Congenital syphilis presenting with granulomatous scalp nodules

We describe a case of congenital syphilis in an adopted infant with a unique dermatologic presentation of scalp granulomas, along with lymphadenopathy, anemia, and elevated liver transaminases. To our knowledge, this cutaneous morphology has not been previously reported in the literature. This case highlights the varied clinical presentation of congenital syphilis and the diagnostic challenge it poses for clinicians, especially in the context of unknown prenatal history/unknown risk factors, or if syphilis is acquired during pregnancy after routine screening is performed. As the incidence of congenital syphilis has more than tripled in recent years, this diagnosis should be considered when a neonate or infant presents with unexplained skin nodules.

A crack in the armor: Wolf isotopic response manifesting as cutaneous lupus

Wolf isotopic response represents the development of skin lesions of one particular morphology occurring at the same site as another morphologically distinct and unrelated skin lesion. Cutaneous lupus erythematosus (CLE) is an autoimmune connective tissue disorder encompassing a wide range of phenotypes that may be associated with systemic involvement. Although CLE is a well-described entity with a broad spectrum, the occurrence of lesions manifesting as an isotopic response is rare. We present a patient with systemic lupus erythematosus who developed CLE in a dermatomal distribution following herpes zoster. When CLE lesions present in a dermatomal distribution, these cases may be difficult to distinguish from recurrent herpes zoster infection in an immunosuppressed patient. Therefore, they pose a diagnostic challenge and require balancing antiviral therapy with immunosuppression to sufficiently maintain adequate control of the autoimmune disease while addressing possible infections. To avoid treatment delay, clinicians should have elevated suspicion for an isotopic response when disparate lesions erupt in areas previously affected by herpes zoster or in cases of persistent eruptions at sites of prior herpes zoster. We discuss this case within the context of Wolf isotopic response and review the literature for similar cases.

Neurotropic Cutaneous Malignancies: Case Report on Keratinocyte Derived Malignancies of the Head and Neck With Perineural Invasion

Background

The recent addition of immunotherapy as a treatment modality to surgery and radiation has vastly improved disease control for patients with keratinocyte-derived carcinomas (KCs) that are incurable with local therapies alone. With the advent of immune checkpoint inhibitors (ICPis) in non-melanoma skin cancers comes diagnostic and therapeutic challenges when considering treatment strategies for patients presenting with clinical perineural invasion (cPNI) of locally advanced KC of the head and neck.

Objectives

We report four cases that convey the diagnostic and therapeutic complexity of managing patients with neuropathic symptoms from cutaneous neurotropic carcinomas of the head and neck. We also discuss an updated review regarding immunotherapies and perineural invasion within KC management.

Conclusion

Patients presenting with symptoms suspicious for cPNI warrant an expanded diagnostic evaluation to correlate neurological findings with neurotropic spread of disease. While nerve biopsies can be precarious in sensitive areas, a history of skin cancer and clinical presentation suggestive of neurotropism may be enough to pursue timely management in the form of surgery, radiation, and/or systemic therapy given each patient’s individual priorities, comorbidities, and prognosis. When adding ICPi as a treatment modality for patients with disease not amenable to local therapies, the potential for immune-related adverse events must be considered. A multi-disciplinary review and approach to the management of patients with KC and cPNI is essential for obtaining optimal patient outcomes.

Genomic data reveal local endemism in Southern California Rubber Boas (Serpentes: Boidae, Charina) and the critical need for enhanced conservation actions

The mountains of southern California represent unique, isolated ecosystems that support distinct high-elevation habitats found nowhere else in the area. Analyses of several moisture-dependent species across these sky-islands indicate they exist as locally endemic lineages that occur across these fragmented mountains ranges. The Rubber Boa is a semi-fossorial snake species that is widely distributed in the cooler and more moist ecoregions regions of western North America, including isolated populations across southern California mountain ranges. We developed a genomic and ecological dataset to examine genetic diversity within Rubber Boas and to determine if the endemic Southern Rubber Boa represents a distinct lineage. We quantified current and future habitat suitability under a range of climate change scenarios, and discuss the possible environmental threats facing these unique montane isolates. Our results support four major lineages within Rubber Boas, with genetic breaks that are consistent with biogeographic boundaries observed in other co-distributed, cool-temperature, moisture adapted species. Our data support previous studies that the Southern Rubber Boa is an independent evolutionary unit and now includes multiple locally endemic sky-island populations, restricted to isolated mountain tops and ranges across southern California. Analyses of future habitat suitability indicate that many of these sky-island populations will lose most of their suitable habitat over the next 70 years given predicted increases in drought, rising temperatures, and wildfires. Collectively these data emphasize the critical conservation needs of these montane ecosystems in southern California under current and projected climate change conditions.

USP6 rearrangement in pediatric nodular fasciitis

Nodular fasciitis (NF) is a myofibroblastic proliferation that uncommonly presents in pediatric patients. These benign neoplasms can masquerade as more insidious sarcomatous proliferations on both clinical exam and initial histopathologic review, often prompting undue concern in patients, parents and providers. While immunohistochemical analysis of NF can be variable, adding to the diagnostic uncertainty, molecular analysis documenting ubiquitin-specific protease 6 (USP6) gene rearrangement can help confirm the diagnosis as an association between NF and USP6 overexpression was first identified 10 years ago in an analysis that found rearrangements of the involved locus in over 90% of studied samples.¹ In this report, we review one case of nodular fasciitis located on the chin of a 9-year-old in which molecular testing was essential to secure the correct diagnosis, and provide a summary of documented cases of USP6 overexpression in transient pediatric neoplasms. This article is protected by copyright. All rights reserved.

Histopathologic and Genetic Findings in Atypical Spindle Cell/Pleomorphic Lipomatous Tumors and Atypical Pleomorphic Fibromas

BACKGROUND

Spindle cell lipomas, pleomorphic lipomas (SCL/PLs) and pleomorphic fibromas (PF) are tumors with loss of retinoblastoma (RB). The latest World Health Organization classification includes a category of atypical spindle cell/pleomorphic lipomatous tumors (ASPLT) that encompasses tumors in this spectrum that show atypical histopathologic features. We have observed PFs that show similar atypical features.

METHODS

Cases of SCL/PL and PF with atypical features were collected from tissue archives between 2010-2019. Genetic alterations were investigated using array comparative genomic hybridization (aCGH).

RESULT

Of 15 cases found, most tumors were dermal-based with fibrocytic or fibroadipocytic appearance and occasional lipoblasts. All cases had a high proliferation index with atypical mitotic figures in 71% of cases. Chromosome 13q loss was present in all cases with CGH data. Additional recurrent chromosomal losses included 17p, 16q, 17q, 20p, 4, and 10. No recurrence was found in limited follow up.

CONCLUSIONS

ASPLTs are characterized by loss of RB, prominent nuclear pleomorphism, mitotic activity including atypical mitotic figures, and genomic instability with multiple chromosomal aberrations. A similar group of tumors with these histopathologic features lacks lipomatous differentiation, and we propose the diagnosis of atypical PF as a fibromatous variant of ASPLT. Limited clinical follow up appears benign.

Atypical keratosis pilaris-like lesions in a patient with Bethlem myopathy

Bethlem myopathy is a collagen VI-related myopathy. Collagen VI is primarily not only associated with the extracellular matrix of skeletal muscle, but is also found in the skin, blood vessels, and other organs. Dermatologic findings described for Bethlem myopathy include follicular hyperkeratosis and abnormal scar formation, although clinical and histopathologic photographs remain elusive in the literature. We present a case of atypical keratosis pilaris-like follicular lesions in a patient with Bethlem myopathy and provide histopathologic correlation to better characterize the development of skin lesions in this rare neuromuscular disease.

Could climate change benefit invasive snakes? Modelling the potential distribution of the California Kingsnake in the Canary Islands

The interaction between climate change and biological invasions is a global conservation challenge with major consequences for invasive species management. However, our understanding of this interaction has substantial knowledge gaps; this is particularly relevant for invasive snakes on islands because they can be a serious threat to island ecosystems. Here we evaluated the potential influence of climate change on the distribution of invasive snakes on islands, using the invasion of the California kingsnake (Lampropeltis californiae) in Gran Canaria. We analysed the potential distribution of L. californiae under current and future climatic conditions in the Canary Islands, with the underlying hypothesis that the archipelago might be suitable for the species under these climate scenarios. Our results indicate that the Canary Islands are currently highly suitable for the invasive snake, with increased suitability under the climate change scenarios tested here. This study supports the idea that invasive reptiles represent a substantial threat to near-tropical regions, and builds on previous studies suggesting that the menace of invasive reptiles may persist or even be exacerbated by climate change. We suggest future research should continue to fill the knowledge gap regarding invasive reptiles, in particular snakes, to clarify their potential future impacts on global biodiversity.

Smartphone adapter time trial analysis: A low-cost, time-efficient method to disseminate quality photomicrographs at the microscope

BACKGROUND

Within the field of pathology there is a need for a uniform low-cost option for securing high-quality photomicrographs. Advances in smartphone photography and 3D-printing technology allow for custom adapters to be designed for the purpose of photomicrograph capture.

METHODS

Photomicrograph acquisition was performed using four core modalities: a novel 3D-printed smartphone-to-microscope adapter, freehand smartphone-to-microscope technique, a commercial adaptor (LabCam Pro), and a microscope-mounted digital camera. Eight skin diagnoses were photographed using each of the modalities and time to image capture was measured. The photomicrographs were blindly reviewed by two academic dermatopathologists and one pathologist using a side-by-side comparison technique to determine the image quality. Cost assessments were evaluated by obtaining free pricing information on manufacturer websites.

RESULTS

The 3D-printed adapter was the most efficient method of capturing a high-quality photomicrograph in addition to being budget neutral. The microscope-mounted camera produced the highest quality photomicrographs followed by the 3D-printed adapter.

CONCLUSIONS

The 3D-printed smartphone-to-microscope adapter offers a low-cost, time-efficient method of capturing high-quality photomicrographs.

Characteristics of Superficial Basal Cell Carcinomas Containing More Aggressive Subtypes on Final Histopathologic Diagnosis

BACKGROUND

The prognosis and treatment of basal cell carcinoma (BCC) are largely dependent on tumor subtype, which is typically determined by punch or shave biopsy. Data regarding concordance between BCC subtype on initial biopsy and final histopathology for Mohs micrographic surgery (MMS) or excision with frozen sections (EFS) are limited.

OBJECTIVES

To determine the concordance between initial biopsy and final MMS or EFS subtyping of BCC. We aim to investigate the incidence and clinical characteristics of lesions initially diagnosed as superficial BCC (sBCC) that are later found to have a nodular, micronodular, or infiltrative component.

METHODS

We conducted a retrospective review of all MMS or EFS cases performed at a single academic center from August 1, 2015 to August 31, 2017. Inclusion criteria were a biopsy-proven diagnosis of sBCC and presence of residual tumor following stage I of MMS or EFS. Fisher’s exact test was used to evaluate significance of clinical characteristics and outcomes associated with the presence of a nodular, micronodular, or infiltrative BCC component.

RESULTS

A total of 164 MMS or EFS cases had an initial biopsy showing sBCC. Of these, 117 had residual BCC on stage I, and 43 (37%) were found to have a nodular, micronodular, or infiltrative component. Significant predictors of reclassified BCC subtype included age over 60 years (P=0.006) and location on the head or neck (P=0.043). Reclassified lesions required significantly more stages of MMS to clear (P=0.036). Shave biopsy was used to diagnose 114 (98%) of the included cases.

CONCLUSIONS

Over one third of shave biopsies that initially diagnosed sBCC failed to detect a nodular, micronodular, or infiltrative component. Management of biopsy-proven sBCC should take into account the possible presence of an undiagnosed deeper tumor component with appropriate margin-assessment treatment modalities when clinically indicated. J Drugs Dermatol. 2021;20(3):283-288. doi:10.36849/JDD.5383.

Congenital cutaneous non-neural granular cell tumor mimicking herpetic infection: Case report and review of the literature

We present a case of a female neonate with a cluster of six skin colored to yellowish pseudovesicular papules on her right forearm present since birth, initially thought to be a herpes simplex virus infection. Punch biopsy with immunostaining revealed a diagnosis of S100-negative, CD163-positive congenital cutaneous non-neural granular cell tumor. Only four other reports are presented in the literature of this entity, three of which also presented on the arm with somewhat similar clinical findings. We briefly reviewed the subtypes of classic and S100-negative non-neural granular cell tumors.

Local immune cell infiltration in cutaneous acute graft versus host disease

Background

Hematopoietic stem cell transplant is a crucial intervention to definitively treat many hematopoietic malignancies, but it carries great risks of morbidity and mortality often associated with graft-versus-host disease (GVHD). Acute and chronic GVHD are distinct entities, defined by a combination of historical, clinical, and pathologic data, but both are generally thought to stem from self-propagating aberrantly activated immune cells inflicting end organ damage, with the potential to cause significant illness or even death. Event-free survival rates after hematopoietic stem cell transplant continue to improve each year, but GVHD remains a major hurdle in improving the efficacy and safety of transplant.

Objective

Recent studies demonstrating tissue-specific immune effector phenotypes underscore the need for a deeper understanding of the cellular and molecular pathways driving the destruction of target tissues in patients with acute GVHD.

Methods

Samples were collected from lesional and unaffected skin in five patients with acute cutaneous GHVD. Fresh tissue was processed for fluorescence-activated cell sorting and analysis of macrophages and lymphocytes.

Results

The percentage of lymphocytes and macrophages as a representation of total cells varied among patients and was not always consistent between lesional and unaffected sites. The heterogeneity in immune cell profiling observed in patients in this study could reflect the diverse demographics, conditioning, and transplant conditions of each individual.

Conclusion

This study provides initial insight into the underlying molecular mechanisms of cutaneous GVHD progression and paves the way for additional studies to examine the cellular and molecular landscape in greater detail.

Lichenoid inflammation of DSAP lesions following treatment with durvalumab, olaparib and paclitaxel: A potential diagnostic pitfall mimicking lichenoid drug eruptions associated with PDL-1 inhibitors

Disseminated superficial actinic porokeratosis (DSAP) is an uncommon skin condition that can be inherited or may occur sporadically with multiple red-brown, thin plaques in a photodistribution. The condition more often affects middle-aged women and is often recalcitrant to therapy. In rare literature reports, systemic medications can trigger exacerbation or promote inflammation in pre-existing lesions of DSAP. We present a novel case of chemotherapy-associated DSAP inflammation in a 66-year-old woman after triple therapy with durvalumab (PD-L1 inhibitor), olaparib (PARP inhibitor) and paclitaxel, showing similarities to primary lichen planus-like eruption from immune checkpoint inhibitors.

Pleomorphic dermal sarcoma in a man with HIV: report with next-generation sequencing analysis and review of the atypical fibroxanthoma/pleomorphic dermal sarcoma spectrum

Atypical fibroxanthoma (AFX) is a rare cutaneous fibrohistiocytic tumor that typically arises on chronically sun-damaged skin, such as the head and neck, as a nondescript ulcerated papule, nodule, or tumor. The clinical prognosis is usually favorable and metastasis is rare. Pleomorphic dermal sarcoma (PDS), or undifferentiated pleomorphic sarcoma, is a recently introduced diagnostic moniker for AFX-like tumors with more aggressive clinical and histologic features such as necrosis and vascular invasion. The exact relationship between AFX and PDS has been debated. Diagnosis of these tumors is generally based on immunohistochemical staining to exclude other mimics. A wholly specific marker for this tumor does not exist, leading to diagnostic ambiguity in certain cases. Herein, we present a case of pleomorphic dermal sarcoma in a 53-year-old man with human immunodeficiency virus that displayed patchy S100 staining concerning for melanoma upon hospital pathology review. Next-generation sequencing analysis confirmed a mutation pattern consistent with published molecular signatures of AFX/PDS. In discussing this case, we review the current understanding of AFX/PDS and discuss diagnostic pitfalls, as well as emphasize on how next-generation sequencing techniques might improve accuracy in the diagnosis of tumors in the spectrum of AFX/PDS.

Cutaneous Syncytial Myoepithelioma: A Nondescript Skin Tumor With Serious Diagnostic Pitfalls

Cutaneous syncytial myoepithelioma (CSM) is a rare tumor with a nondescript clinical presentation in the skin. It represents a relatively uncommon diagnostic entity with approximately 50 examples in the literature to date. We present a 36-year-old man with a new, tender 3-mm firm pink papule on the left bicep, in which a superficial shave technique produced a diagnostic challenge. CSM often poses a diagnostic quandary given shared histomorphological and immunohistochemical attributes with superficial mesenchymal or neurocristic tumors, namely, melanocytic proliferations, fibrous histiocytoma, and epithelioid sarcoma. The molecular profile of CSM may reveal EWSR1 or FUS gene rearrangement, but as we showcase, the diagnosis remains possible in the absence of this oncogenic fusion. Ultimately, there are pitfalls to avoid to correctly distinguish this benign myoepithelial lesion from more biologically aggressive neoplasia.

Innate Immune Dysfunction in Rosacea Promotes Photosensitivity and Vascular Adhesion Molecule Expression

Rosacea is a chronic skin disease characterized by photosensitivity, abnormal dermal vascular behavior, inflammation, and enhanced expression of the antimicrobial peptide LL-37. We observed that dermal endothelial cells in rosacea had an increased expression of VCAM1 and hypothesized that LL-37 could be responsible for this response. The digestion of double-stranded RNA from keratinocytes exposed to UVB blocked the capacity of these cells to induce adhesion molecules on dermal microvascular endothelial cells. However, a synthetic noncoding snoU1RNA was only capable of increasing adhesion molecules on endothelial cells in the presence of LL-37, suggesting that the capacity of UVB exposure to promote both double-stranded RNA and LL-37 was responsible for the endothelial response to keratinocytes. Sequencing of RNA from the endothelial cells uncovered the activation of Gene Ontology (GO) pathways relevant to the human disease, such as type I and II interferon signaling, cell-cell adhesion, leukocyte chemotaxis, and angiogenesis. Functional relevance was demonstrated as double-stranded RNA and LL-37 promoted adhesion and transmigration of monocytes across the endothelial cell monolayers. Gene knockdown of TLR3, RIGI, or IRF1 decreased monocyte adhesion in endothelial cells, confirming the role of the double-stranded RNA recognition pathways. These observations show how the expression of LL-37 can lead to enhanced sensitivity to UVB radiation in rosacea.

Non-uremic calciphylaxis in a patient with multiple rheumatologic diseases

Non-uremic calciphylaxis is a rare, life-threatening condition characterized clinically by cutaneous necrosis and histologically by calcium deposition in small vessel walls. The etiology of non-uremic calciphylaxis remains the subject of ongoing speculation and debate. Herein we present a patient with calciphylaxis who had normal kidney function and numerous rheumatologic diseases, namely systemic lupus erythematosus (SLE), Sjogren syndrome (SS), and myasthenia gravis (MG). We review the pathophysiology, possible mechanisms, and management for non-uremic calciphylaxis.

Agminated blue nevus with a GNAQ mutation: A case report and review of the literature

Agminated blue nevi are dermal melanocytic proliferations that classically present as dark blue macules or papules in a grouped, linear, or blaschkoid distribution. In their more common sporadic form, blue nevi manifest in young adulthood as solitary blue papules or macules on the scalp, face, hands, or feet. By contrast, agminated blue nevi tend to manifest earlier in life, and are distributed more evenly across anatomic sites. Recent studies have identified mutations in sporadic blue nevi in the genes encoding G Protein subunit alpha Q and G protein subunit alpha 11 (GNAQ and GNA11). It is unknown whether agminated blue nevi share the same genetic changes. In the present paper, we present a case of agminated blue nevus on the wrist, and identify an activating mutation (c.626A > T, p.Glu209Leu) in GNAQ. We hypothesize that GNAQ/GNA11 activating mutations arising earlier during development may trigger agminated blue nevi, explaining the broader field of involvement in these cutaneous lesions.

Congenital-type juvenile xanthogranuloma: A case series and literature review

BACKGROUND/OBJECTIVES

Congenital juvenile xanthogranulomas are infrequently described in the medical literature. We report three previously unpublished cases and systematically review the literature to better characterize this variant.

METHODS

We surveyed English-language articles indexed in MEDLINE (1951-March 2017) and EMBASE (1974-March 2017) for cases of congenital-onset juvenile xanthogranulomas confirmed on histopathology. Cases were divided into two categories: cutaneous only or cutaneous with systemic involvement.

RESULTS

We identified 31 cases of congenital juvenile xanthogranulomas involving only the skin and 16 cases with systemic involvement. Congenital juvenile xanthogranulomas involving only the skin were large (> 3 cm), presented with various clinical morphologies, and showed signs of regression by 1 year of age. Atypical clinical presentations included exophytic tumors, infiltrative plaques, agminated plaques, and subcutaneous tumors. Complications included ulceration and anetodermic scarring. Infants with congenital cutaneous juvenile xanthogranulomas who also had systemic involvement typically had multiple cutaneous tumors and hepatic involvement and showed signs of spontaneous regression independent of treatment.

CONCLUSIONS

The medical literature supports that congenital juvenile xanthogranulomas behave in a fashion similar to that of juvenile xanthogranulomas of infancy or childhood. Congenital cutaneous juvenile xanthogranulomas with or without systemic involvement spontaneously regress. The varied clinical presentations in the skin may lead to misdiagnosis, inappropriate examination, and unnecessary treatments. Infants with multiple congenital cutaneous juvenile xanthogranulomas should be evaluated for systemic involvement, with a particular focus on the liver, because 72.2% of these children were found to have hepatic juvenile xanthogranulomas.

Livedo Racemosa, Reticulated Ulcerations, Panniculitis and Violaceous Plaques in a 46-year-old Woman

Clinically amyopathic dermatomyositis (CADM) is a subset of dermatomyositis (DM) that has conventional cutaneous manifestations of DM, but paradoxically, little or no muscle involvement. In 2005, a novel antibody was described in association with CADM – anti-melanoma differentiation-associated gene 5 (anti-MDA5). Patients with this serologic marker have a characteristic mucocutaneous phenotype consisting of skin ulceration among other signs. We describe the case of a 46-year-old woman with CADM, elevated anti-MDA5 autoantibodies, and unusual clinical features (livedo racemosa, florid acral edema) among the classical phenotype of MDA5 DM (arthralgias, ulcerations, panniculitis) and classical DM lesions (Gottron papules, heliotrope rash). The patients did not develop interstitial lung disease or internal malignancies and experienced a rapid response to prednisolone and intravenous immunoglobulins. After 2 years, she has no relapse of her cutaneous disease and continues 5 mg prednisolone and 2 g/kg kilogram of intravenous immunoglobulin every 3 months for maintenance. Our case highlights the clinical heterogeneity of CADM and underscores the importance of a comprehensive approach to DM patients. It was previously postulated that anti-MDA5 antibody could target vascular cells and compromise vascular function, the presence of livedo racemosa lesions, and MDA5 antibodies in a patient with negative thrombophilia workup, reinforce this idea. This is the first case, to our knowledge, of CADM with acral panniculitis and livedo racemosa.

Dual MEK/AKT inhibition with trametinib and GSK2141795 does not yield clinical benefit in metastatic NRAS-mutant and wild-type melanoma

Aberrant MAPK and PI3K pathway signaling may drive the malignant phenotype in NRAS-mutant and BRAF^WT NRAS^WT metastatic melanoma. To target these pathways, NRAS-mutant and BRAF^WT NRAS^WT patients received oral trametinib at 1.5 mg daily and GSK2141795 at 50 mg daily in a two-cohort Simon two-stage design. Participants had adequate end-organ function and no more than two prior treatment regimens. Imaging assessments were performed at 8-week intervals. A total of 10 NRAS-mutant and 10 BRAF^WT NRAS^WT patients were enrolled. No objective responses were noted in either cohort. The median PFS and OS were 2.3 and 4.0 months in the NRAS-mutant cohort and 2.8 and 3.5 months in the wild-type cohort. Grade 3 and grade 4 adverse events, primarily rash, were observed in 25% of patients. We conclude that the combination of trametinib and GSK2141795 does not have significant clinical activity in NRAS-mutant or BRAF^WT NRAS^WT melanoma.

Loss of retinoblastoma in pleomorphic fibroma: An immunohistochemical and genomic analysis

BACKGROUND

Pleomorphic fibroma is a curious neoplasm that exhibits striking cytologic atypia, yet behaves in benign fashion. The cytologic features include single cells with pleomorphic nuclei and scattered giant cells resembling the neoplastic cells of pleomorphic lipoma, a tumor with known retinoblastoma (Rb) loss.

METHODS

We assessed the demographic and histopathologic features of a cohort of 26 pleomorphic fibromas, including assessment with immunostaining for Rb, p16 and Ki-67. Array comparative genomic hybridization (aCGH) was used to assess a limited number of tumors for genomic aberrations.

RESULTS

Of the 26 pleomorphic fibromas analyzed, 19 occurred in women and 7 in men, with a mean age of 47 years. The anatomic locations were variable. Immunostaining showed loss of Rb protein expression in all cases and diffuse p16 expression in 85%. Ki-67 labeling rate was below 10% in 85%. Chromosome 13q loss was found in 7 of 7 pleomorphic fibromas assessed with aCGH. Recurrent loss of 17p, 16q and 10q were also found.

CONCLUSION

We report recurrent loss of RB1 on chromosome 13q in pleomorphic fibromas, confirmed by both protein expression loss and loss of 13q by aCGH. This result indicates pleomorphic fibroma shares the same genetic abnormalities as spindle cell and pleomorphic lipomas.

Agminated melanocytic nevus status post dabrafenib therapy for metastatic melanoma

Agminated melanocytic nevus is an uncommon type of mole, characterized by a local group of macular or papular pigmented lesions, well demarcated, without a common pigmented background. This pattern has also been associated with Spitz nevi, dysplastic melanocytic nevi, and non-melanocytic lesions.We describe the onset of an acquired agminated melanocytic nevus after dabrafenib treatment. Our case highlights paradoxical MAPK activation in the setting of single-agent BRAF blockade and underscores the importance of characterizing the diverse side effects of selective BRAF inhibitors. This is the first case, to our knowledge, of agminated melanocytic nevus in association with dabrafenib.

Contaminated drinking water in one town manifesting as an outbreak of cryptosporidiosis in another

In early 1992 we identified an outbreak of cryptosporidiosis in Oregon and sought to identify and control its source. We used a series of studies to identify risk factors for illness: (i) a case-control study among employees of a long-term-care facility (LTCF); (ii) a matched case-control study of the general community; (iii) a cohort study of wedding attendees; and (iv) a cross-sectional survey of the general community. Drinking Talent water was associated with illness in the LTCF (OR = 22.7, 95 % CI = 2.7-1009.0), and in the community (matched OR = 9.5, 95% CI 2.3-84.1). Drinking Talent water was associated with illness only among non-Talent residents who attended the wedding (P < 0.001) and in the community (RR = 6.5, 95 % CI 3.3-12.9). The outbreak was caused by contaminated municipal water from Talent in the absence of a discernible outbreak among Talent residents, suggesting persons exposed to contaminated water may develop immunity to cryptosporidiosis.