What's Eating You? Carpet Beetles (Dermestidae)

Carpet beetle larvae of the family Dermestidae have been documented to cause both acute and delayed hypersensitivity reactions in susceptible individuals. These larvae have specialized horizontal rows of spear-shaped hairs called hastisetae, which detach easily into the surrounding environment and are small enough to travel by air. Exposure to hastisetae has been tied to adverse effects ranging from dermatitis to rhinoconjunctivitis and acute asthma, with treatment being mostly empiric and symptom based. Due to the pervasiveness of carpet beetles in homes, improved awareness of dermestid-induced manifestations is valuable for clinicians.

What's Eating You? Noble False Widow Spider (Steatoda nobilis)

Noble false widow spider (Steatoda nobilis) bites have been documented to cause symptoms ranging from pain and pruritus to systemic bacterial infection resulting in death. This species is found in a broad range of environments, often alongside human activity, and the spiders most often bite defensively when disturbed or when the body is compressed. Due to the rapid expansion of noble false widow spiders and their relatively recent emergence in the United States, it is important for dermatologists to be aware of how to manage their bites.

KAT6A::EP300 fusion in congenital myeloid sarcoma: Yet another novel molecular marker indicating spontaneous remission?: A case report

RATIONALE

Acute myeloid leukemia (AML)/myeloid sarcoma (MS) is risk-stratified based on cytogenetics. Although most congenital AML/MS have a dismal prognosis, certain genetic variants such as t (8, 16) [KAT6A::cAMP response element-binding protein (CREB) - binding protein fusion] and more recently t (8, 22) [KAT6A::EP300 fusion] have shown spontaneous remissions. KAT6A located on chromosome 8p11 encodes KAT6A protein, a histone/lysine acetyltransferase enzyme. Numerous partner genes associated with KAT6A include cAMP response element-binding protein (CREB) - binding protein (16p13), EP300 (22q13), LEUTX (9q13), NCOA2, NCOA3, and ASXL2.

PATIENT CONCERNS

In this article, we describe an otherwise healthy infant who presented with skin nodules on the face and scalp without any systemic or CNS involvement. A biopsy of the cutaneous lesion was consistent with congenital MS.

DIAGNOSES

Through molecular testing, we found that our patient had the KAT6A::EP300 mutation. This is one of the rare recurrent cytogenetic abnormalities that are linked to congenital AML.

INTERVENTION

Our patient underwent spontaneous remission with watchful waiting.

OUTCOME

Our patient has remained in spontaneous remission for 24 months.

LESSONS

Even though the KAT6A::EP300 mutation in adults is a poor prognostic marker, a similar mutation in congenital AML has a higher likelihood of spontaneous remission. Hence, conservative management might be an initial management strategy for clinically stable patients.

T-Cell-Rich Angiomatoid Polypoid Pseudolymphoma: A Case Report and Comparison With Key Differential Diagnoses

T-cell-rich angiomatoid polypoid pseudolymphoma (TRAPP) is a rare and recently defined entity, conceptualized just over a decade ago. Recognition of TRAPP is important because it can be clinically and microscopically confused with low-grade cutaneous lymphomas and other vascular proliferations. We report a case of a 28-year-old male with a solitary 1.2 cm red polypoid papule on the middle posterior base of the neck. The histopathological examination revealed a well-circumscribed dermal nodular proliferation of banal-appearing lymphovascular spaces with plump endothelial cells. Immunohistochemical analysis showed a T-cell-rich infiltrate. The clinical-pathological differential diagnosis for TRAPP includes pyogenic granuloma, angiolymphoid hyperplasia (epithelioid hemangioma), acral pseudolymphomatous angiokeratoma of children, cutaneous lymphoid hyperplasia, and low-grade cutaneous lymphomas and lymphoproliferative disorders. We review the literature and discuss the key differentiating features between TRAPP and its common differential diagnoses.

Cytotoxic t lymphocyte (CTL) to macrophage ratio to predict survival in stage II-III melanoma: Validation in a second cohort

e21595

Background: Cutaneous melanoma is an aggressive dermatologic malignancy with stage II-III recurrence rates ranging from 27-46%. Analysis of the tumor microenvironment (TME) is a promising mechanism to identify the patients who would benefit most from adjuvant immunotherapy given the risk for potential immune-related adverse events. Previous research by our group established the potential of utilizing CD3+CD8+ cytotoxic lymphocyte (CTL) and CD68+ macrophage densities, as well as the CTL/macrophage ratio in the TME, as prognostic biomarkers for metastatic progression and disease-specific survival (DSS). We sought to test the prognostic accuracy of the CTL/macrophage ratio in a second cohort of stage II-III melanoma patients from the Geisinger Health System. Methods: We utilized quantitative multiplex immunofluorescence (qmIF) to analyze 43 patient samples with stage II-III melanoma to validate the prospective biomarkers established in our previous CUIMC cohort. TME cell phenotype and cell density data were acquired for both the stroma as well as the combined tumor + stroma (“total TME”) via utilization of a trainable machine learning program. Cell densities and ratios were subsequently analyzed to determine associations with clinical outcomes including both disease recurrence and DSS. Results: In patients without distant metastatic recurrence (DMR), the density of CTLs and activated HLA-DR+ CTLs was higher in both the stroma ( p= 0.0003, p= 0.0152, respectively), as well as total TME ( p< 0.0001, p= 0.0165, respectively), when compared to those with DMR. The CTL/macrophage ratio in the total TME was greater in those without recurrence ( p= 0.0031). The ratio of CTLs to MPO+ neutrophils was higher in both the stroma ( p= 0.0015) and the total TME ( p= 0.0016) in those without recurrence. Survival analysis of 38 patients with known cause of death indicated a higher CTL/macrophage ratio in the total TME was associated with improved survival ( p= 0.0005). Improved survival was also associated with high CTL/neutrophil ratios in both the stroma ( p< 0.0001) and the total TME ( p< 0.0001). Cox regression analysis demonstrated a strong association between low CTL/macrophage and CTL/neutrophil ratios in the total TME and an increased risk of death ( p= 0.003, HR: 7.24, CI: 1.99-26.31; p= 0.003, HR: 22.35, CI: 2.87-173.97, respectively). Conclusions: Patients without disease recurrence display an increased infiltration of CTLs and activated HLA-DR+ CTLs, in addition to higher ratios of CTLs to macrophages and neutrophils, in the TME. High CTL/macrophage and CTL/neutrophil ratios in the total TME were also independently associated with improved DSS. Validation is underway with an additional cohort to further explore the use of these prospective biomarkers as clinical decision-making support tools to help guide the determination of patient risk and the use of adjuvant immunotherapy in melanoma.

Deep Learning Based on Standard H&E Images of Primary Melanoma Tumors Identifies Patients at Risk for Visceral Recurrence and Death

PURPOSE

Biomarkers for disease-specific survival (DSS) in early-stage melanoma are needed to select patients for adjuvant immunotherapy and accelerate clinical trial design. We present a pathology-based computational method using a deep neural network architecture for DSS prediction.

EXPERIMENTAL DESIGN

The model was trained on 108 patients from four institutions and tested on 104 patients from Yale School of Medicine (YSM, New Haven, CT). A receiver operating characteristic (ROC) curve was generated on the basis of vote aggregation of individual image sequences, an optimized cutoff was selected, and the computational model was tested on a third independent population of 51 patients from Geisinger Health Systems (GHS).

RESULTS

Area under the curve (AUC) in the YSM patients was 0.905 (P < 0.0001). AUC in the GHS patients was 0.880 (P < 0.0001). Using the cutoff selected in the YSM cohort, the computational model predicted DSS in the GHS cohort based on Kaplan-Meier (KM) analysis (P < 0.0001).

CONCLUSIONS

The novel method presented is applicable to digital images, obviating the need for sample shipment and manipulation and representing a practical advance over current genetic and IHC-based methods.

Acute hemorrhagic edema of infancy: guide to prevent misdiagnosis

We report the case of a 10-month-old previously healthy boy who presented with acute rash, edema, and low-grade fever in the setting of recent diarrhea. We differentiate between acute hemorrhagic edema of infancy (AHEI) and Henoch-Schönlein purpura (HSP).

What's eating you? clothes moths (Tineola species)

Common household insects can be confused with ectoparasites. Understanding the basic identification and monitoring techniques of clothes moths will help the clinician identify if a patient has an infestation of the household versus his/her body. Clothes moth larvae are not parasites but are found on infested clothing and can be confused with myiasis.