Fibroblastic rheumatism - case report

Fibroblastic rheumatism is a rare fibro-proliferative disease, of unknown etiology. It is characterized by sudden onset of symmetric inflammatory polyarthritis simultaneously or preceded by multiple cutaneous nodules, ranging from 5 to 20mm in diameter, with predilection for the upper and lower extremities. With only a few dozens of cases described, it has a worldwide distribution, affecting primarily caucasians of all ages (cases described ranging 8 to 68 years), without gender predilection. The authors describe the case of a patient presenting multiple cutaneous nodules located on the back of the hands, without any articular or sistemyc complaints. Correlation between clinical and histopathological aspects led to the diagnosis and treatment, with a favorable outcome.

Multiple glomus tumors and segmental neurofibromatosis: there are no coincidences

Segmental neurofibromatosis is a rare subtype of neurofibromatosis type 1 (NF1). Glomus tumors are uncommon benign tumors. The authors report the association between these two rare conditions, not yet reported.

Nasal septum perforation as the presenting sign of lupus erythematosus

Nasal septum perforation is an uncommon and not well known feature of lupus erythematosus (LE). In general, it occurs during exacerbations and in a context of systemic vasculitis. Very rarely it can be a presenting sign, accompanying more usual manifestations of LE. We report the case of a 30-year-old woman who presented with a 2-year history of painful, slowly progressive nasal septum perforation. Laboratory study disclosed positive antinuclear antibodies, circulating immune complexes, hypocomplementemia, nuclear epidermal deposition of IgG in normal skin and transitory positive antiphospholipid antibodies. Symmetric peripheral joint arthritis, photosensitivity and diffuse alopecia subsequently developed. This case seems unique in that the nasal septum perforation occurred as an isolated presenting sign; it emphasizes the value of this feature in the diagnosis of LE.

Pemphigus vulgaris with nail involvement presenting with vegetating and verrucous lesions

We report the case of a 68-year-old female with longstanding insulin-treated diabetes mellitus, observed for the first time in our department in August 1999 with multiple painful erosive lesions of the oral cavity and many bullous or erosive lesions on the abdominal wall, back, and thigh. She also had vegetating and verrucous lesions, similar to common warts, involving the hands and feet, mainly on the palms, palmar surface of the fingers, and nail folds. Her lesions were present for 1 year. Skin and mucous biopsies showed the characteristic histopathologic findings of pemphigus vulgaris, with an epidermal intercellular IgG deposition on direct immunofluorescence. Histology of a warty lesion of the finger also showed suprabasal acantholysis. After partial improvement with low doses of oral steroids and azathioprine, her disease progressed to involve the oral cavity, trunk, hands, feet, and scalp. Control of her disease required successive treatments of mycophenolate mofetil and cyclophosphamide, as well as corticosteroids. A partial response was obtained with all these treatments. After being controlled by cyclophosphamide that was slowly tapered, she is now well controlled with azathioprine and oral steroids, showing only discrete lesions of the oral mucosa after 1 year of followup. We report this case of pemphigus vulgaris with unusual clinical aspects, namely vegetating and verrucous lesions as well as nail involvement, rarely described in this disease.

Temporal arteritis presenting with scalp ulceration

We report the case of a 75-year-old-woman who presented with bilateral scalp ulcerations and blindness, accompanied by severe headache and scalp tenderness, due to bilateral temporal arteritis without systemic involvement. A biopsy taken from the border of an ulceration showed evidence of giant cell arteritis. She was treated with oral prednisone, 60 mg per day. The ulcerations healed in a few weeks but the vision loss was irreversible. This case highlights for temporal arteritis the importance of accurate and timely diagnosis as well as the need for prompt therapy with systemic steroids in order to avoid major complications, namely loss of vision. It also demonstrates that scalp necrosis and ulcerations are skin signs associated with a poor prognosis.

[Plantar hidradenitis]

Tender, plantar nodules occurring in pediatric patients can be associated to different clinical entities, despite similar morphological features, therefore dermatopathology is the best technique for the definitive diagnosis. We describe the case for a 12-year-old patient with tender, red nodules on the left sole 3 days in duration, and with moderate functional disability. The onset of the lesions was preceded by low fever, and occurred 6 days after hepatitis B vaccination (Engerix B). The clinical diagnoses were juvenile plantar erythema nodosum, insect bites, pressure urticaria and plantar hidradenitis; Laboratory and radiographic studies, as well as microscopic examination of a skin biopsy specimen, were performed. The lesions resolved spontaneously in about 10 days, without recurrence after a year. A skin biopsy specimen revealed dense neutrophilic infiltrate surrounding and involving eccrine glans with abscess formation at the dermal-hypodermal junction. The diagnosis of idiopathic plantar hidradenitis was made. We discuss this entity, recently described by Stahr et al, and other erythematous plantar nodules in the pediatric age.

[The blue rubber bleb nevus syndrome or Bean's syndrome. A rare cause of digestive hemorrhage]

A 71-year-old male who had previously suffered from chronic alcoholism was admitted to the Internal Medicine Service of Coimbra Hospital Center in January 1996 due to asthenia, loss of weight, icterus and abdominal pain, clinical features that had begun six months before admittance to hospital. A physical examination revealed that, in addition to icterus, the patient presented multiple hemangiomas of 1 to 5 cm in diameter, located in the oral cavity, neck, breast and left axilla. These lesions were bluish, elevated and with a rubber-nipple consistency, and had been developing for about 15 years. Subsequent examination revealed normocytic normochromic anemia, cholestatic icterus and the existence of a gastrointestinal hemangioma located in the esophagus. Excisional biopsy of an element proved that it was cavernous hemangioma. A subsequent angio-scintigraphy indicated other aspects suggestive of deep hemangiomas located in the legs, face and cervical region. The authors had the opportunity of examining other members of the patient's family, who apparently did not exhibit similar lesions. They concluded that it was a case of blue rubber bleb nevus syndrome (BRBNS), probably in its sporadic form. Treatment was essentially conservative and the patient is well.

[A skin lymphoepithelial tumor (skin lymphadenoma)]

The study of a case of cutaneous lymphadenoma and a literature review allowed us to verify that, in contrast to immunohistochemical findings, clinical and histological dates are basically reproducible. Accordingly the eccrine or hair follicle natures of the pleonasm cannot be either excluded or confirmed. The initial terms "cutaneous lympho-epithelial tumor" or "epithelial lymphohistiocytic tumor" seem more suitable than that of "cutaneous lymphadenoma" to describe this peculiar skin neoplasm.

Verrucous cyst

A verrucous cyst is an unusual, histopathologically distinctive, epidermoid cyst characterised by verrucous changes in its wall. We report two cases of verrucous cysts in different patients, one on the back and the other on the cheek. Clinically, the lesions were thought to represent an epidermoid cyst and a basal cell carcinoma, respectively. Histologically, we found in both cases an intradermal epidermoid cyst lined by a stratified squamous epithelium with focal cytopathogenic viral changes, consisting of papillomatosis, ortho- and parakeratosis, and hypergranulosis. One case also showed, within the squamous areas of the hyperplastic epithelium, occasional squamous eddies. These histopathological features support the diagnosis of verrucous cyst, which may represent a manifestation of human papillomavirus infection. This virus may induce cyst formation or just infect a pre-existing one.

Oesophageal lichen planus

Lichen planus is a common skin and mucosal disease, with very rare symptomatic oesophageal involvement. We report a case of painful dysphagia due to oesophageal lichen planus in a 60-year-old woman who also had oral, cutaneous and genital lichen planus lesions. Steroid treatment produced considerable improvement of all lesions and a rapid symptomatic remission.

Sebaceous adenitis

A 32-year-old man had an asymptomatic erythematous, annular and circinate eruption on the face for 2 months. Histologic examination revealed sebaceous lobules surrounded by a lymphomonocytic infiltrate and some areas of necrotic sebocytes. The lesions healed without treatment in 1 month. These clinical features can be observed in "neutrophilic sebaceous adenitis," recently described by Renfro et al. The most striking abnormality is the nearly exclusive perisebaceous distribution of the dermal cellular infiltrate with inflammatory cell permeation of the sebaceous epithelium.

Neonatal lupus erythematosus in an infant with Turner syndrome

Neonatal lupus erythematosus (NLE) is characterized by transient, annular cutaneous lesions, congenital heart block, and a variety of systemic or hematologic abnormalities. We describe a white infant girl with onset of skin lesions on the face and scalp at 4 days of age. At age 4 weeks she had generalized, erythematous, scaly, annular skin lesions that underwent spontaneous regression at age 5 months. Her mother had no cutaneous or other lesions, but complement examinations revealed the presence of anti-Ro(SSA) and anti-La(SSB) antibodies, and absence of anti-Sm and anti-RNP antibodies. Karyotyping revealed Turner syndrome (TS) with 45,XO sex chromosome constitution. Ro(SSA) and La(SSB) antibodies were found, and direct immunofluorescence testing on healthy skin was positive. At age 5 months, follow-up immunologic examination of the infant had normal results but the mother still had anti-Ro(SSA) and anti-La(SSB) antibodies. We believe that this is the first reported case of NLE in association with TS.

Tubular apocrine adenoma with eccrine and apocrine immunophenotypes or papillary tubular adenoma?

A case of papillary tubular adenoma is reported. On microscopic examination the lesion, located on the scalp, showed a tubular-branching pattern, opening on the skin surface, and features of decapitation secretion. Immunohistochemical evidence of both eccrine and apocrine differentiation was found. This case, which on a clinicopathological basis alone could be classified as tubular apocrine adenoma, illustrates the difficulties in contrasting the latter to its eccrine counterpart (papillary eccrine adenoma) and suggests that the terms papillary tubular adenoma or tubulopapillary hidradenoma more accurately describe these lesions.

Dermal cylindroma. An immunohistochemical study of thirteen cases

Thirteen dermal cylindromas (DC) have been studied immunohistochemically using a panel of antibodies that stain different portions of normal eccrine and apocrine glands. Distinct staining patterns were found in the different cell populations of the tumor. Although the expression of cytokeratins (CK) 19 and 1/10/11 in occasional duct structures could indicate excretory (ductal) differentiation, a link between DC and apocrine secretory coil is suggested by the expression of alpha-1-antichymotrypsin, lysozyme, human milk factor globulin 1, alpha smooth muscle actin (1A4), and CK 8 and 18. The presence of intermingled S-100 protein-, HLA DR-, and CD1a-positive cells argues for the existence of Langerhans cells within the neoplasm. DC shares epithelial membrane antigen, carcinoembryonic antigen, mucin-like carcinoma-associated antigen (B12), laminin, collagen IV, fibronectin, and CD34(QBEND/10) expression with both eccrine and apocrine glands.

Congenital sensory neuropathy with anhidrosis

A 6-year-old girl had congenital sensory neuropathy with anhidrosis (CSNA), one of the five variants of a group of very rare genetic disorders of the peripheral nervous system--hereditary sensory neuropathies (HSN). Clinical, laboratory, and physiopathologic aspects are discussed. Dermatologic findings of anhidrosis and self-mutilation suggest the diagnosis.

Monoclonal antibody Ber EP4 distinguishes basal-cell carcinoma from squamous-cell carcinoma of the skin

Twenty-two cases of basal-cell carcinoma (BCC) and 21 cases of squamous-cell carcinoma of the skin (SCC) were stained for Ber EP4 using indirect immunofluorescence and avidin-biotin-peroxidase techniques. The results showed that all BCCs were diffusely and intensely labeled, whereas none of the SCCs expressed Ber EP4, irrespective of their histological type or grade of differentiation. This difference may prove useful in (a) histologically differentiating between these two neoplasms; and (b) in clarifying the histogenesis of neoplasms considered to be intermediate between BCC and SCC, or derived from BCC. In addition, because significant differences between the staining of hair follicles and BCC were noted, evaluation for Ber EP4 expression could assist in distinguishing between BCC and hair follicles in Mohs micrographic sections.

Trichilemmal carcinoma: review of 8 cases

Clinical and histological data from 8 trichilemmal carcinomas are reviewed. The tumors occurred mainly on sun-exposed skin of the face of elderly people as small solitary, frequently ulcerated nodules. Histologically, they consisted of multilobulate, infiltrative growths, connected to the epidermis and pilosebaceous structures and showing features reminiscent of the outer root sheath of the hair follicle. The presence of lobules of clear, glycogen-rich cells with peripheral palisading, hyaline basement membranes, trichilemmal keratinization, and abortive follicular sheaths and the absence of ductal or acinar differentiation allow distinction from other clear cell tumors of the skin. Although the histological picture suggests a high-grade malignant neoplasm, trichilemmal carcinoma has an indolent course. No recurrence or metastases have been observed.

Desmoplastic trichilemmoma

Seven cases of desmoplastic trichilemmoma (DT), a recently described pseudomalignant variant of trichilemmoma, are reviewed. The tumor generally occurs in men after the fifth decade of life and presents as a small solitary nodule on the face. It is frequently misdiagnosed clinically as a basal cell carcinoma or a papilloma. Histologically DT displays a superficial lobular growth arranged about a central prominent desmoplastic stroma. At the periphery, the tumor lobules show the typical features of trichilemmoma. In contrast, at the center the cells assume a more random pattern of cords and strands traversed by the hyaline stroma, mimicking invasive carcinoma. The tumor's architectural pattern, in particular the perilobular hyaline mantle, enables DT to be differentiated from basal cell carcinoma and malignant trichilemmoma. Immunohistochemical analysis failed to demonstrate human papilloma virus (HPV), epithelial membrane antigen (EMA), carcinoembryonic antigen (CEA), and alpha-lactalbumin in tumor epithelium. Keratin was expressed by the central pseudoinvasive epithelial cords. Neither factor XIIIa nor keratin expression was found in the stromal cells, which stained only for vimentin. These findings suggest that DT is not an HPV-induced epithelial proliferation and that the stroma is not the result of degenerative changes in tumor epithelium. Instead, there appears to be a fibroblast-mediated, dendrocyte-independent, stromal reaction producing this appearance.

[Dermal nerve sheath myxoma. (Neurothekeoma)]

A 59-year-old male presented with a painful nodule on the interscapular area of 20 year duration. The microscopic examination showed a myxomatous lobulated tumor composed of dendritic fusiform cells with some epithelioid and multinucleated cells typical of a nerve sheath myxoma. Immunohistochemical analysis demonstrated reactivity for S100 protein. Neither factor XIIIa nor epithelial membrane antigen (EMA) expression was found in the tumor cells. These findings suggest a schwannian origin for this tumor.

Nucleolar organizer regions argyrophilic associated proteins in cutaneous melanocytic lesions

We applied a simple silver staining technique to visualize nucleolar organizer regions associated proteins (AgNORs) for the study of 47 melanocytic lesions (20 malignant melanomas, 5 dysplastic nevi, 4 Spitz nevi, 2 Reed and Gartman's fusiform nevi and 16 melanocytic nevi). A statistically significant difference existed between the numbers of AgNORs per cell in benign and malignant lesions as a group. However, some overlapping counts were found, limiting the usefulness of the technique in differentiating benign from malignant lesions in individual cases.