Relapsing Helicobacter cinaedi Cellulitis without Bacteremia in a Patient with X-linked Agammaglobulinemia after 1 Year of Antibiotic Prophylaxis

A 23-year-old man with Bruton's X-linked agammaglobulinemia (XLA), who required intravenous immunoglobulin G (IgG) every 3 weeks, presented with an erythematous scaly eruption adjacent to the chest port for antibiotic therapy (Figures 1A,B). His past medical history included Helicobacter cinaedi cellulitis in 2015 that was treated with intravenous vancomycin and ertapenem with no improvement after several months. The therapy was switched to ertapenem and amikacin, which was also unsuccessful after 1 year. Subsequently, on switching to oral doxycycline for 6 months, he had a 2-year period without skin lesions. He presented to Mount Sinai Hospital in 2019 with 2-day fever and newly appearing skin lesions. (SKINmed. 2022;20:457-459).

Oral lymphangiectasia and gastrointestinal Crohn disease

Lip edema with non-caseating granulomas or lymphangiectasia pose a clinical and pathological challenge. These findings can be attributed to cheilitis granulomatosa (CG), Melkersson-Rosenthal syndrome (MRS), or Crohn disease (CD) depending on the appropriate clinical context. Lymphangiectasis, in particular, is a common pathological finding in CD due to lymphatic obstruction by granulomas and intralymphatic granulomas. Because oral symptoms can precede gastrointestinal symptoms of CD or be seen in patients with asymptomatic gastrointestinal disease, the identification of lymphangiectasia should raise the possibility of underlying CD. We present a case of a young woman with several years of lip swelling, with notable lymphangiectasia and subtle granulomas on pathological evaluation. The patient was diagnosed with MRS at an outside institution and treated with systemic steroids, without further systemic evaluation. We believe that early recognition of lymphangiectasia and consideration of CD early in the work-up are critical for early diagnosis and appropriate management. Neither clinical nor histopathological findings should be used in isolation to diagnose GC, MRS, or CD as there is significant debate as to the etiology and overlapping findings of these conditions. We highlight the importance of lymphangiectasia in diagnosing underlying CD in the appropriate clinical context.

Tumor Necrosis Factor Inhibitor-Induced Psoriasis in a Pediatric Crohn's Disease Patient Successfully Treated with Ustekinumab

BACKGROUND

Tumor necrosis factor (TNF) inhibitors are widely used in pediatric patients with inflammatory bowel disease, as well as psoriasis. However, there is growing evidence that these medications can also paradoxically induce a psoriasiform skin reaction in a subset of patients.

GOALS

We seek to share our experience in treating severe TNF inhibitor-induced psoriasis in a pediatric patient with Crohn’s disease.

STUDY

We report a case of a 10-year-old female with Crohn’s disease, who developed psoriasis after twelve months of infliximab therapy. Her skin disease was recalcitrant to topical therapies, methotrexate, and phototherapy.

RESULTS

The patient was transitioned to ustekinumab with significant improvement in her symptoms and maintenance of remission of her bowel disease.

CONCLUSION

This is the first reported case of a school-age pediatric patient with TNF inhibitor-induced psoriasis treated with ustekinumab. Controlled trials are warranted to fully assess the safety and efficacy of ustekinumab for treating TNF inhibitor-induced psoriasis in the pediatric population.J Drugs Dermatol. 2020;19(3): doi:10.36849/JDD.2020.2106.

What would I tell my intern-year self?

The preliminary year before dermatology training can be the source of much anxiety. However, there are aspects of it that can be rewarding and even fun. Herein, I present some of my own experiences as well as those of colleagues to help relieve stress and hopefully focus on the positive aspects of this busy year and the transition into dermatology training.

Physician burnout in dermatology

Physician burnout is a hot topic today, but what is burnout and who is at risk? In the field of dermatology-one with relatively few emergencies and often modest work hours-does burnout even apply to us? Herein, I provide a working definition of physician burnout and discuss who it affects as well as potential causes in dermatology.

Tattoos: from ancient practice to modern treatment dilemma

Tattoos have a long history in the United States and the world. As dermatologists, we often treat patients who regret their tattoos and are seeking to have them removed. Laser technology allows for more effective tattoo removal. There are many unique risks to tattoo removal compared to general laser procedures, including paradoxical tattoo ink darkening and even allergic reactions to tattoo ink. Given the persistence of tattoos throughout history, this treatment challenge will likely persist for many years to come.

Melkersson-Rosenthal syndrome successfully treated with adalimumab

Melkersson-Rosenthal syndrome (MRS) is a rare syndrome of facial nerve palsy, facial edema, and lingua plicata that can be difficult to treat. We observed a patient with MRS of 4 years' duration that was unsuccessfully treated with multiple therapies. After a variety of diagnoses were considered at outside institutions, including Bell palsy, we diagnosed the patient with MRS based on clinical presentation of the classic triad. Treatment with adalimumab, a tumor necrosis factor α (TNF-α) antibody, showed improvement and relapse-free progress. Further research is needed regarding the role of TNF-α inhibitors in managing this rare condition.

Immune biomarkers are more accurate in prediction of survival in ulcerated than in non-ulcerated primary melanomas

INTRODUCTION

Ulcerated melanomas may have a unique biology and microenvironment. We test whether markers of immune infiltration correlate with clinical outcome in ulcerated compared to non-ulcerated primary melanoma tumors.

METHODS

Sixty-two stage II-III cutaneous melanomas, 32 ulcerated and 30 non-ulcerated, were analyzed for tumor-infiltrating lymphocytes (TILs). Immunohistochemistry (IHC) was performed for CD2, a marker previously shown to correlate with overall survival (OS) and recurrence-free survival (RFS) in this patient population. IHC using antibody, VE1, to BRAF V600E was also performed on a subset of 41 tumors to assess the relationship of BRAF mutation to immune markers.

RESULTS

We found, using Cox regression models, that the presence of TILs was associated with improved OS (p = 0.034) and RFS (p = 0.002) in ulcerated melanoma tumors, but not in non-ulcerated melanoma (p = 0.632, 0.416). CD2 expression also was correlated with improved OS (p = 0.021) and RFS (p = 0.001) in ulcerated melanoma, but no relationship was seen in non-ulcerated melanoma (p = 0.427, 0.682). In this small population, BRAF status did not correlate with TILs or CD2+ count.

CONCLUSION

Our data show that immune markers including TILs and CD2 count correlate more closely with survival in ulcerated melanomas than that in non-ulcerated melanomas. We propose that immune biomarkers may be particularly relevant to ulcerated, as compared to non-ulcerated, melanomas and that this merits study in larger populations.

Requirement for innate immunity and CD90⁺ NK1.1⁻ lymphocytes to treat established melanoma with chemo-immunotherapy

We sought to define cellular immune mechanisms of synergy between tumor-antigen-targeted monoclonal antibodies and chemotherapy. Established B16 melanoma in mice was treated with cytotoxic doses of cyclophosphamide in combination with an antibody targeting tyrosinase-related protein 1 (αTRP1), a native melanoma differentiation antigen. We find that Fcγ receptors are required for efficacy, showing that antitumor activity of combination therapy is immune mediated. Rag1(-/-) mice deficient in adaptive immunity are able to clear tumors, and thus innate immunity is sufficient for efficacy. Furthermore, previously treated wild-type mice are not significantly protected against tumor reinduction, as compared with mice inoculated with irradiated B16 alone, consistent with a primarily innate immune mechanism of action of chemo-immunotherapy. In contrast, mice deficient in both classical natural killer (NK) lymphocytes and nonclassical innate lymphocytes (ILC) due to deletion of the IL2 receptor common gamma chain IL2γc(-/-)) are refractory to chemo-immunotherapy. Classical NK lymphocytes are not critical for treatment, as depletion of NK1.1⁺ cells does not impair antitumor effect. Depletion of CD90⁺NK1.1⁻ lymphocytes, however, both diminishes therapeutic benefit and decreases accumulation of macrophages within the tumor. Tumor clearance during combination chemo-immunotherapy with monoclonal antibodies against native antigen is mediated by the innate immune system. We highlight a novel potential role for CD90⁺NK1.1⁻ ILCs in chemo-immunotherapy.

Dissection of immune gene networks in primary melanoma tumors critical for antitumor surveillance of patients with stage II-III resectable disease

Patients with resected stage II-III cutaneous melanomas remain at high risk for metastasis and death. Biomarker development has been limited by the challenge of isolating high-quality RNA for transcriptome-wide profiling from formalin-fixed and paraffin-embedded (FFPE) primary tumor specimens. Using NanoString technology, RNA from 40 stage II-III FFPE primary melanomas was analyzed and a 53-immune-gene panel predictive of non-progression (area under the curve (AUC)=0.920) was defined. The signature predicted disease-specific survival (DSS P<0.001) and recurrence-free survival (RFS P<0.001). CD2, the most differentially expressed gene in the training set, also predicted non-progression (P<0.001). Using publicly available microarray data from 46 primary human melanomas (GSE15605), a coexpression module enriched for the 53-gene panel was then identified using unbiased methods. A Bayesian network of signaling pathways based on this data identified driver genes. Finally, the proposed 53-gene panel was confirmed in an independent test population of 48 patients (AUC=0.787). The gene signature was an independent predictor of non-progression (P<0.001), RFS (P<0.001), and DSS (P=0.024) in the test population. The identified driver genes are potential therapeutic targets, and the 53-gene panel should be tested for clinical application using a larger data set annotated on the basis of prospectively gathered data.