Disseminated cutaneous fungal infection and AIDS

We report a case of recalcitrant generalized cutaneous polydermatophyte and Candida infection in an AIDS patient who responded very poorly to topical, oral, and intravenous therapy. The patient died of respiratory arrest secondary to pneumonia 14 months after a cutaneous fungal infection developed and 12 months after AIDS was diagnosed. Extensive cutaneous fungal infections refractory to treatment may be a presenting sign of HIV infection.

Oral melanoacanthoma with prominent spongiotic intraepithelial vesicles

Oral melanoacanthoma is a rarely-reported, benign pigmented lesion of oral mucosa. Spongiosis was only recently mentioned as a light-microscopical finding occasionally seen in oral melanoacanthoma, and the formation of spongiotic intraepithelial vesicles to our knowledge has never been reported. The authors discuss a case of a 34-year-old, black woman who acutely developed extensive hyperpigmented oral lesions which on the biopsy showed both intraepithelial dendritic melanocytes and severe spongiosis forming intraepithelial vesicles. These lesions resolved spontaneously in a few months which led the authors to believe that the term melanoacanthoma, implying that it is a tumor, is a misnomer. This report supports findings of other investigators who consider oral melanoacanthoma to be a mucositis with unusual proliferation of dendritic melanocytes in the epidermis.

Malignant angioendotheliomatosis: an angiotropic lymphoma

Malignant angioendotheliomatosis is a rare, systemic, usually fatal disease characterized by massive proliferation of large, neoplastic, mononuclear cells within the lumen of small blood vessels. Recent studies suggested that the tumor cells are of lymphoid origin. We studied two cases of malignant angioendotheliomatosis by Southern blot hybridization analysis that showed rearrangements of the immunoglobulin heavy chain and kappa light chain (case 2), indicating the presence of a monoclonal B cell lymphoma. Our results provide further evidence that malignant angioendotheliomatosis is an angiotropic lymphoma.

Bullous systemic lupus erythematosus

Two patients with bullous systemic lupus erythematosus are reported. In one, the disease appears to have been caused by hydralazine. The cutaneous lesions of bullous SLE have not been previously reported in drug-induced lupus.

Eosinophilic cellulitis and eosinophilic pustular folliculitis

This report describes a patient with a drug reaction and histologic changes of both eosinophilic cellulitis and eosinophilic pustular folliculitis. We propose that some cases of eosinophilic pustular folliculitis, like eosinophilic cellulitis, may occur as a result of a hypersensitivity phenomenon.

Treatment of chronic idiopathic urticaria with astemizole

Astemizole is a new, long-acting H1 receptor antagonist that has proven effective in controlling the signs and symptoms of chronic idiopathic urticaria, without the sedative and anticholinergic side effects that typify use of many antihistamines. In an eight-week open study of 20 patients, astemizole significantly decreased the signs and symptoms of urticaria, as well as the severity of urticaria by anatomic location. Five patients reported complete clearing. Modest weight gain while on chronic therapy appears to be a significant side effect.

Extensive alopecia areata. Results of treatment with 3% topical minoxidil

A 3% topical minoxidil solution was used to treat 31 normotensive persons (13 male, 18 female) with extensive alopecia areata. After 15 months, three patients (14%) had 75%-100% regrowth, 13 (59%) had some form of regrowth, and nine (41%) had no regrowth. In the initial three-month double-blind portion of the study, minoxidil was not shown to be more effective than placebo. Biopsy specimens from eight patients who underwent biopsy prior to treatment, after three months, and posttreatment showed no significant change in peribulbar or perivascular inflammation. Prominent, new anagen follicles were observed. The 3% topical minoxidil was generally well tolerated and skin irritation was minimal. Blood pressure monitoring revealed no significant changes in diastolic or systolic pressures. Minoxidil is a relatively safe treatment for extensive alopecia areata and may be effective in the treatment of some cases of recalcitrant disease.

Mucous gland basement membrane immunofluorescence in cicatricial pemphigoid

Three patients are described with cicatricial pemphigoid and positive immunofluorescence findings in the basement membrane zone of mucous glands of the pharynx, mouth, and nose. These findings appear to be unique to cicatricial pemphigoid.

Pyoderma gangrenosum: a review

Pyoderma gangrenosum is a poorly understood disease characterized by exacerbations and remissions of morphologically unique skin ulcers. It frequently is thought to be the cutaneous manifestation of an underlying systemic disease. In this review of pyoderma gangrenosum, the characteristics of the disease are described and a differential diagnosis is formulated. Associations with systemic diseases are made through a review of the literature. The pathophysiology of pyoderma gangrenosum and probable causes are considered, and special consideration is given to the immunologic mechanisms that may be operative in the disease. Finally the currently available therapeutic alternatives are reviewed.

Linear IgA bullous dermatosis mimicking erythema multiforme in adult

This report describes a 49-year-old woman with an erythema multiforme--like rash and direct immunofluorescence showing linear IgA deposits at the dermoepidermal junction. Light microscopy revealed features of bullous pemphigoid, dermatitis herpetiformis, and erythema multiforme; immunoelectron microscopy demonstrated IgA deposition beneath the lamina densa about anchoring fibrils. These data provide additional information about the variable clinical and histologic manifestations of the adult linear IgA bullous dermatosis and emphasize the diagnostic dilemmas of light microscopy, which are resolved by immunohistochemical methods.

Perforating granuloma annulare in a patient with acquired immunodeficiency syndrome. Immunohistologic evaluation of the cellular infiltrate

The inflammatory infiltrate found in the lesions of perforating granuloma annulare in a patient with acquired immunodeficiency syndrome was analyzed. Double labeling with fluorescent antibody tags fluorescein isothiocyanate-Leu 4 (peripheral T cells) and phycoerythrin-Leu 2a (cytotoxic/suppressor) revealed the infiltrate to consist predominantly of cytotoxic/suppressor T cells. This finding is a reflection of the patient's altered immune status and calls into question the role of specific T-cell subsets in the pathogenesis of granuloma annulare.

Hirsutism

The androgen status of a hirsute woman can be diagnosed today by new techniques for measuring circulating androgens. Unfortunately, a battery of expensive tests is required to make this assessment. Two specific basic screening tests, DHEA-S and total free testosterone determinations, should be done. If the patient is interested in and can afford it, further testing can be done; it includes 17-hydroxyprogesterone, prolactin, compound S (serum 11-deoxycortisol) and cortisol measurements and a dexamethasone suppression test. Elevations of androgens, whereas elevations of testosterone can be due to ovarian or adrenal secretion. Establishing the site of androgen hypersecretion allows one to be more selective regarding the antiandrogen therapy. When excess androgen secretion is primarily adrenal in origin, adrenal suppression is effective with the use of such drugs as dexamethasone. If the excess androgen is primarily of ovarian origin, cyclic estrogens, for example, Demulen or Premarin with Provera, would be helpful. The evaluation of a hirsute patient takes time, interest, and knowledge of specific androgen-dependent cutaneous syndromes involving multiple possible enzymatic defects in the conversion of cholesterol to testosterone or intercellular pathways of androgen metabolism. If the dermatologist is not interested in or lacks the knowledge for such an evaluation, the patient is best referred to an interested endocrinologist.