Aseptic Pustulosis of the Folds Successfully Treated with Methotrexate

An otherwise healthy 47-year-old woman presented with confluent pustular lesions on the scalp for 5 months and asymptomatic pustular lesions on the trunk and extremities for 2 weeks. She did not have systemic clinical manifestations and was treated with oral antifungals and antibiotics (amoxicillin, and clavulanic acid and flucloxacillin), with no effect. The lesions were unrelated to her menstrual cycle, and she had no history of dermatosis, including acne, psoriasis, or folliculitis. (SKINmed. 2022;20:466-468).

Vasculitic Leg Ulcer Revealing an Essential Thrombocythemia

A 64-year-old man was referred to our department due to painful ulcers on the right leg that had evolved over the previous 6 months. There was also progressive weight loss. He had no relevant medical history. Clinically, we observed multiple ulcers, some of them with a necrotic base, located over the medial malleolus and calcaneus (Figures 1 and 2), with an associated livedoid appearance of the dorsum of the feet. A skin biopsy revealed epidermis with ulceration. The superficial and deep dermis showed perivascular and interstitial neutrophilic inflammatory infiltrate, with fibrinoid necrosis of the vessels as well as leukocytoclasia (Figure 3). Blood analysis showed significant thrombocytosis (1128×10⁶ per µL) and leukocytosis (21.38×10⁶ per µL). The autoimmune study showed no abnormalities. Abdominal ultrasound showed hepatosplenomegaly. The patient was seen in the hematology department, and a bone marrow biopsy was obtained that was compatible with essential thrombocythemia (ET). The patient had a karyotype that showed no metaphases, and was BCR-ABL-negative and JAK2-positive. He started treatment with α-interferon 1.8 million units, three times per week. Daily polyacrylate wound dressing was carried out to debride the skin lesions, and there was gradual improvement of the ulcers (Figure 4).

EGFR Inhibitors-related Panniculitis: A New Side Effect

Epidermal growth factor receptor (EGFR) inhibitors are widely used in the treatment of advanced malignancies, and their skin toxicity is frequent and well recognized in the literature. We report the case of a 69-year-old patient with a history of adenocarcinoma of the lung treated with several EGFR inhibitors and the development of skin lesions compatible with panniculitis. The reproducibility of the lesions with different inhibitors reinforces the causal relationship with the drug, representing the first report in the literature of this side effect.

Perianal purpuric plaques revealing an amyloid light-chain amyloidosis: case report and review of the literature

Systemic immunoglobulin light chain amyloidosis is the most common and severe type of amyloidosis. There is an abnormal fibrillary protein deposition in tissues that leads to progressive and irreversible organ dysfunction. The most commonly affected organs are kidney and heart. Although rare, cutaneous manifestations may be the first clinical sign of the disease and usually present as hemorrhagic lesions, such as purpura, petechiae, and ecchymosis. We present a 71-year-old man that presented to our department because of exuberant purpuric plaques in the anogenital area as the first manifestation of an amyloid light-chain (AL) amyloidosis. The multi-organ involvement in addition to rapid clinical deterioration precipitated the patient's death four months later.

TERT promoter mutations are associated with poor prognosis in cutaneous squamous cell carcinoma

BACKGROUND

Telomerase reverse transcriptase gene (TERT) promoter (TERTp) mutations have been reported as potential predictors of poor prognosis in several cancers, but the prognostic value of TERTp mutations for cutaneous squamous cell carcinoma (cSCC) has not been determined.

OBJECTIVE

To evaluate the frequency of TERTp mutations and correlate it with clinicopathologic features and patient outcome.

METHODS

We performed genetic profiling of TERTp mutations in a retrospective series of cSCCs. The predictive value of TERTp mutations and clinicopathologic parameters were assessed by using logistic regression models.

RESULTS

A total of 152 cSCCs from 122 patients were analyzed for TERTp mutations; the mutation rate was 31.6% (48 of 152), and it was higher in invasive cSCC (42 of 121 [34.7%]) than in in situ cSCC (6 of 31 [19.4%]). Age older than 75 years (odds ratio [OR], 14.84; P = .013] and TERTp mutation (OR, 8.11; P = .002) were independent predictors of local recurrence. TERTp mutation (OR, 15.89; P = .022) was independently associated with higher risk of lymph node metastasis.

LIMITATIONS

The restricted number of metastatic cases.

CONCLUSION

TERTp mutations may prove to be a molecular biomarker with prognostic significance in invasive cSCC, but larger studies are needed.

Pemphigoid gestationis successfully treated with intravenous immunoglobulin

Pemphigoid gestationis (PG), also known as herpes gestationis, is a rare autoimmune blistering disease specific to pregnancy, which usually presents in the second or third trimesters and, in 15%-25% of cases, during the immediate postpartum period.¹Although the ethiopathogeny of PG is not fully clarified, most patients develop antibodies against a 180 kDa transmembrane hemidesmosomal protein (BP180; BPAG2; collagen XVII).² PG has a strong association with human leucocyte antigens DR3 and DR4.³We report a case of a 29-year-old female patient with PG successfully treated with intravenous immunoglobulin.

Glycogenic hepatopathy in young adults: a case series

Glycogenic hepatopathy is a rare and under-recognized complication in long-standing poorly controlled type 1 diabetes mellitus patients. This is a distinct entity from other causes of hepatomegaly and elevated liver enzymes in diabetics, such as nonalcoholic fatty liver disease. Glycogenic hepatopathy is characterized by the combination of poorly controlled diabetes, acute liver injury with marked elevation in serum aminotransferases, and the characteristic histological features on liver biopsy. It is important to distinguish this entity as it has the potential for resolution following improved glycemic control. In this report, we describe four cases of adult patients presenting elevated serum transaminases and hepatomegaly with a history of poorly controlled type I diabetes mellitus. One of the patients had also elevated amylase and lipase in the serum, without clinical or imagiologic evidence of acute pancreatitis (AP). Liver biopsy was performed in all patients and revealed glycogenic hepatopathy. Clinician's awareness of glycogenic hepatopathy should prevent diagnostic delay or misdiagnosis and will provide better insight and management for this condition.

SDHD promoter mutations are rare events in cutaneous melanomas but SDHD protein expression is downregulated in advanced cutaneous melanoma

BACKGROUND

SDHD promoter mutations were reported in 4-10% of cutaneous melanomas. The advanced clinico-pathological and patient survival association with SDHD mutation and/or expression in cutaneous melanoma remains controversial.

OBJECTIVES

To evaluate the presence of SDHD promoter mutations and SDHD protein expression in a melanoma series and its possible association with prognosis and survival of the patients.

METHODS

We assessed SDHD promoter status in cutaneous melanomas (CM), ocular melanomas (OM) and melanoma cell lines, and the expression of SDHD protein by immunohistochemistry in CM and OM, and by western blot in melanoma cell lines. We explored the putative association between SDHD protein expression and clinico-pathological and prognostic parameters of melanoma.

RESULTS

We detected 2% of SDHD promoter mutations in CM, but none in OM and cell lines. SDHD protein expression was present in all CM, in OM and in all CM and OM derived cell lines analysed. A significant association between lower SDHD mean protein expression and presence of ulceration and higher pT stage was found.

CONCLUSIONS

SDHD promoter mutation seems to be a rare event in CM but SDHD lower expression might associate with worst prognostic features in CM.

Cutaneous Richter Syndrome mimicking a lower limb cellulitis infection - a case report and review of the literature

Richter syndrome (RS) is characterized by the development of a high-grade lymphoma in patients with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). Herein, we present the case of an 85-year-old woman with a 3-year history of stable asymptomatic CLL that developed a cutaneous RS. The patient presented with painless inflammation in the left leg and foot that was initially diagnosed as a cellulitis infection. She was treated accordingly with ceftriaxone and clindamycin. However, after completing the antibiotic regimen, not only did the inflammation persist, but also superimposed painless nodules gradually appeared on the left leg and foot over the course of four months. The histopathological examination of the nodules revealed a large B-cell cutaneous lymphoma. The patient underwent chemotherapy with CVP, followed by R-CHOP, resulting in a reduction of size of the nodules and remission of the inflammation. The patient died five months after the diagnosis owing to a bacterial pneumonia. We identified in previous reports a total of fifteen cases of cutaneous RS. Most cases presented with rapidly growing tumors or multiple erythematous nodules, similar to our case. This case of a cutaneous RS mimicking a cellulitis infection underlines the importance of a low threshold for performing biopsies of suspicious skin lesions in patients with CLL/SLL.

Overexpression of pyruvate dehydrogenase kinase supports dichloroacetate as a candidate for cutaneous melanoma therapy

OBJECTIVE

We aimed to verify if there is evidence to consider dichloroacetate (DCA), which inhibits the pyruvate dehydrogenase kinase (PDK) and reverts the metabolic shift of cancer cells from glycolysis to oxidative phosphorylation, as a promising drug for therapy of cutaneous melanoma (CM) patients.

RESEARCH DESIGN AND METHODS

We assessed the expression profile of PDK 1, 2 and 3 in a series of melanoma samples, to verify if melanoma tumors express the DCA targets, if this expression correlates with the activation of important signaling cascades for melanomagenesis and also with the prognosis of melanoma patients. We also established the sensitivity of melanoma cell lines to DCA treatment, by assessing their metabolic alterations, proliferation and survival.

RESULTS

We observed that both PDK 1 and 2 isoforms are overexpressed in CM compared to nevi, this expression being associated with the expression of the mTOR pathway effectors and independent of the BRAF mutational status. Melanoma cell lines treated with DCA showed a shift in metabolism, that is, a decrease in glucose consumption and lactate production, downregulation of proliferation, an increase of apoptosis and a decrease in mTOR pathway activation.

CONCLUSION

Our results suggest that PDK expression may play a role in melanoma development and that DCA can be useful for CM therapy, alone or in combination with mTOR inhibitors.

Oral Lichen Planus in IBD Patients: A Paradoxical Adverse Effect of Anti-TNF-α Therapy

INTRODUCTION AND AIMS

The efficacy of tumor necrosis factor alpha (TNF-α) inhibitors in the treatment of Inflammatory Bowel Disease (IBD) is well established. Many cutaneous and mucosal lesions have been described under anti-TNF-α therapy, some of them being considered as paradoxical. In this series we aimed to review the cases of oral lichen planus (OLP) in IBD patients under treatment with anti-TNF-α agents.

METHODS

Histologic findings from oral lesions of IBD patients treated with anti-TNF were revised.

RESULTS

Three female patients with IBD developed oral lichen planus (OLP) after starting anti-TNF-α therapy. Other etiologies were excluded.

CONCLUSIONS

In light of the increasing use of TNF-α inhibitors the occurrence of OLP is a potentially emerging side effect, thus we recommend a careful monitoring for oral manifestations in IBD patients treated with anti-TNF-α agents.

Photoletter to the editor: Congenital atrichia associated with an uncommon mutation of HR gene

Congenital atrichia (CA) is a rare form of irreversible alopecia with an autosomal recessive mode of inheritance, usually associated with a mutation in the human hairless (HR) gene located at chromosome 8. Papular lesions may develop as an additional phenotypic feature. Herein we describe a case of CA supported by trichoscopy, histology and genetic analysis. The patient's single brother had also universal alopecia. To our knowledge this is the second report of a specific pathogenic mutation (c.2818C>T) of the HR, which until now had only been identified in a family with CA and papular lesions, emphasizing the difficulty to establish a strict correlation between HR genotyping and the phenotype.

[Descamative interstitial pneumonia in a patient with undifferentiated connective-tissue disease]

A 49 year-old Caucasian male, smoker (15 pack-year), had at the beginning of his disease an additive, symmetric polyarthritis, affecting predominantly the small joints of the hands, wrists, shoulders and tibiotarsal joints. The autoimmune study revealed ANA and anti-ribosomal P protein antibodies positivity. An undifferentiated connective tissue disease was diagnosed and treatment with deflazacort, naproxen and hydroxychloroquine was begun. Two years later, he starts exertional dyspnea, without other respiratory symptoms. A chest high-resolution computerized tomography scan was performed, evidencing diffuse "ground-glass" opacities. Respiratory functional study showed low diffusion capacity. The bronchoalveolar lavage (BAL) revealed a neutrophilic and eosinophilic (20%) alveolitis, which was not associated with peripheral blood eosinophilia. The definitive diagnosis was obtained by a surgical lung biopsy, which showed features consistent with Descamative Interstitial Pneumonia (DIP). This rare entity is referred as a smoke-related disease. The debate about an eventual association of DIP with autoimmune diseases and BAL eosinophilia is discussed by the authors based on the present clinical case features.

A recombinant protein-based enzyme immunoassay for IgM antibody to human cytomegalovirus

The reliability of an enzyme-linked immunosorbent assay (ELISA) which used recombinant antigen to detect human cytomegalovirus IgM was studied. Serum samples from each of 283 children aged 5 +/- 2 years were studied. In all samples the anti-IgM antibodies were investigated with the ELISA techniques Enzygnost (Behring) and ETI-Cito (Sorin) which were both based on whole viral particles, and OPUS (Behring) based on recombinant antigen. Of the samples, 254 (89.4%) were negative with all three tests. The 29 remaining samples were positive with one or two of the three techniques. The diagnostic efficacy of Enzygnost, ETI-Cito and OPUS, respectively, was for sensitivity of 50%, 66.7% and 50%, and for specificity of 100%, 95.6% and 96%, respectively. The results with each of the three ELISAs did not differ widely and their diagnostic efficacy was similar. The method based on recombinant antigen was not found to be more effective than tests based on whole viral particles.

Movement disorders and depression due to flunarizine and cinnarizine

Over the last few years, cases of movement disorders induced by flunarizine and cinnarizine have been increasingly reported. We describe a series of 101 patients, whose ages ranged from 37 to 84 years (mean 69.1), developing abnormal movements frequently associated with depression, secondary to treatment with either or both drugs. Symptoms closely resembled those induced by neuroleptic drugs and remitted on drug discontinuance in all but five cases after 5-22 months' follow-up. Whether or not such undesirable side effects are attributable to calcium antagonism and/or dopamine receptor blockade, long-term treatment with flunarizine or cinnarizine should be discouraged, particularly in the elderly.