Cavernous Haemangioma with Kasabach-Merritt Syndrome: Treatment with Alpha-Interferon

A small number of patients with haemangioma need treatment for serious complications such as Kasabach-Merritt syndrome, cardiac failure and obstruction of the airway. We report on the management of an infant with Kasabach-Merritt syndrome.

Six new HLA class I alleles detected by PCR-SSO genotyping

This paper describes six new alleles; A*0240, A*2614, B*3924, B*4425, Cw*0807 and Cw*12023, which were discovered during routine genotyping with sequence specific oligonucleotides (SSO's). Five of the new alleles have changes in residues which belong to the antigen binding site of the HLA protein. These new variants may have altered antigen binding properties and may cause differential immunological responses that could affect transplantation outcome1.

Wiskott-Aldrich syndrome, vasculitis and critical aortic dilatation

Wiskott-Aldrich syndrome is a rare X-linked disorder, comprising the triad eczema, thrombocytopenia and progressive immunodeficiency. The prognosis has been poor in the past but is now improving with therapeutic options including splenectomy and bone marrow transplantation. We report the case of a 21-year-old male with an established diagnosis of Wiskott-Aldrich syndrome, who developed aortic root dilatation with severe aortic regurgitation requiring aortic valve and root replacement. Histology confirmed a destructive, full-thickness, chronic aortitis.

CONCLUSION

As treatment and prognosis improve, large vessel vasculitis may become an increasingly recognized late complication of this syndrome, which now extends into adult practice.

Assessment of Ropivacaine as a Local Anesthetic for Skin Infiltration in Skin Surgery

BACKGROUND

There has been limited examination of the use of ropivacaine, a relatively new amide local anesthetic, for skin surgery following local infiltration. Initial studies of ropivacaine show it to have a rapid onset and long duration of action.

OBJECTIVE

To establish the injection characteristics of different concentrations of ropivacaine and to compare the pain of infiltration of ropivacaine with lidocaine 2% + epinephrine 1:80,000.

METHOD

A double-blind placebo-controlled study was carried out on 18 healthy volunteers. Four concentrations of ropivacaine (1, 2, 5, and 7.5 mg/ml) were injected intradermally. Normal saline was used as the control. Sensation for pinprick was used to assess the onset and duration of anaesthesia. Pain of infiltration of ropivacaine and saline was additionally compared with lidocaine 2% + epinephrine 1:80,000.

RESULTS

Pain of ropivacaine infiltation increased with increasing strength, but only 5 mg/ml was significantly more painful than the control P =.002). Lidocaine and epinephrine infiltration was significantly more painful than the control P =.0002) and 7.5 mg/ml ropivacaine (P =.0005). Mean times to reach full anesthesia were 74 seconds for 5 mg/ml and 51 seconds for 7.5 mg/ml. Mean times to regain full sensation were estimated as 692 minutes for 5 mg/ml and 773 minutes for 7.5 mg/ml. A vasoconstrictor effect was noted in the ropivacaine sites.

CONCLUSION

Ropivacaine has a rapid onset and long duration of action. Ropivacaine produces vasoconstriction which may be clinically relevant. Even at maximum strength ropivacaine is less painful to inject than lidocaine with epinephrine.

Cutaneous presentation of steroid responsive blastoid natural killer cell lymphoma

CD56+ lymphomas derived from natural killer (NK) cell lineage are rarely encountered in Western populations and their clinical and pathological features have not been fully defined. The majority of reported cases are lymphomas of the nasal cavity, which are most commonly seen in Asia. A subtype of CD56+ lymphoma has recently been described (blastoid NK-cell lymphoma) which characteristically presents in older patients with cutaneous infiltrates and disease at other nodal and extranodal sites. We describe a case that correlates well with the clinicopathological features of blastoid NK-cell lymphoma. An unusual feature in our patient was that the cutaneous features of the lymphoma showed complete resolution shortly following commencement of oral steroid therapy.

Routine HLA-B genotyping with PCR-sequence-specific oligonucleotides (PCR-SSO) detects eight new alleles: B*0807, B*0809, B*1551, B*3529, B*3532, B*4025, B*5304 and B*5508

This paper describes eight new alleles (B*0807, B*0809, B*1551, B*3529, B*3532, B*4025, B*5304 and B*5508) that have been found by routine HLA-B genotyping with sequence-specific oligonucleotides (SSOs). All of the new alleles have variations which cause changes in residues that occur within antigen binding pockets and T-cell recognition sites of the antigen. The new polymorphisms within these new alleles may affect the nature and specificity of peptide binding and cause differential T-cell activation, which may have an affect in transplantation.

Identification of a novel mutation R42P in the gap junction protein beta-3 associated with autosomal dominant erythrokeratoderma variabilis

We report a missense mutation in the gap junction protein beta-3 (encoding Connexin 31), which was detected in only the affected members of a family in which the autosomal dominant skin disease erythrokeratoderma variabilis was segregating. The nucleotide change results in an arginine to proline substitution in codon 42. This residue is positioned on the first transmembrane/first extracellular domain of the gap junction protein with the mutation replacing a negatively charged residue with a nonpolar residue. This change may disrupt the conformation of the protein and voltage gating polarity leading to impaired channel function.

The epidemiology of head lice and scabies in the UK

Anecdotal evidence suggests that the prevalence of both scabies and head lice is increasing and also that both conditions are becoming refractory to pesticide treatment. Using information obtained from the Office of National Statistics, Royal College of General Practitioners Weekly Returns Service, Department of Health, local surveys of school children from Bristol and drug sales of insecticides, we have confirmed that there has been a rise in the prevalence of both conditions. We have shown that scabies is significantly more prevalent in urbanized areas (P < 0.00001), north of the country (P < 0.000001), in children and women (P < 0.000001) and commoner in the winter compared to the summer. Scabies was also shown to have a cyclical rise in incidence roughly every 20 years. Head lice were shown to be significantly more prevalent in children and mothers (P < 0.000001) though both conditions were seen in all age groups. Head lice were also less common during the summer. Host behaviour patterns, asymptomatic carriage, drug resistance and tourism from countries or districts with a higher incidence may be important factors in the currently high prevalence of both scabies and head lice.

Multilocus linkage identifies two new loci for a mendelian form of stroke, cerebral cavernous malformation, at 7p15-13 and 3q25.2-27

Cerebral cavernous malformation (CCM) is a Mendelian model of stroke, characterized by focal abnormalities in small intracranial blood vessels leading to hemorrhage and consequent strokes and/or seizures. A significant fraction of cases is inherited as an autosomal dominant trait with incomplete penetrance. Among Hispanic Americans, virtually all CCM is attributable to a founder mutation localized to 7q ( CCM1 ). Recent analysis of non-Hispanic Caucasian kindreds, however, has excluded linkage to 7q in some, indicating at least one additional CCM locus. We now report analysis of linkage in 20 non-Hispanic Caucasian kindreds with familial CCM. In addition to linkage to CCM1, analysis of linkage demonstrates linkage to two new loci, CCM2 at 7p13-15 and CCM3 at 3q25.2-27. Multilocus analysis yields a maximum lod score of 14.11, with 40% of kindreds linked to CCM1, 20% linked to CCM2 and 40% linked to CCM3, with highly significant evidence for linkage to three loci (linkage to three loci supported with an odds ratio of 2.6 x 10(5):1 over linkage to two loci and 1.6 x 10(9):1 over linkage to one locus). Multipoint analysis among families with high posterior probabilities of linkage to each locus refines the locations of CCM2 and CCM3 to approximately 22 cM intervals. Linkage to these three loci can account for inheritance of CCM in all kindreds studied. Significant locus-specific differences in penetrance are identified. These findings have implications for genetic testing of this disorder and represent an important step toward identification of the molecular basis of this disease.

Eruptive collagenomas of the skin: a case history

We present a case of eruptive collagenomas of the skin in a young girl. The typical clinical features and histology of this rare condition are described. The differential diagnosis and other types of cutaneous collagenomas are briefly discussed. A biopsy is required to confirm the excessive mature collagen which predominates in these lesions.

Scleroatrophic syndrome of Huriez in an infant

We present a 3-year-old boy with scleroatrophic syndrome of Huriez, a rare autosomal dominant condition with only seven affected families worldwide. Although assumed to occur from birth, an evolving case has not previously been documented. Infants do not possess the focal areas of keratoderma on the palms or soles; these develop in adult life. Of particular interest is the high incidence of squamous cell carcinomas that arise from the scleroatrophic skin.

The effects of topical doxepin on responses to histamine, substance P and prostaglandin E2 in human skin

The tricyclic antidepressant, doxepin, is known to have H1 and H2 antihistaminic effects. Recently, 5% doxepin cream has been marketed in the U.S.A. for treatment of eczematous dermatoses. We investigated the effects of topical doxepin treatment on histamine-, substance P- and prostaglandin E2- (PGE2) induced responses in the skin of normal and atopic subjects. We compared the effects of topical doxepin with those of the oral antihistamine terfenadine. The weal volume and flare area responses to histamine were significantly reduced by treatment with topical doxepin or oral terfenadine in both normal and atopic subjects (P < 0.05). The mean +/- SEM percentage reduction in flare area for 10 micrograms/site of histamine in non-atopics and atopics was 48 +/- 8% and 60 +/- 17% with terfenadine, and 54 +/- 12% and 81 +/- 4% with topical doxepin, respectively. The mean percentage reduction in weal volume for the same dose of histamine in non-atopics and atopics was 70 +/- 9% and 63 +/- 16% with terfenadine, and 96 +/- 2% and 89 +/- 6% with topical doxepin, respectively. The flare but not the weal response to substance P was inhibited by both treatments in all subjects (P < 0.05). The mean +/- SEM percentage reduction in flare area for 200 pmol/site of substance P in non-atopics and atopics was 53 +/- 10% and 73 +/- 4% with terfenadine, and 74 +/- 7% and 75 +/- 4% with topical doxepin, respectively. The cutaneous responses to PGE2 were not affected by either drug. The inhibitory effects of doxepin were as great as those of terfenadine, and doxepin had a significantly greater effect than terfenadine in inhibiting the weal response to histamine and flare response to substance P in normal volunteers (P < 0.05). There was no significant difference between atopics and non-atopics in the percentage reduction of cutaneous responses by oral terfenadine or topical doxepin. Marked sedation occurred in three of the first 10 subjects treated with topical doxepin, necessitating a reduction in dosage for the remaining six subjects. In summary, topical doxepin was as effective as, and sometimes more effective than, a standard dose of oral terfenadine in the inhibition of histamine-induced and axon-reflex-mediated cutaneous responses. The marked sedative effect may limit its clinical use in some patients.

Weathering nodules of the ear: a clinicopathological study

Twenty-five cases of distinctive ear nodules on the helices of the ears in elderly males are presented. We believe the clinicopathological features of these lesions allow them to be defined as a distinct entity. They are probably more common than is currently recognized. Histologically, a typical nodule comprises a spur of fibrous tissue with a focus of cartilage metaplasia. While the pathogenesis of weathering nodules remains unclear, there is an association with age and chronic UV exposure.

Facial granulomatous lymphoedema and syringomyelia

The term orofacial granulomatosis was introduced for orofacial lesions which resemble Crohn's disease clinically and histologically in patients without gastrointestinal disease. The Melkersson-Rosenthal syndrome and its oligosymptomatic form Meischers granulomatous cheilitis are usually felt to be part of the same spectrum of disease. Oedema usually involves tissues of the lower half of the face. We describe a patient with histological changes consistent with those found in orofacial granulomatosis, but with isolated localized oedema of the right periorbital tissues. The patient also had syringomyelia which has not previously been described in association with orofacial granulomatosis.

Dermatomyositis treated with high-dose intravenous immunoglobulins and associated with panniculitis

Polymyositis and dermatomyositis are idiopathic inflammatory myopathies characterized by subacute symmetrical weakness of proximal limb and trunk muscles. Dermatomyositis is distinguished from polymyositis by the presence of rash. We describe an adult patient with treatment-resistant childhood-type dermatomyositis who made a good response to high dose intravenous immunoglobulins. Additionally, there was evidence of panniculitis which is an unusual histopathological finding in dermatomyositis.

Hypertrichosis and algodystrophy: an hypothesis to explain this uncommon association

Various skin changes have been described in algodystrophy, but the association of hypertrichosis with this condition is poorly documented. We describe a patient who developed algodystrophy after a mild inflammatory arthritis, in association with a number of skin manifestations, including hypertrichosis. We suggest a mechanism to explain this particular association.

A fatal case of scleredema of Buschke

Scleredema of Buschke is a rare disorder characterized by the development of areas of skin induration which usually resolve spontaneously. It is occasionally associated with a benign gammopathy, and rarely with myelomatosis. We describe a 60-year-old woman with extensive skin changes, who developed IgA myeloma. Unusually, her skin disease did not respond to conventional myeloma therapy. Death occurred as a consequence of the progressive skin disease.

Necrobiosis lipoidica--involvement of atypical sites

Necrobiosis lipoidica (NL) has distinctive clinical and histological appearances. The legs are the commonest site of involvement, and 85% of cases involve the legs exclusively. We describe a patient in whom NL did not involve the legs, but was found to occur on unusual areas: the back and nipple. This is possibly the first report of NL affecting the nipple.

Vulvitis chronica plasmacellularis (Zoon's vulvitis)

Vulvitis chronica plasmacellularis (Zoon's vulvitis) is rare. We describe a case in whom all the typical features, as delineated by Zoon, are demonstrated.

Juvenile dermatomyositis associated with partial lipoatrophy

A 26-year-old woman developed partial lipoatrophy 12 years after juvenile dermatomyositis was diagnosed. Renal function was normal, but she had other features typically associated with partial lipoatrophy, including hepatomegaly, acanthosis nigricans, hypertrichosis, and hyperinsulinemia.

Hypercalcaemia and sarcoidosis in infancy

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Temporal association between Der pI exposure, immediate hypersensitivity and clinical severity of eczema

Uncontrolled studies of avoidance of house dust mite (Dermatophagoides pteronyssinus) by atopic subjects have reported clinical improvement in the severity of eczema. The aim of the present study was to examine the temporal relationship between environmental exposure to the major mite allergen (Der pI) and clinical disease severity in children with chronic atopic eczema. Twelve children were identified as being house dust mite-sensitive on the basis of skin prick test and RAST to Der pI. They were examined on two occasions with a median interval of 63 days. Clinical severity of eczema improved in nine children and deteriorated in two children during this period. Der pI concentration in dust from mattresses changed significantly in only three subjects and there was no correlation between changes in clinical severity and changes in environmental Der pI exposure. Change in RAST against Der pI did correlate positively with change in Der pI exposure (rho = 0.56, P less than 0.05) but these changes were not associated significantly with changes in eczema severity or skin test response to Der pI. It is concluded that the observed changes in clinical severity were unlikely to be due to immediate hypersensitivity responses to natural variations in Der pI concentrations in the personal environments of these subjects.

Does EMLA reduce the discomfort associated with local-anaesthetic infiltration?

The effectiveness of EMLA cream in relieving the discomfort associated with percutaneous infiltration of lignocaine was assessed in a double-blind, placebo-controlled study. Patients undergoing minor skin surgery were divided into two groups, according to the number of lesions requiring surgery. The first group had a single lesion and were randomized to apply either EMLA or placebo cream 1 h prior to infiltration, whilst the second group received EMLA to one and placebo to the other of two lesions treated at the same clinic attendance. In neither group was there a clinically useful reduction of discomfort, probably due to inadequate dermal anaesthesia, and we would not, therefore, recommend the routine use of EMLA for this purpose. The most recent evidence suggests that a 2-h application time may give more effective dermal anaesthesia, but this would probably limit its use to occasional problematical cases.

Cutaneous reaction to diltiazem resulting in an exacerbation of angina

A 77-year-old woman developed a widespread erythematous rash after treatment with the calcium antagonist, diltiazem, which resulted in an exacerbation of the angina for which the drug was originally described. Drugs which may give widespread cutaneous side-effects should be used with caution in patients with compromised cardiac function.

Agranulocytosis caused by dapsone therapy for granuloma annulare

Dapsone has been suggested as a useful drug in the treatment of granuloma annulare; however, adverse reactions include a potentially life-threatening agranulocytosis. We report the case of a 50-year-old woman in whom agranulocytosis and septicemia developed after 7 weeks of therapy with dapsone for granuloma annulare. Full recovery followed cessation of this drug, but caution is advised in prescribing dapsone for relatively benign skin conditions.