Statin-associated anti-HMGCR immune-mediated necrotizing myopathy with dermatomyositis-like features: A case report

Anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) immune-mediated necrotizing myopathy is a subtype of idiopathic inflammatory myopathy which may be associated with statin exposure. It presents with severe proximal muscle weakness, high creatine kinase levels and muscle fiber necrosis. Treatment with intravenous immunoglobulins and immunosuppressants is often necessary. This entity is not commonly known among dermatologists as there are usually no extramuscular manifestations. We report a rare case of statin-associated anti-HMGCR immune-mediated necrotizing myopathy with dermatomyositis-like cutaneous features. The possibility of anti-HMGCR immune-mediated necrotizing myopathy should be considered in patients with cutaneous dermatomyositis-like features associated with severe proximal muscle weakness, highly elevated creatine kinase levels and possible statin exposure. This indicates the importance of muscle biopsy and specific autoantibody testing for accurate diagnosis, as well as significant therapeutic implications.

Improvement in Hailey-Hailey disease with a combination of low-dose naltrexone and oral magnesium chloride: A case report

Hailey–Hailey disease is a rare autosomal dominant acantholytic disorder due to mutation in the ATP2C1 gene and presents with flaccid blisters in intertriginous regions. Its chronic and relapsing course may negatively impact patients’ quality of life. Multiple medical and interventional treatments have been described with various efficacy. Low-dose naltrexone and oral magnesium chloride represent emerging treatments. Sustained improvement in Hailey–Hailey disease has been reported with the former in case series, while others have shown variable results. Oral magnesium chloride has been reported in four patients with possible results after 2–4 weeks. Two recent cases suggest that the combination of both treatments may have a synergistic effect. Herein, we present a 63-year-old woman with long-standing and recurrent bilateral inguinal Hailey–Hailey disease who significantly improved with low-dose naltrexone and oral magnesium chloride, representing the third case described with this combination.

A case of dermatomyositis with anti-TIF1γ antibodies revealing isolated para-aortic lymphadenopathy metastatic recurrence of endometrial cancer: A case report

Dermatomyositis is an inflammatory myopathy presenting with characteristic cutaneous eruption and may be accompanied by proximal muscle weakness. Dermatomyositis may represent a paraneoplastic syndrome in 15%–25% of cases and has rarely been associated with endometrial cancer. Herein, we report a case of dermatomyositis with anti-TIF1γ antibodies as the first clinical manifestation revealing isolated para-aortic lymphadenopathy metastatic recurrence of endometrial cancer after 4 years of remission. Interestingly, dermatomyositis rash completely resolved after lymphadenectomy. This case highlights the importance of early dermatomyositis diagnosis, thorough cancer screening, and that cancer treatment may, in some patients, foster dermatomyositis remission.

Multifocal cocaine-induced pyoderma gangrenosum: A report of two cases and review of literature

Pyoderma gangrenosum is often associated with a systemic disease. Cocaine-induced pyoderma gangrenosum, most probably caused by levamisole, has been described recently and typically presents as multiple, large cribriform ulcers. Peri-nuclear antineutrophil cytoplasmic antibody is the most common serological finding. A strong counseling for cocaine cessation, combined with wound care and immunosuppressive therapy, is the mainstay of treatment. We present two cases of cocaine-induced pyoderma gangrenosum and correlate their findings with the typical clinical, histological and serological presentation.

Basal cell carcinoma stroma as a mimicker of lymphatic invasion: A case report

Basal cell carcinoma metastases are rare. We report a case of an 83 year-old male with recurrent cutaneous infiltrative basal cell carcinoma on the right vertex with tumor aggregates of infiltrative basal cell carcinoma in the lymphatic vessels of the superficial dermis strongly suspected on pathology slide evaluation during Mohs micrographic surgery. D2-40 immunohistochemical stain allows the detection of lymphatic invasion by highlighting endothelial cells. Further histologic review and D2-40 stains performed on the paraffin-embedded sections did not reveal an endothelial cell lining in favor of lymphatic invasion. What was identified as lymphatic invasion was the result of a peculiar basal cell carcinoma stroma. Correct identification of basal cell carcinoma stroma as a mimicker of lymphatic invasion would prevent potentially invasive investigation as well as associated costs. This is of great importance as the prognostic and therapeutic implications can be of significant value for the patient.

Refractory extensive vulvar high-grade squamous intraepithelial lesion in an immunosuppressed transplant patient treated with topical cidofovir: A case report

High-grade squamous intraepithelial lesion of the vulva is a premalignant condition which may be especially resistant to treatments among immunosuppressed patients. We present our experience with the use of topical cidofovir in a refractory case of extensive vulvar high-grade squamous intraepithelial lesion in a 37-year-old transplant patient. Eighteen cycles of cidofovir over a 2-year period led to a sustained significant improvement, mainly of the mucosal lesions and was well tolerated. To our knowledge, we have not seen this therapy described in transplant patients with extensive high-grade squamous intraepithelial lesion.

Toxic epidermal necrolysis associated with pembrolizumab

INTRODUCTION

Stevens-Johnson syndrome and toxic epidermal necrolysis are severe cutaneous drug eruptions characterized by epidermal detachment. Pembrolizumab is a monoclonal antibody that binds to the programmed death-1 receptor, and it has been associated with numerous cutaneous adverse side-effects, including Stevens-Johnson syndrome.

CASE REPORT

We describe a 63-year-old male with metastatic lung adenocarcinoma who developed a rapidly progressing maculopapular rash three days after a first dose of pembrolizumab. On day 16, the rash affected more than 80% of body surface area with detachment of large sheets of necrolytic epidermis in 30-40% of body surface area. However, the patient only presented with mild mucosal involvement. Histopathologic examination of a skin biopsy showed a subepidermal blister with overlying prominent full thickness epidermal keratinocytic necrosis and a superficial perivascular infiltrate of lymphocytes. A toxic epidermal necrolysis secondary to pembrolizumab was then diagnosed. Management and outcome: In addition to supportive cares, the patient received corticosteroids and cyclosporine. The patient responded rapidly to the immunosuppressant therapy, and nearly complete re-epithelialization was achieved 24 days after the start of the reaction.

DISCUSSION

In our review of the literature, 15 other cases of Stevens-Johnson syndrome/toxic epidermal necrolysis were reported with programmed death-1/programmed cell death ligand-1 inhibitors. To our knowledge, this is the first case of toxic epidermal necrolysis secondary to pembrolizumab published in the literature. The American Society of Clinical Oncology guidelines suggest that cyclosporine, in addition to corticosteroids, be initiated when toxic epidermal necrolysis is suspected. Clinicians should be aware of this rare dermatological emergency with the increasing use of pembrolizumab in oncology.

Exaggerated Arthropod Bite Reaction During Pregnancy: A Case Report

INTRODUCTION

The diagnosis of exaggerated bite reactions is based on the clinical and pathological characteristics of the lesions. These reactions can be an indicator of impending immune suppression.

METHODS

The authors report the case of a 35-year-old pregnant woman who presented with a pruriginous vesicular and pustular eruption over her thighs and buttocks. The clinical and pathological findings were compatible with an exaggerated bite reaction. The patient did not report any severe or exaggerated reaction to insect bites in the past. It was her first episode.

CONCLUSION

Exaggerated bite reactions have been described with hematological malignancies, mostly chronic lymphocytic leukemia. In our literature review, we did not find any reports of severe local bite reactions occurring during pregnancy. We hypothesize that the changes in the immune system during pregnancy might explain the development of exaggerated bite reactions in our patient.

Azacitidine-induced pyoderma gangrenosum at injection sites in a patient with myelodysplastic syndrome

Pyoderma gangrenosum (pg) is a rare neutrophilic dermatosis characterized by painful necrotic ulceration affecting preferentially the lower extremities. Diagnosis is challenging, and a thorough workup (including biopsy) is required. In this case report, we describe a 67-year-old patient with a diagnosis of myelodysplastic syndrome (mds) who developed fever and pg two days after the first cycle of subcutaneous azacitidine (Vidaza; Celgene Corporation, Summit, NJ, USA). On physical examination, the patient had four erythematous plaques at sites of subcutaneous injections of azacitidine on the arms, as well as three other plaques in proximity. A skin biopsy demonstrated a dense neutrophilic interstitial infiltrate in the dermis. After the diagnosis of pg, prednisone 1 mg/kg was started and the fever subsided rapidly. This was followed by the resolution of the cutaneous lesions. Changing the route of administration of azacitidine from subcutaneous to intravenous and adding a daily dose of prednisone during the treatment allowed the patient to receive a total of 10 cycles of azacitidine. This is the second case reported in the literature. Because azacitidine is frequently used in mds and acute myeloid leukemia, clinicians should be aware of this rare cutaneous adverse event. Our approach can be used to avoid the recurrence of pg when continuing azacitidine treatment.

Performance of residents using digital images versus glass slides on certification examination in anatomical pathology: a mixed methods pilot study

BACKGROUND

It is anticipated that many licensing examination centres for pathology will begin fully digitizing the certification examinations. The objective of our study was to test the feasibility of a fully digital examination and to assess the needs, concerns and expectations of pathology residents in moving from a glass slide-based examination to a fully digital examination.

METHODS

We conducted a mixed methods study that compared, after randomization, the performance of senior residents (postgraduate years 4 and 5) in 7 accredited anatomical pathology training programs across Canada on a pathology examination using either glass slides or digital whole-slide scanned images of the slides. The pilot examination was followed by a post-test survey. In addition, pathology residents from all levels of training were invited to participate in an online survey.

RESULTS

A total of 100 residents participated in the pilot examination; 49 were given glass slides instead of digital images. We found no significant difference in examination results between the 2 groups of residents (estimated marginal mean 8.23/12, 95% confidence interval [CI] 7.72-8.87, for glass slides; 7.84/12, 95% CI 7.28-8.41, for digital slides). In the post-test survey, most of the respondents expressed concerns with the digital examination, including slowly functioning software, blurring and poor detail of images, particularly nuclear features. All of the respondents of the general survey (n = 179) agreed that additional training was required if the examination were to become fully digital.

INTERPRETATION

Although the performance of residents completing pathology examinations with glass slides was comparable to that of residents using digital images, our study showed that residents were not comfortable with the digital technology, especially given their current level of exposure to it. Additional training may be needed before implementing a fully digital examination, with consideration for a gradual transition.

Rosai-Dorfman Disease Treated with Methotrexate and Low-Dose Prednisone: Case Report and Review of the Literature

Background:

Rosai-Dorfman disease is a rare condition characterized by an accumulation of histiocytes within lymph nodes and tissue. Treatment is indicated when the condition is highly symptomatic and when widespread involvement causes vital organ compression.

Objective:

To review the classic physical and histologic findings in Rosai-Dorfman disease and summarize the literature supporting the use of methotrexate in this condition.

Methods and Results:

We describe a case of Rosai-Dorfman disease that failed to respond to monotherapy with systemic corticosteroids but improved with the addition of methotrexate. Methotrexate alone or in combination with other agents has been described in at least 12 other cases in the literature and lead to a partial or complete resolution of disease in over half of these.

Conclusion:

The rapid improvement of clinical and physical symptoms with minimal side effects in our case and others reinforces the utility of antimetabolites in patients with Rosai-Dorfman disease who fail to respond to corticosteroids.

Disseminated Histoplasma capsulatum infection presenting with panniculitis and focal myositis in rheumatoid arthritis treated with etanercept

We report the case of a patient with rheumatoid arthritis (RA) on etanercept who presented with panniculitis and focal myositis as manifestations of disseminated histoplasmosis. Systematic search of the literature showed 11 additional case reports of disseminated histoplasmosis with tumour necrosis factor-alpha (TNFalpha) blockade therapy (infliximab, n = 8; etanercept, n = 3). Although disseminated histoplasmosis may manifest with classical symptoms of fever and respiratory complaints, it may also present atypically, such as with panniculitis and focal myositis. This review illustrates and emphasizes the importance of being highly suspicious for infection, including by opportunistic organisms, and to exclude such process in patients treated with a TNFalpha inhibitor when faced with unusual complications, even when an alternative aetiology appears plausible.

Primary abdominal wall clear cell carcinoma: case report and review of literature

BACKGROUND

The development of a mass in a surgical scar poses a diagnostic dilemma due to similarities in appearance to hernias, abscesses, hematomas or desmoid tumors. Scar endometriosis is uncommon and malignant change within this ectopic tissue is rare.

CASE REPORT

The case of a 55-year-old woman with an isolated clear cell adenocarcinoma in an area of scar endometriosis more than 17 years after a cesarean section is presented. Initially, this tumor was thought to be a chronic abscess, but was finally diagnosed as clear cell carcinoma. This case highlights the difficulties in preoperative diagnosis as well as the poor prognosis of these tumors.

CONCLUSION

Accurate diagnosis of a lump within a scar is important to define the prognosis and treatment. Further data are needed for the management of this pathology.

A collision tumor involving Basal cell carcinoma and lentigo maligna melanoma

Basal cell carcinomas (BCC) are known to co-exist with other cutaneous lesions, but the collision of BCC with malignant melanoma is rare. We report on the case of an 82-year-old woman with a translucent papule set on a beige-brown plaque on the right side of the nose. Histologic examination showed lesions of lentigo maligna melanoma (LMM) in situ and invasive melanoma involving nests of BCC that invaded the dermis. Immunohistochemical studies with S100 protein, HMB-45, and Melan-A antibodies showed the melanocytic component in the epidermis and dense clusters of "atypical" melanocytes in the dermal nests of BCC. On examination of the biopsy specimen, melanoma was still in situ because it was limited to the nests of BCC and not detectable between dermal collagen bundles. However, the re-excision of the lesion showed residual BCC and invasive LMM, level II, measuring 0.2 mm in thickness. The diagnosis, pathogenesis, and prognosis of this collision tumor are discussed.