[Therapeutic indications for percutaneous laser in patients with vascular malformations and tumors]

Lasers are increasingly used to treat vascular abnormalities. Indeed, this technique is non-invasive and allows a specific treatment. The aim of this review is to present some biophysical principles of the lasers, to describe the different sorts of lasers available for treatment in vascular medicine indications. Three principal lasers exist in vascular medicine: the pulsed-dye laser, for the treatment of superficial pink lesions, the NdYAG-KTP laser for purple and bigger lesions, and the NdYAG long pulse laser for even deeper and bigger vascular lesions. In vascular malformations, port wine stains can also be treated by pulsed-dye laser, KTP or NdYAG when they are old and thick. Telangiectasias are good indications for the three sorts of lasers, depending on their depth, color and size. Microcystic lymphatic malformations can be improved by laser treatment. Arterio-venous malformations constitute a contraindication of laser treatment. In vascular tumors, involuted infantile hemangiomas constitute an excellent indication of pulsed-dye laser treatment. Controlled studies are necessary to evaluate and to compare the efficacy of each laser, in order to determine their optimal indications and optimal parameters for each machine.

Mycosis fongoïde tumoral et pilotrope sans mucine : évolution vers une érythrodermie pustuleuse

INTRODUCTION

Pilotropic mycosis fongoides is a particular form of the disease, because of its clinical and histological aspects, its poor prognosis and its resistance to treatment. We report a case of pilotropic mycosis fongoides without mucinosis, immediately tumoral, the fatal progression of which was marked by the occurrence of pustular erythroderma.

OBSERVATION

In 1998 a 69 year-old man presented with infiltrated erythro-squamatous plaques and nodules on the limbs associated with follicular lesions predominating on the cervical-cephalic area. Histological explorations revealed a pilotropic infiltrate with atypical CD4+ CD8 CD30 T-cells, without epidermotrophism or mucinosis. Study of genetic rearrangements found a clone lymphocyte T-cell in the skin. Diagnosis of pilotropic mycosis fongoides at the tumoral stage was made and, despite various treatments, the disease developed towards fatal pustular erythroderma.

DISCUSSION

At the onset of its progression, pilotropic mycosis fongoides is sometimes difficult to distinguish from classical mycosis fongoides, during which follicular involvement is often seen. However it is important to differentiate these entities because of the poor prognosis of pilotropic mycosis fongoides. Development of tissue micro dissection techniques and lymphocyte T-cell clones from human skin would help to separate these cutaneous T-cell lymphoma sub-groups. Our case report is original because of the absence of dermal mucinosis combined with an immediately tumoral form and the progression towards generalized pustulosis. It also underlines the poor prognosis and resistance to treatment of pilotropic mycosis fongoides.

[Simvastatin-induced lichen planus pemphigoides]

INTRODUCTION

Simvastatin is a competitive inhibitor of the 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase which is effective in the treatment of various hyperlipidemia. We report a case of lichen planus pemphigoides induced by simvastatin treatment.

CASE REPORT

A 63-year-old man was treated for two months with simvastatin for hypercholesterolemia. One month later he developed a pruriginous and bullous lichenoid eruption. Histological and direct immunofluorescent features were consistent with the diagnosis of lichen planus pemphigoides. The Western blot analysis revealed antibodies directed against BP 180 kDa antigens. All the lesions progressively disappeared after treatment was discontinued.

DISCUSSION

Lichen planus pemphigoides may be due to the intake of drugs such as cinnarizine, captopril, ramipril and furosemide. Simvastatin may induce various drug eruptions such as pruritus, eczematous rash, cheilitis, angio-oedema and urticaria, porphyria cutanea tarda, lupus-like syndrome, dermatomyositis and lichenoid eruption. With the increasing use of HMG-CoA reductase inhibitors, an association between simvastatin and lichen planus pemphigoides should be kept in mind.

[Septic embolism complicating an aorto-duodenal fistula]

INTRODUCTION

Aorto-duodenal fistulas are rare complications of aortal prostheses. We report a case revealed by septic embolism.

OBSERVATION

A 63 year-old man with past history of obliterating arteriopathy of the legs and bifemoral aortal bypass was hospitalized in a dermatology unit because of bilateral ecchymotic and purpural lesions of the soles of the feet and fever. Hemocultures were positive for E. coli and alpha hemolytic streptococci. The search for a deep infectious area was negative. Gastro-esophageal fibroscopy revealed an aorto-duodenal fistula showing a fresh blood clot in the second duodenum.

DISCUSSION

Aorto-duodenal fistulas are rare complications of aortal prostheses, the high mortality of which is often related to late diagnosis. The initial symptoms such as fever, abdominal pain, palpable mass and digestive bleeding are inconstant and the clinical profile polymorphous. Any suspicion of septic embolism in a patient with an aortal vascular prosthesis must lead to the search for prosthetic infection and an aorto-duodenal fistula, notably in the presence of osteomyelitis at distance from the prosthesis. A scan and/or scintigraphy with normal polynuclears do not eliminate the diagnosis of an aortal-duodenal fistula and a gastro-esophageal fibroscopy should be performed.