatility, pressure, and turbulence at the venous anastomosis. Hyperplastic lesions developed in a reproducible manner at the venous anastomosis of the unbanded but not the banded grafts, as evidenced by combined intimal-medial thickness measurements: unbanded grafts 0.68 +/- 0.13 mm (p less than 0.01 versus control), banded grafts 0.25 +/- 0.03 mm (p greater than 0.05 versus control). Stepwise regression analysis indicated Reynolds number had the best correlation with the development of hyperplasia (r = 0.915, p less than 0.005), this being the first time this correlation has been quantitatively determined. We conclude that flow disturbance or turbulence is a major factor in the development of venous intimal-medial hyperplasia in arteriovenous loop grafts.

Treatment of multiple apocrine hidrocystomas with the carbon dioxide (CO2) laser

The apocrine hidrocystoma tends to occur as a solitary facial cystic lesion. We report an unusual patient in whom there were multiple apocrine hidrocystomas scattered over the periorbital region and ears. Although solitary apocrine hidrocystomas are easily treated with excision, we had good results employing carbon dioxide laser vaporization in the treatment of numerous hidrocystomas.

Iatrogenic femoral arteriovenous fistula: diagnosis with color Doppler imaging

Color Doppler imaging was used to identify and localize arteriovenous fistulas in six patients after cardiac catheterization. In all six, there was a focal region of persistent intraarterial flow throughout the cardiac cycle at the site of the fistula, in contrast to normal arterial flow, which is forward only in systole. In all cases, turbulent pulsatile venous flow was present at the site of the fistula and nonturbulent pulsatile venous flow was present proximal to the fistula. In five cases a focal area of apparent extravascular tissue vibration was identified. In four cases the communication between the artery and vein was identified. Familiarity with these color Doppler imaging findings should allow for accurate noninvasive diagnosis of arteriovenous fistulas, at the patient's beside if necessary.

The Muir-Torre syndrome: a disease of sebaceous and colonic neoplasms

The Muir-Torre syndrome of sebaceous neoplasms of the skin, with or without keratoacanthomas, and multiple low-grade visceral malignancies with prolonged survival is a rare disorder. Colonic polyps are frequently present, and the syndrome appears to be familial. We report 2 unrelated patients with the Muir-Torre syndrome. Each case exhibited sebaceous adenomas. Gastrointestinal findings included colonic adenocarcinomas and a tubulovillous adenoma. Although an unusual disease, the Muir-Torre syndrome requires recognition because these patients are at risk for multiple primary malignancies and may have family members also at risk.

Bullous pemphigoid and rheumatoid arthritis

Bullous pemphigoid and rheumatoid arthritis are rarely found co-existent in one patient. We report a patient with severe rheumatoid arthritis who four years later showed bullous pemphigoid. This association is rare but may be more than coincidental.

Upper extremity limb salvage accomplished by in situ vein bypass graft

The need for revascularization procedures in individuals with hand ischemia is uncommon. Previous reports describe the successful utilization of reversed saphenous vein to reconstruct the distal vasculature of the arm. This case report details the use of in situ arm vein to restore perfusion to a threatened hand.

Repair of symptomatic diaphragmatic hernia during pregnancy

Congenital diaphragmatic hernia complicating pregnancy is a rarity, accounting for only six out of 17 cases of diaphragmatic hernia reported in the English literature. This case report describes the first successful repair of an acutely symptomatic foramen of Bochdalek hernia during pregnancy, with maternal and fetal survival. In the asymptomatic patient, surgery should be performed promptly on an elective basis in the first and second trimesters. During the third trimester, an asymptomatic defect should be repaired at the time of elective cesarean section. Active labor should be avoided. If symptoms of obstruction arise, this lesion represents a true surgical emergency, and immediate operative intervention should be undertaken regardless of the stage of pregnancy. Delay can result in both fetal and maternal mortality in up to half of cases. Tube gastrostomy may be performed at the time of repair to avert a potential prolonged gastric ileus and gastric volvulus.

Excision of the large congenital melanocytic nevus facilitated by the use of the tissue expander

Large congenital melanocytic nevi both present a cosmetic problem and may predispose to the development of a melanoma. We present a series of three patients in whom the tissue expander was employed to facilitate a large excision with primary closure and excellent cosmesis.

Intraoperative duplex scanning after carotid artery reconstruction: a valuable tool

The operative management of extracranial cerebrovascular occlusive disease requires meticulous surgical technique. Intraoperative duplex imaging (10 MHz B-mode ultrasound combined with 7.5 MHz Doppler spectrum analysis) was used in an attempt to recognize technical problems that might result in serious neurologic injury. Eighty-four carotid arteries were studied in 76 consecutive patients undergoing carotid endarterectomy or reconstruction. Indications for operation included carotid territory transient ischemic attack (n = 36 [43%]), amaurosis fugax (n = 16 [19%]), stroke (n = 11 [13%]), asymptomatic stenosis (n = 11 [13%]), vertebrobasilar transient ischemic attack (n = 7 [8%]), recurrent stenosis (n = 2 [2%]), and trauma (n = 1 [1%]). Arterial anatomy was assessed ultrasonographically and duplex-derived velocity measurements were obtained to assess hemodynamics. Increased velocity measurement was noted to correlate with ultrasound image of stenosis. Technical errors were identified in 17 patients (22%), including six persons with residual internal carotid artery stenoses, three persons with hemodynamically significant stenoses caused by "kinked" internal carotid arteries, eight persons with debris or intimal flaps in their external carotid arteries, and one person with an occluded external carotid artery. The intraoperative duplex scan led to corrective measures during the surgical procedure in eight patients (11%). No new ipsilateral brain injury was noted in the 76 patients postoperatively. Intraoperative duplex scanning accurately identified residual stenosis, intraluminal thrombus, and loose debris. Duplex scanning altered intraoperative decision making in a significant proportion of patients studied.

Successful repair of a ruptured abdominal aortic aneurysm in a renal transplant recipient

A 53-year-old renal transplant recipient went into hypovolemic shock due to rupture of his abdominal aortic aneurysm. His successful perioperative and postoperative management are described. Fourteen cases of infrarenal aortic aneurysm repair in hemodynamically stable transplant recipients are reviewed with a discussion of management alternatives.

Neurologic complications of herpes zoster

Encephalitis, contralateral hemiplegia and postherpetic neuralgia are the most serious neurologic sequelae of herpes zoster infections. Encephalitis occurs more frequently in the presence of cutaneous dissemination and cranial nerve lesions. Contralateral hemiplegia following herpes zoster ophthalmicus results from vasculitic and thrombotic lesions. The combination of a tricyclic antidepressant and a phenothiazine is the most effective medical treatment for postherpetic neuralgia.

Cutaneous onchocerciasis

Onchocerciasis was diagnosed when a skin biopsy specimen immersed in saline revealed microfiliariae. The patient was a 22-year-old student from Cameroon, West Africa, complaining of small, recurrent, pruritic papules on his thighs. Chemotherapy with ivermectin, an established antiparasitic agent with newly recognized anti-onchocercal potential, was well tolerated, and microfilariae were not detected in post-therapy skin biopsy specimens. The diagnosis of onchocerciasis should be entertained in individuals returning or emigrating from endemic areas.

Immunopathological changes after multiple spider bites

Utilizing a panel of immune complex assays, antigen-antibody complex formation in a 29-year-old man shortly after a spider bite was documented. The clinical picture and laboratory parameters were consistent with a serum sickness reaction. Immune hyperactivity was evidenced by a detectable autoimmune serological response. This constellation of findings may be a common attendant to arthropod envenomation.

Granulomatous reaction to purple tattoo pigment

An acute dermatitis overlying an immunologic granuloma was noted at the site of purple "dye" injection in a man with multiple multicolored tattoos. The skin reaction was observed 3 weeks after the injection, which proved to contain manganese, the usual metallic salt used for purple colored tattoos. Atomic absorption spectrometry showed a large amount of manganese in the biopsy specimen. Neither the dermatitis nor an immunologic granuloma could be reproduced with manganese salts or the alleged tattoo pigment. In addition, his peripheral blood lymphocytes were shown to be normal both in subset distribution and in their function, but these cells did not respond by blastogenesis to dilutions of the alleged pigment or to 2 manganese salts tested.

Indolent lymphadenopathic Kaposi's sarcoma

Kaposi's sarcoma is usually an indolent skin neoplasm. Diffuse lymph node and visceral involvement have been described in young African patients and in patients who are immunosuppressed; in such patients the disease is usually rapidly progressive. We describe the case of a 64-year-old man of Italian ancestry with diffuse lymph node involvement by Kaposi's sarcoma in the absence of any skin lesions. The patient had no evidence of immunosuppression. The course has been indolent, with no disease progression over 2 years of follow-up on no therapy.

Bowenoid papulosis in a penile epidermal inclusion cyst

We report a case of bowenoid papulosis occurring in an epidermal inclusion cyst. This is, to our knowledge, the first reported case of these lesions occurring in an inclusion cyst.