Stressful life events and pemphigus

BACKGROUND

Stress might be a triggering factor causing pemphigus. We studied 11 consecutive cases of pemphigus over 5 years.

OBJECTIVE

Studying and looking for a link between severe life events and the history of the disease.

METHODS

An epidemiological retrospective and prospective study was carried out, including an interview and a collection of the clinical history; then the life events were integrated into the clinical history with the patient blind. Two scales were used: Paykel's inventory (assessing the negative impact of life events) and the Mini International Neuropsychiatric Interview DSM-IV (MINI).

RESULTS

10 patients out of 11 were included. With the MINI, 2 patients presented anxiety. Paykel's inventory showed type 3 life events for numerous patients, life event type 4 for 7 patients and type 5 for 3 patients, happening from 1 to 6 months before the first signs or worsening of pemphigus. We found stressful life events before the start or worsening of pemphigus for all patients with no other risk factors.

CONCLUSION

Stressful life events can worsen or trigger off a pemphigus. Psychological care, associated with the immunosuppressive treatment, should entail a better management of these patients.

Subcorneal pustulosis and Pyoderma gangrenosum associated with a biclonal gammopathy

Pyoderma gangrenosum and subcorneal pustulosis are two neutrophilic dermatoses. Their occurrence in the same patient is rare and may be related to an IgA dysglobulinemia. We report a case presenting these two conditions associated with a biclonal benign IgA and IgG gammopathy. A 67-year-old man exhibited typical pyoderma gangrenosum associated after three years duration with subcorneal pustulosis lesions, confirmed by cutaneous biopsy. Laboratory results showed a biclonal benign IgA and IgG kappa gammopathy. Therapeutic management was difficult: Pyoderma gangrenosum responded well to corticosteroids but subcorneal pustulosis management was harder and treatments were poorly effective.Pyoderma gangrenosum and subcorneal pustulosis are a part of the neutrophilic spectrum. Their association has been only reported in eleven patients. In eight cases, an IgA dysglobulinemia was associated suggesting its responsibility in the occurrence of both dermatoses. Treatments are various and not fully effective. If the Pyoderma gangrenosum usually responds to corticosteroids, the subcorneal pustulosis treatments are not well defined and often not efficient. Our case illustrates the dissociated evolution of these two dermatoses and their difficult global management. During the follow-up, a regular search for dysglobulinemia is required in order to detect malignant transformations.

Photodynamic action of red light for treatment of erythrasma: preliminary results

BACKGROUND

Erythrasma is a superficial cutaneous infection caused by Corynebacterium minutissimum and is characterized by fluorescence under Wood's light (UV) because of the presence of porphyrins. These molecules are photosensitizing and we propose to assess efficacy of red light that activates porphyrins (photodynamic reaction) in treatment of this pathology.

OBJECTIVES

Assessment of effects of photodynamic action of red light for treatment of erythrasma without exogenous photosensitizing molecules.

METHODS

Thirteen patients with erythrasma were treated by one illumination (80 J/cm2) by red light (broad band, peak at 635 nm) without exogenous photosensitizing molecules. Disappearance or reduction of extent of lesions were observed 2 weeks later. If lesions were still present, a second irradiation was conducted with the same method.

RESULTS

Preliminary results are presented. As a result of red light irradiation, we noticed a complete recovery for three patients and, in most other cases, reduction of extent of lesions (mean: -29% after one session). The treatment was well tolerated.

CONCLUSION

We report first cases of photodynamic treatment of erythrasma. There are other reports of clinical applications of antimicrobial action of photodynamic therapy in dermatology (acne vulgaris, leishmaniasis, warts, etc.). But there are few applications without addition of exogenous photosensitizing agent. The originality and interest of our study is to use spontaneous presence of porphyrins in the lesions. This technique seems to be an interesting alternative, inexpensive and easy, for the treatment of this localized infection. But an optimal method is still to be determined to improve efficacy.

Exanthème maculo-papuleux néonatal révélateur d’une septicémie à Klebsiella pneumoniae par infection maternofœtale

BACKGROUND

Neonatal exanthema of bacterial origin is caused very rarely by Gram-negative bacilli. We report a case of neonatal maculopapular exanthema evocative of Klebsiella pneumoniae septicemia resulting from maternofetal infection.

OBSERVATION

On the fourth day of life, a newborn infant presented incipient morbilliform maculopapular exanthema on the face. During delivery, the mother had presented hyperthermia and meconium was found in the amniotic fluid. Clinical examination of the newborn was normal. No clinically obvious site of entry of infection was seen. Laboratory tests revealed major inflammatory syndrome. Blood cultures were positive for K. pneumoniae, which was also found in blood cultures from the mother. Screening for other causes of infection was negative. Parenteral antibiotics for 10 days yielded favorable results with simultaneous resolution of the exanthema, normalization of laboratory values and negative blood cultures.

DISCUSSION

Exanthemas of infectious origin are not associated with any specific organism. The most common causative micro-organisms are Listeria monocytogenes, B streptococci, colibacilli, and more rarely, staphylococci. There have been reports of a number of cases of neonatal septicemia due to Gram-negative bacilli responsible for maculopapular exanthemas but the causative organism was not identified. To our knowledge, Klebsiella pneumoniae has never been incriminated in the appearance of this type of rash via maternofetal transmission. Consequently, the presence of neonatal exanthema should prompt screening for sepsis, even in the absence of other evocative signs, and in particular in settings of apyrexia.

[Topical haemotherapy as treatment for necrotic angiodermatitis: a pilot study]

INTRODUCTION

Necrotic angiodermatitis is a variety of leg ulcer, characterized by very painful and rapidly spreading lesions. Healing takes time, a mean of 4 to 11 months. Current treatment is difficult and rarely satisfactory. Only early skin grafts lead to rapid sedation of pain and stop the lesion from extending. However, this technique, performed during a progressive phase, enhances the risk of losing a certain number of grafts. We wanted to confirm the efficacy of local auto-haemo-therapy proposed in 2 non-controlled studies.

PATIENTS AND METHODS

Eleven patients with necrotic angiodermatitis were included in our non-controlled prospective study. The topical hemotherapy was applied three times a week for one month, with initial hospitalization for 15 days. The criteria of assessment were: evolution of pain, surface of the ulcer, colorimetric scale and the date of disappearance of the purple halo.

RESULTS

Ten patients were relieved by the treatment, with progressive withdrawal of the analgesics. The progression of the lesion had stopped and the purple halo had disappeared in general by D6 (range: 2 to 21 days). The percentage of granulation tissue with regard to the surface of the ulcer was of 45.4 p. 100 on D0, 80 p. 100 on D14 and 85 p. 100 on D28.

CONCLUSION

Topical hemotherapy applied during the initial phase of treatment would reduce the pain and prepare the lesion for a secondary skin graft.

Carcinome neuroendocrine cutané primitif géant de la jambe

INTRODUCTION

Primitive cutaneous neuroendocrine carcinoma or Merkel cell carcinoma is a tumor characterized by rapid evolution. The size at the time of diagnosis is a mean of 2 to 3 centimeters. We report a case of a particular clinical and anatomopathological presentation.

OBSERVATION

A 76 year-old woman had a voluminous tumoral plaque on the left leg with multiple ulcero-necrotic lesions involving the bone structure without palpable, inguinal lymphadenopathy. The histological and immunocytochemistry examination led to the diagnosis of cutaneous neuroendocrine carcinoma. The normality of the chest, abdominal and pelvis investigations confirmed the primitive cutaneous origin. The patient died a few months later without lymph involvement.

DISCUSSION

To the best of our knowledge, such a presentation of primitive cutaneous neuroendocrine carcinoma has never been reported. The absence of lymphadenopathy despite the tumor volume and extensive skin involvement suggest the hypothesis of a non lymphophilic form of primitive cutaneous neuroendocrine carcinoma. This case report shows that lymphophily depends neither on the tumoral size nor to the degree of differentiation of tumoral cell proliferation, but on biological factors that require specification.

Juvenile xanthogranuloma: a congenital giant form leading to a wide atrophic sequela

Juvenile xanthogranuloma is the most common non-Langerhans cell histiocytosis of infancy and childhood. It is a benign disorder that usually regresses spontaneously, more often without or with limited skin changes. The clinical features are very pleomorphic and recognition of the atypical presentations should facilitate the diagnosis. We report a 9-month-old boy who had an extensive, atrophic lesion on the proximal thigh that followed the course of the congenital giant form. The large size of the lesion does not alter the clinical course or result in extracutaneous involvement, which remains rare. However, uncommon clinical presentations raise the problem of differential diagnosis, requiring biopsy to eliminate other tumors with a less favorable prognosis.

[Lichenoid drug reaction to leflunomide]

INTRODUCTION

Leflunomide (Arava) is an immunomodulator, recently introduced for systemic treatment of rheumatoid arthritis. We report the first case of lichenoid drug reaction due to this drug.

CASE REPORT

A sixty-four year-old woman received leflunomide for rheumatoid arthritis. Two months after initiation of treatment, pruritus and lichenoid papules appeared on her hands and subsequently on her arms and her trunk, with a few bullous lesions. A skin biopsy was evocative for the diagnosis of drug induced lichenoid eruption. The treatment was stopped, and a wash out with colestyramine and topical corticotherapy resulted in dramatic improvement. No relapse was observed. Two months later, patch-tests with leflunomide diluted to 30 p. 100 in white petrolatum were negative.

DISCUSSION

Side effects of leflunomide are frequent, generally benign for the cutaneous features. In our case, the delay, clinical and histological aspect and improvement on withdrawal of the drug emphasize the imputability of leflunomide. Few cases have been reported with others immunomodulators.

[Primitive cutaneous neuroendocrine carcinomas or Merkel's tumor. Clinical and therapeutic aspects in 22 patients]

INTRODUCTION

Primitive cutaneous neuroendocrine carcinoma (PCNC) is a rare tumor with poor prognosis. Surgery is the treatment of choice, but radiotherapy is taking a larger place in the management of these patients.

METHODS

The files of 22 patients were studied retrospectively over a period of 14 years.

RESULTS

The study included 17 women and 5 men with a mean age of 75.5 years. The localization of the tumor was the cephalic extremity in 12 cases. At the initial stage, the tumor in 3 of the 22 patients was of glandular or visceral localization. Thirteen stage I patients were treated surgically. Adjuvant radiotherapy was performed in 10 of these patients and only one relapsed (incomplete initial exeresis). The other three relapsed. Exclusive radiotherapy led to complete response in 4 patients who could not undergo surgery and in 2 with local relapses. Seven patients exhibited glandular involvement and 6 of them died (median 7 months) after the adenopathy had been discovered.

DISCUSSION

Our series illustrates the clinical characteristics of this tumor of the elderly, which is predominantly cephalic and of rapid progression. From a therapeutic point of view, our results underline the benefit of radiotherapy as adjuvant to surgery. When surgery is impossible, and in the case of local relapse, radiotherapy gives good results.

[Rhabdomyosarcoma at site of pacemaker implantation]

BACKGROUND

Malignant proliferation at the site of implantation of a pacemaker generator is uncommon. We report the case of a patient who developed rhabdomyosarcoma.

CASE REPORT

A 85-year-old man presented with a voluminous and rapidly evolving tumor localised beneath the right clavicle. This inflammatory and necrotic lesion developed on the area where a titanium pacemaker had been implanted five years earlier. Rhabdomyosarcoma was diagnosis on the basis of immunohistochemistry findings. In spite of a wide surgical excision of this primitive tumour, visceral dissemination appeared, rapidly leading to the patient's death.

DISCUSSION

This observation rises the question of the role of the pacemaker implantation in tumor development. The excellent in vivo tolerance and the widespread utilization of titanium as biomaterial is an argument against its carcinogenic action. Inversely, a metal-related chronic inflammatory reaction could favor the neoplastic process in predisposed subjects as has been observed with prosthetic materials used in orthopaedics.