Malignant Pilomatricoma of the Lower Extremity: A Difficult and Rare Diagnosis

Malignant pilomatricoma is a rare cutaneous malignancy that is commonly found on the head and neck. We present a patient with malignant pilomatricoma of the lower extremity with intralesional calcification and giant cells, confirmed by histopathology. This patient’s case represents a clinically important variation of malignant pilomatricoma in an uncommon anatomical location.

Tropical aquarium aquatic dermatoses: bristle worm envenomation

A 55-year-old high school science teacher with diabetes presented with severe pain and swelling of his left hand. He reported receiving a "shock" 2 days earlier while cleaning out his classroom's aquarium with a bare left hand. Thinking it was a "short" in the electrical connections to the aquarium's pump, he disconnected the electrical cord and continued to clean behind the pump mechanism. After a few more such shocks he put on a glove and retrieved 10 foot-long worms. Antibiotics were started. It took more than 2 weeks for the hand to return to its normal size. On presentation to our office, the patient's left hand was moderately swollen, with blistering and purpura seen on his distal fingers. He reported pain, itching, and numbness in the hand, which was getting worse. No systemic symptoms were reported. The patient was a non-insulin-dependent diabetic who was also taking warfarin for a carotid vascular problem. He brought to our office a bucket with coiled aquatic worms at the bottom (Figure 1). When extended, they measured about 1 foot and their morphology could be better seen (Figure 2). No spicules could be seen in the patient's hand on magnification, but taping was performed to remove any possible residual spicules. The patient was given oral antibiotics, a Medrol dose pack, oral antihistamines, and topical corticosteroids. Within 1 day of starting treatment his symptoms and hand swelling began to abate, by 1 week his hand skin peeled, and by 2 weeks the swelling and skin appearance was almost back to normal. Bacterial cultures of the hand's wounds showed no growth.

Antioxidants in hereditary pancreatitis

OBJECTIVE

The cause of hereditary pancreatitis (HP) remains unknown. This study evaluated the hypothesis that patients with HP have genetically determined low concentrations of antioxidants that may predispose them to repetitive pancreatic injury.

METHODS

This cross-sectional analysis compared antioxidant levels in four groups of patients. Group 1 included 14 related people with chronic pancreatitis. Group 2 (11 individuals) belonged to the same kindred but did not have pancreatitis. Group 3 was a group of 65 unrelated control subjects, and Group 4 consisted of seven unrelated children with chronic pancreatitis from other causes. The antioxidant levels analyzed included glutathione peroxidase, superoxide dismutase, glutathione reductase, glutathione transferase, selenium, and vitamin E. Amylase levels were measured in all patients in groups 1, 2, and 4.

RESULTS

People with chronic pancreatitis or relatives of people with hereditary pancreatitis (groups 1, 2, and 4) had significantly lower mean glutathione peroxidase values than controls (group 3, p < 0.001). Group 1 also had significantly lower selenium levels than groups 2 and 3 (p < 0.001) but greater levels than group 4 (p = 0.029). Vitamin E levels were lower in group 1 than in groups 2 and 4. The superoxide dismutase levels were significantly different between each group (p < 0.001), and group 1 had the highest level. The glutathione reductase, glutathione transferase, and amylase levels did not differ significantly between groups. However, group 1 had a significantly higher glutathione transferase level than group 4.

CONCLUSION

We identified antioxidant deficiencies in a group of patients with hereditary pancreatitis. Higher selenium and vitamin E levels may have prevented their relatives in group 2 from having pancreatitis secondary to oxidant injury, despite low glutathione peroxidase levels. Supplementation with selenium or vitamin E or both may be a beneficial therapeutic option in these patients to decrease the frequency of pancreatitis.

Therapeutic intervention for nonvariceal gastrointestinal hemorrhage

The choice of therapeutic endoscopic technique depends on the training and equipment available to the endoscopist. If the technique is properly performed, the results are similar using injection, thermal coagulation, or laser therapy. We recommended that pediatric endoscopists concentrate on one thermal and one injection technique, since individual bleeding lesions may be more amenable to one method than another based on their anatomic location or briskness of bleeding.

Applications of gastrointestinal endoscopy in infants and children

Gastrointestinal endoscopy has become an integral part of defining and treating gastrointestinal disease in children. Premalignant conditions that have been identified by endoscopy with histologic evaluation include Barrett's esophagus, juvenile polyposis coli, generalized juvenile polyposis, familial polyposis, Gardner's syndrome, and Turcot's syndrome. Advances in endoscopic instrumentation has allowed successful endoscopic retrograde cholangiopancreatography (ERCP) to be performed in infants and children. Therapeutic ERCP has been performed to remove stones, ligate strictures, and place stents. This review focuses on selected advances in gastrointestinal endoscopy and related diseases.

Colonoscopy and therapeutic intervention in infants and children

Colonoscopy is an established procedure for the investigation of large bowel and terminal ileal disease in infants and children. Specific indications vary with the child's age. Preparation and sedation of the pediatric patient and colonoscopy techniques must be tailored to the age and physical stature of the patient.

Alpha interferon therapy in children with chronic active hepatitis B and delta virus infection

Two children with chronic hepatitis B virus and delta virus infection were treated with alpha interferon. Both tolerated the therapy without complications, and one demonstrated clearance of the infection and development of immunity.

The value of the autopsy in congenital heart disease

We reviewed autopsies in 50 consecutive cases of congenital heart disease between 1980 and 1988. Autopsy results were compared to premortem clinical diagnosis. The patients ranged in age from two days to 66.5 years with a mean age of 6.42 years; 68% were less than one year of age. The most common diagnoses were hypoplastic left heart syndrome in 16 (32%) and ventricular septal defect in five (10%). Other common diagnoses included coarctation of the aorta, hypoplastic right heart syndrome, tetralogy of Fallot, transposition of the great vessels and tricuspid atresia. No patient had a missed diagnosis that would have changed survival (Class 1). Four (8%) of the patients had one missed major diagnosis that did not change their survival because they were already being symptomatically treated or because no clinical treatment was available (Class 2). The majority of autopsy derived data were missed minor diagnoses that were related [14 (28%)-Class 3] or unrelated [12 (24%) - Class 4] to the terminal disease process. However, despite the small percentage of autopsy findings that would have directly affected survival, the autopsy provided important additional clinical information in 30 (60%) patients. This information could be used to correct management errors and to develop protocols for prophylaxis against known complications. The pediatric autopsy can provide useful clinical data that may be a guide to altering clinical therapy and is essential in providing genetic counseling.

Reactive annular erythema after intramuscular vitamin K

We present a case of a 70-year-old woman who received multiple intramuscular vitamin K injections before undergoing an invasive diagnostic procedure. Four weeks later she noted enlarging annular erythematous plaques at the sites of each injection. Although this occurrence has been recognized in the European literature, it either occurs less frequently in the United States or is not commonly reported. This is the second case report in the English literature.

Oral lesions in pityriasis rosea

Oral lesions are not commonly reported with pityriasis rosea (PR). We encountered a patient with clinical and histologic evidence of PR who developed aphthous ulcer-like oral lesions on the buccal mucosa, palate, and tongue. The oral lesions resolved concomitantly with the patient's skin lesions. The previous literature reports a wide variety of oral lesions in association with PR, but few dermatologists, to our knowledge, are aware of such an occurrence.