Mpox Case Presenting With Genital Lesions and Proctitis

ABSTRACT

Monkeypox (Mpox) is a zoonotic Orthopoxvirus of the Poxviridae family, endemic to Africa. In August 2022, the US government declared it an emergency because of the worldwide spread. Traditionally, Mpox infection spreads through contact with infected animals. However, the 2022 outbreak Centers for Disease Control and Prevention (CDC) data note that 94% of cases had recent male-to-male sexual or close intimate contact, suggesting a novel sexual transmission. In this article, we report a 39-year-old HIV-positive man presenting with a diffuse cutaneous rash, perianal pain, and bloody stool of 2-week duration. A medical history includes intravenous drug use and multiple sexual partners. Physical examination revealed umbilicated, tan-colored, crusted cutaneous papules scattered across the face, trunk, and genital regions. Perianal lesion biopsy showed an acanthotic epidermis with spongiosis, ballooning degeneration of keratinocytes, and the formation of multinucleated syncytial keratinocytes. A dermal superficial/lichenoid mixed inflammatory cell infiltrate with multinucleated giant cells was noted. Perianal lesion polymerase chain reaction (PCR) was positive for Mpox. Colonoscopy revealed a 3-cm circumferential rectal ulcer with gray exudate and necrosis. A rectal ulcer biopsy showed an ulcerated mucosa with acute proctitis and necrosis. There were scattered macrophages with intranuclear inclusion and glassy vacuolization, and Mpox infection was confirmed by immunostaining with a Mpox-specific anti-Vaccinia virus antibody.

A Comparison of Preferentially Expressed Antigen in Melanoma Immunohistochemistry and Diagnostic Gene Expression-Profiling Assay in Challenging Melanocytic Proliferations

ABSTRACT

Most melanocytic tumors are classified as benign or malignant based on clinical morphology, histology, and immunohistochemical (IHC) analysis. A subset of more challenging cases with ambiguous features may require further evaluation with established ancillary diagnostic molecular studies, including fluorescence in situ hybridization and/or single nucleotide polymorphism array, to increase diagnostic certainty. More recently, a diagnostic gene expression-profiling (GEP) assay and an IHC stain for the detection of PRAME (PReferentially expressed Antigen in MElanoma) have been developed. The use of PRAME IHC has been validated in cases of unequivocal and ambiguous melanocytic proliferations via comparing results with fluorescence in situ hybridization and/or single nucleotide polymorphism array. A study comparing performance metrics of PRAME IHC and diagnostic GEP has not been previously published. Herein, we evaluated the use of PRAME IHC in 55 melanocytic tumors with challenging histomorphology by comparing the results with diagnostic GEP and final histomorphologic diagnosis. Intertest agreement occurred in 88% of cases. PRAME IHC supported the final diagnosis in 89% of cases with a sensitivity of 79%, specificity of 95%, and positive predictive value of 88.2%. GEP agreed with the final diagnosis in 88% of cases with a sensitivity of 65%, 97% specificity, and positively predicted melanoma in 91.7% of cases. Because the results of this study align with past publications evaluating the performance metrics of PRAME IHC, showing it to be as sensitive as and more cost effective than all other ancillary molecular tests, we propose the use of PRAME IHC as the optimal first-line diagnostic tool for ambiguous melanocytic proliferations.

Acute generalized exanthematous pustulosis associated with clindamycin in a patient with Hailey-Hailey disease

A 61-year-old African-American female with moderately controlled Hailey-Hailey disease (HHD) presents to the emergency department with a rash and fever. One day prior to her presentation, she was started on oral clindamycin for a tooth extraction procedure. Her physical examination shows diffuse erythema on the trunk and extremities with multiple nonfollicular pustules. A punch biopsy of her upper extremity revealed intraepidermal acantholysis, neutrophilic spongiosis, and subcorneal pustules. The perivascular and interstitial superficial dermal infiltrate is mixed and composed of predominantly neutrophils, with lymphocytes and rare eosinophils. These findings suggest a superimposed acute generalized exanthematous pustulosis (AGEP) in the background of HHD. AGEP is a potentially severe cutaneous condition characterized by the abrupt onset of numerous nonfollicular pustules in a background of pruritic edematous erythroderma. To date, only two case reports have described AGEP in patients with HHD. Early diagnosis of AGEP is essential to initiate prompt and aggressive systemic therapy, prompt medication cessation, close monitoring for end-organ damage, and improve overall morbidity and mortality.

Disseminated Protothecosis Due to Prototheca zopfii and Literature Review

ABSTRACT

Prototheca species are achlorophyllic algae that are a rare cause of infection in humans. It most commonly causes localized cutaneous disease and rarely disseminated infection. Immunocompromised patients have the highest risk of disseminated protothecosis, with a higher mortality rate than localized cutaneous infections. At the species level, infections caused by Prototheca zopfii are reported less frequently than those caused by Prototheca wickerhamii. The diagnosis can be made using histopathology, culture, and molecular testing. There is no definitive evidence for an effective treatment, which currently consists of antifungals (primarily amphotericin B). With only a handful of cases of disseminated protothecosis reported worldwide that are caused by P. zopfii , we herein present an additional case of a postbone marrow transplant patient in the Midwest of the United States.

Solitary Vulvar Syringoma With Deep Extension; Potential for Misdiagnosis as the Microcystic Adnexal Carcinoma (MAC)

ABSTRACT

A 43-year-old woman presented with a palpable, pruritic, minimally painful right vulvar lesion. Physical examination revealed approximately 2.0-cm tender nodule at 70' clock in the right labia majora. Histological sections of the excision specimen showed an unremarkable epidermis with large, well-circumscribed dermal proliferation with extension to the reticular dermis. Within this proliferation are small solid and ductal structures relatively evenly distributed in the sclerotic stroma. The epithelial elements consisted of monomorphous cuboidal cells and assumed round, oval, curvilinear, or have other peculiar geometric shapes, including "comma-like" or "tadpole"-like configurations. The tumor cells were positive for CEA, EMA, and estrogen receptor and negative for progesterone receptor. The clinical presentation and the deep extension of the tumor were similar to the microcystic adnexal carcinoma. Although a syringoma generally presents with multiple lesions and usually involves the superficial dermis, a syringoma with deep extension was favored based on the lack of follicular differentiation, atypia, mitoses, and perineural invasion. Microcystic adnexal carcinoma and syringoma have a morphologic overlap and are misdiagnosed in 30% of the cases. Thus, it is exceptionally important for pathologists to be aware of and be able to distinguish these entities. To the best of our knowledge, this is the first case of a solitary, painful vulvar syringoma with deep extension.

A Case of Primary Myelofibrosis With Transformation to Leukemia Cutis

ABSTRACT

We report an extraordinary case of primary myelofibrosis with transformation to leukemia cutis. A 64-year-old Caucasian man with a history of JAK2-positive primary myelofibrosis presented with erythematous papulonodules on his right lower extremity. A punch biopsy revealed a normal epidermis with an underlying diffuse dermal infiltrate composed of medium-to-large-sized myeloid cells and leukocytes. Neoplastic cells were immunoreactive for LCA, CD34, CD61, CD117, and CD68 and negative for lysozyme, CD20, CD3, myeloperoxidase, and TdT. These findings were consistent with a diagnosis of leukemia cutis. A concurrent bone marrow biopsy demonstrated a markedly fibrotic, hypercellular marrow without a significant increase in blasts. With no morphologic evidence of bone marrow involvement by acute myeloid leukemia, our case suggests that the patient's primary myelofibrosis transformed to leukemia cutis. Our patient died 2 months after the onset of his skin nodules. Our case demonstrates that leukemia cutis should be included in the differential diagnosis for cutaneous nodular lesions in patients with a history of an advanced-stage hematological malignancy.

A comparison of imaging software and conventional cell counting in determining melanocyte density in photodamaged control sample and melanoma in situ biopsies

BACKGROUND

Objective methods for distinguishing melanoma in situ (MIS) from photodamaged skin (PS) are needed to guide treatment in patients with melanocytic proliferations. Melanocyte density (MD) could serve as an objective histopathological criterion in difficult cases. Calculating MD via manual cell counts (MCC) with immunohistochemical (IHC)-stained slides has been previously published. However, the clinical application of this method is questionable, as quantification of MD via MCC on difficult cases is time consuming, especially in high volume practices.

METHODS

ImageJ is an image processing software that uses scanned slide images to determine cell count. In this study, we compared MCC to ImageJ calculated MD in microphthalmia transcription factor-IHC stained MIS biopsies and control PS acquired from the same patients.

RESULTS

We found a statistically significant difference in MD between PS and MIS as measured by both MCC and ImageJ software (P < 0.01). Additionally, no statistically significant difference was found when comparing MD measurements recorded by ImageJ vs those determined by the MCC method.

CONCLUSION

MD as determined by ImageJ strongly correlates with the MD calculated by MCC. We propose the use of ImageJ as a time-efficient, objective, and reproducible tool to assess MD.

The functional role of Notch signaling in triple-negative breast cancer

The term "triple-negative breast cancer" (TNBC) is a heterogeneous subtype of breast cancer. Unfortunately, due to the lack of expression of hormone receptors and human epidermal growth factor receptor-2, therefore the lack of US Food and Drug Administration-approved targeted therapies, TNBC has the worst prognosis of all subtypes of breast cancer. Notch signaling has emerged as a pro-oncogene in several human malignancies and has particularly been associated with the triple-negative subtype of breast cancer. This chapter explores the role of Notch signaling in triple negative and other subtypes of breast cancer, the relationship of Notch with other breast cancer biomarkers, prognostic indicators associated with Notch, and potential therapeutic strategies targeting Notch inhibition. Hopefully, better understanding of this signaling pathway in the future will lead to optimal molecular therapeutic treatments for TNBC patients, improving their quality of life and outcome.

Abstract 3135: Notch 1 and notch 4 biomarker expression in triple-negative invasive breast cancer

BACKGROUND: Triple-negative breast cancer (TNBC) is a high-grade tumor showing lack of expression of estrogen and progesterone receptors and human epidermal growth factor receptor (HER-2/neu). Unlike hormone receptor and HER-2/neu positive breast carcinomas, there is no targeted therapy for TNBC. The objective of this study is to investigate Notch 1 and Notch 4 biomarker expression in TNBC and to correlate the expression with known prognostic factors.

DESIGN: We performed a retrospective chart review of 29 TNBC during 1998-2007. Data collected included age at diagnosis, histological type and grade, Ki67 proliferation rate, and patient survival status. Formalin-fixed paraffin embedded tissue blocks from each TNBC was selected. Notch 1 and Notch 4 expression were analyzed by immunohistochemical method (Santa Cruz Biotechnology Inc, USA). The intensity of staining for Notch 1 and 4 expressions and the sub-cellular localization of these receptors (cytoplasmic or nuclear) in tumor epithelial cells and vascular endothelial cells were noted. Only strong cytoplasmic and/or nuclear staining was documented as positive for Notch expression. Student's t test and chi-square test were applied for data analysis.

RESULTS: Age of the patients ranged from 37 to 83 years (mean 57.7). Twenty-seven tumors were infiltrating ductal carcinomas (93.1%) and 2 were infiltrating papillary carcinomas (6.9%). Twenty-one cases were grade 3 (72.4%), 7 were grade 2 (24.2%) and one was grade 1 (3.4%). Unfavorable Ki67 proliferation rate (&gt;20%) was seen in 26 (90%), borderline rate (10-20%) in 2 (6.9%) and favorable rate (&lt;10%) in one (3.1%). Notch 1 expression was evaluable in 25 and Notch 4 in 29 cases. Notch 1 expression was present in 25/25 (100%) cases in tumor cells and in vascular endothelial cells. Notch 4 was expressed in tumor cells in 21/29 (73%) and in vascular endothelial cells in 29/29 (100%). Notch 4 expression was negative in tumor cells in 8/29 (27%) cases. Notch 1 and Notch 4 expression in tumor cells and in vascular endothelial cells are correlated with tumor grade (p&lt;0.05) and Ki67 proliferation rate (p&lt;0.05) in TNBC. Follow-up period ranged from 4-9 years (mean 5.3). Twenty-one patients are alive and well (72.4%), 2 are alive with disease (6.9%), 4 patients died of disease (13.8%), and 2 patients died of causes unrelated to disease (6.9%).

CONCLUSION: This study demonstrates that (1) majority of triple-negative invasive breast cancers are morphologically high grade infiltrating ductal carcinomas with high Ki 67 proliferation rate, (2) both Notch 1 and Notch 4 receptors are over-expressed in tumor cells and in vascular endothelial cells in majority of this molecular subset of breast carcinoma, and (3) this subtype is associated with high overall survival rate with the currently available treatment. Targeting Notch signaling with gamma secretase inhibitors needs to be explored to further improve the survival rate of TNBC patients.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 3135. doi:10.1158/1538-7445.AM2011-3135