[Acyclovir-resistant perineal HSV infection revealing chronic lymphoid leukaemia]

BACKGROUND

Chronic HSV infection is a cause of chronic perineal ulcerations. We report a case of a chronic and refractory HSV infection revealing chronic lymphoid leukaemia.

PATIENTS AND METHODS

An 85-year-old woman with an 8-month history of chronic perineal ulcerations was referred to our dermatology department. She had no previous medical history of herpes infection. Skin biopsies ruled out carcinoma but were consistent with HSV infection. A local swab was positive for HSV2. Treatment with valaciclovir and intravenous acyclovir (ACV) at the recommended doses was ineffective. Laboratory tests revealed type-B chronic lymphoid leukaemia. Molecular biology studies confirmed the presence of ACV-resistant HSV via decreased thymidine kinase activity (stop codon: M183stop). Foscarnet was administered for a period of 3 weeks with almost complete healing of the ulcerations. Treatment was stopped prematurely due to acute renal insufficiency and the remaining lesions were treated using imiquimod cream. Valaciclovir was prescribed to prevent further episodes. The condition recurred a mere 11 months later.

DISCUSSION

The prevalence of ACV-resistant HSV is 0.32 % in immunocompetent patients and 3.5 % in immunocompromised patients. Insufficient dosing regimens or prolonged treatment with TK inhibitors result in the local selection of pre-existing mutant HSV viruses. Foscarnet, a DNA polymerase inhibitor, is the treatment of choice in HSV-resistant infections. ACV-resistant HSV is less virulent and replicates less, with reactivations being mainly due to wild-type HSV latent in the neural ganglia. Valaciclovir can be used as a preventive treatment. To our knowledge, this is the first case of ACV-resistant HSV infection revealing chronic lymphoid leukaemia.

CONCLUSION

Chronic perineal ulcerations can be the first manifestation of immunodeficiency seen for example with haematological diseases. In the event of clinical resistance of an HSV infection to recommended thymidine kinase inhibitor regimens, the use of foscarnet should be considered.

[Anti-p200 pemphigoid: a spectacular response to dapsone]

BACKGROUND

Types of subepidermal autoimmune bullous dermatosis (AIBD) are classified by anatomoclinical picture and target antigen. A new entity has recently been identified: anti-p200 pemphigoid.

PATIENTS AND METHODS

An 82-year-old man consulted for a profuse pruritic bullous eruption refractory to the standard treatments for bullous pemphigoid (BP). Direct immunofluorescence examination of a skin biopsy revealed linear deposits of IgG and of C3 at the dermal-epidermal junction, but Elisa screening for circulating anti-BP180 and anti-BP230 antibodies was negative. Indirect immunofluorescence (IIF) testing of cleaved skin revealed a deposit of IgG4 antibodies on the dermal side. Immunoblotting was negative for a dermal extract but showed an antibody directed against a 200-kD epidermal antigen. A diagnosis of anti-p200 pemphigoid was eventually made and the patient was successfully treated with dapsone.

DISCUSSION

The diagnosis of anti-p200 pemphigoid was made in this case in spite of discrepancy between the IIF and immunoblotting results, and despite the fact that the target antigen in this disease is considered as being restricted to dermal sites. Anti-p200 pemphigoid usually begins in the second part of life and differs from standard bullous pemphigoid in terms of more frequent mucous membrane and cephalic involvement, as well as a greater degree of miliary scarring. This disease appears more prominent in males and is associated with psoriasis in around one third of cases. Autoantibodies recognize laminin gamma-1, an extra-desmosomal protein that contributes to dermal-epidermal adhesion.

CONCLUSION

This recently described disease as probably under-diagnosed in France. It should be considered in atypical presentations of bullous disease. Diagnosis is confirmed by immunoblotting detection of autoantibodies directed against a 200-kD antigen normally present in the extract. Dapsone appears to be the most effective treatment.

[Recurrent breast cellulitis associated with lymphangiectasia after tumorectomy for breast cancer]

BACKGROUND

Recurrent breast cellulitis has been described as a complication following breast conservation therapy.

OBSERVATION

A 50-year-old woman undergoing tumour excision, postoperative radiotherapy and chemotherapy presented recurrent breast cellulitis in the same region. The presence of lymphangiectasia suggested a complication subsequent to lymph stasis.

DISCUSSION

Conservative therapy for breast cancer, allowing the development of subclinical or patent lymphœdema, constitutes a prominent risk factor for recurrent cellulitis. This complication has also been considered in patients with lower extremity cellulitis following saphenous venectomy for coronary bypass surgery. The unusual presence of lymphangiectasia observed in our patient provides clear evidence that lymphœdema is the most prominent risk factor for the development of cellulitis after breast conservation therapy.

Prevalence and prognostic value of cutaneous manifestations in patients with myelodysplastic syndrome

BACKGROUND

Skin manifestations associated with myelodysplastic syndrome (MDS) may reveal bone marrow transformation into acute myeloid leukaemia.

OBJECTIVE

The objective of this study was to assess the prevalence of skin manifestations associated with MDS. In addition, we evaluated the risk of acute myeloid leukaemia transformation associated with skin manifestations.

METHODS

We studied a cohort of 157 patients with primary MDS followed up prospectively for a median of 44 months. Skin lesions were prospectively assessed as part of medical examination every 6 months by a board certified dermatologist. Survival analyses were performed to assess the association between the presence of skin lesions and the risk of acute myeloid leukaemia.

RESULTS

Fifteen patients (9.55%) experienced skin lesions previously reported as associated with MDS. These were neutrophilic dermatosis (7, 4.46%), specific lesions (5, 3.18%), cutaneous vasculitis (2, 1.27%) and Behçet disease (1, 0.63%). Survival analysis showed that the risk of transformation into acute myeloid leukaemia was slightly but not significantly increased in patients with skin lesions as compared with patients without skin lesions with a relative risk of 2.08 (95% CI 0.92-4.67).

CONCLUSION

The prevalence of skin lesions, mostly neutrophilic dermatosis and specific lesions, is relatively high in patients with MDS. There is a trend for a higher risk of transformation into acute myeloid leukaemia in patients with skin lesions.

Joint clinical and pathological review meetings improve patient care: a prospective evaluation in dermatology

BACKGROUND

Joint clinical and pathological review meeting exists in most academic dermatology departments.

OBJECTIVE

The primary objective of the study was to assess the impact of the joint clinical and pathological review meeting in dermatology on patient care.

METHODS

Prospective descriptive study over 6 months (May to October 2008) on all clinical cases of dermatology reviewed at the joint clinical and pathological review meeting in our University Hospital.

RESULTS

A total of 139 cases were reviewed during the 6-month period. In 97 cases (69.8%), the joint clinical and pathological review meeting had a positive impact on final diagnosis and/or on patient management. For 27 cases, a consensus diagnosis different from the initial proposal was established. In 21 cases, the joint clinical and pathological review meeting led to additional investigations or therapeutic proposals. The impact of the joint clinical and pathological review meeting was highest for inflammatory skin diseases.

CONCLUSIONS

The joint clinical and pathological review meeting is a useful procedure to improve diagnostic accuracy in difficult cases.

[BCG infection of the glans penis after intravesical BCG therapy]

BACKGROUND

BCG therapy is an effective adjuvant treatment for superficial bladder tumors. Therapy involves intravesical instillation of live attenuated Calmette-Guérin bacilli. BCG infection of the glans is a rare local complication associated with this treatment, two cases of which are reported below.

PATIENTS AND METHODS

Case 1: A 77-year-old man presented relapsing urothelial bladder carcinoma treated by endoscopic resection and BCG therapy. One week after the seventh instillation, severe balanitis developed. Three months later, examination revealed massive painful perimeatal ulceration with yellowish papules in the peripheral regions. Histology revealed epithelioid giant-cell granulomas. Ziehl-Neelsen staining was positive. Slow cure of the lesions was achieved within 12months using double antitubercular antibiotic therapy. Case 2: In a 61-year-old man receiving BCG therapy for relapsing bladder carcinoma in situ, the sixth instillation was considered traumatic since it was highly painful. One week later, papular nodules appeared on the glans with a sclerosing lesion of the balanopreputial sac, dark purple perimeatal papules and a mass beneath the mucosa of the glans. Antibiotic treatment comprising ofloxacin followed by rifampicin for two months proved ineffective. Histology revealed granulomatous dermal lesions with eosinophilic necrosis. Triple antitubercular antibiotic therapy was initiated.

DISCUSSION

The first reported case of BCG infection of the glans in patients undergoing intravesical BCG therapy was published in 1992. Since then, there have been nine other reports. There is no stereotypical clinical presentation. In most cases, an infiltrated erythematosus plaque is seen together with yellowish papules in certain patients. Diagnosis is based upon history and histological examination.

Pemphigus vulgaire évolutif sous corticoïdes et immunosuppresseurs: rémission sous rituximab. Deux observations

INTRODUCTION

Pemphigus vulgaris frequently requires corticoids and immuno-suppressive drugs. The disease and the side effects of the drugs severely affect the quality of life, and sometime the vital prognosis of the patients. Other treatments than corticosteroids and immunosuppressive drugs are needed.

EXEGESIS

We report 2 additional cases of pemphigus vulgaris uncontrolled by corticoids and immuno-suppressive drugs that responded spectacularly to rituximab. One patient had a recently onset disease, that was active despite 1,5 mg/kg/day prednisone and 1,5 g/day mycophenolate. She had a complete remission during 15 months after rituximab treatment. At relapse, another rituximab cycle led to a prompt remission. The other patient had longstanding pemphigus vulgaris complicated by cutaneous infections on prednisone (20 mg/d), immunosuppressive drugs and intravenous immune globulins. She had a prompt and complete remission after rituximab.

CONCLUSION

Rituximab seems to be a promising drug for refractory pemphigus vulgaris. The benefit to risk ratio of this drug in this new indication must be precisely documented.

Histological evolution of recurrent basal cell carcinoma and therapeutic implications for incompletely excised lesions

BACKGROUND

It has been proposed that the management of incompletely excised recurrent basal cell carcinomas (BCCs) should depend on their histological appearance, and that nonaggressive recurrent BCCs may not require re-excision.

OBJECTIVES

To determine the histological evolution of recurrent BCCs.

METHODS

In a 14-year retrospective study analysing histological sections of recurrent BCCs, 390 specimens from 191 patients were blindly classified by three physicians into aggressive and nonaggressive types according to Sexton's classification. Initial histological sections were available for 33 of the recurrent BCCs. Descriptive analysis was performed.

RESULTS

Eight of 33 (24%) recurrent BCCs became histologically more aggressive. Four of 20 (20%) originally nonaggressive BCCs became aggressive during recurrence and four of 13 (31%) originally aggressive BCCs showed a more aggressive component during recurrence. These incompletely excised aggressive BCCs were sited in periorbital and perinasal areas and on the cheek, and were re-excised.

CONCLUSIONS

Management of incompletely excised nonaggressive BCCs (nodular or superficial types) is still a matter of debate. Previously reported studies have shown recurrence in < 10% of nonaggressive incompletely excised BCCs. Our study showed that rare recurrences of these initially nonaggressive BCCs showed an aggressive component in 20% of cases. These results suggest that initially nonaggressive incompletely excised BCCs do not require re-excision except if they are located in sites with a poor prognosis.

Virological exploration of individuals with discordant HIV screening tests

Screening for HIV infection can use many algorithms. When two different HIV antibody assays are used, discordant results may occur. To discriminate between HIV seroconversion, HIV variant infection and false positive reactivity, 30 consecutive subjects with two discordant HIV antibody-screening assays were extensively investigated for HIV infection. No subject had HIV seroconversion or reached HIV seropositivity criteria after a follow-up of 3 months. By contrast 36% became HIV negative by the use of both HIV screening assays. p24 Antigen, HIV-1 RNA, HIV-1 DNA, HIV-2 DNA assays and HIV isolation by sensitive culture were unable to identify HIV infection in the 30 subjects with discordant HIV screening assays. The data suggest that the use of two HIV screening assays increase false-positive HIV results without increasing clinical sensitivity. To compliment follow-up of HIV screening, early testing for HIV RNA could be useful to identify or eliminate a recent infection.

[Trigeminal neuralgia presenting as a deep recurrent desmoplastic neurotropic melanoma of a lentigo maligna]

INTRODUCTION

Neurotropic melanoma is a particular anatomopathological form corresponding to dermal proliferation of desmoplastic cells of neuroid differentiation. We report a new case of neurotropic melanoma revealed by facial neuralgia.

CASE REPORT

A 64 year-old man presented in 1996 with a lentigo maligna on the right cheek treated by complete excision. After 2 years of medical supervision, a pigmented lesion recurred leading to new surgical treatment. The histological examination of the total lesion showed intra-epidermal atypical melanocyte proliferation without dermal invasion. In 1999, right trigeminal neuralgia occurred without associated cutaneous change. Cranial MRI revealed an infiltration of the right trigeminal nerve. Endo-buccal surgery disclosed a black swelling of the trigeminal nerve. Histological examination and immunohistochemistry revealed a desmoplastic melanoma.

DISCUSSION

Neurotropic melanoma with nerve invasion by malignant cells presenting as a trigeminal neuralgia is rare. Our case report underlined the depth of the neurotropic melanoma and the initial existence of a lentigo maligna without associated "neurotropic" melanoma.

Oral nicorandil-induced lesions are not aphthous ulcers

OBJECTIVES

(i) To accurately define these lesions determining whether oral nicorandil-induced lesions are aphthous ulcers; (ii) To determine clinical characteristics of oral nicorandil-induced lesions.

MATERIALS AND METHODS

Two slide conferences were held. A total of 60 dermatologists assigned diagnosis and clinical criteria to 11 photographs of oral nicorandil-induced lesions. Two slides were randomly selected and duplicated to be used as control. The panel of slides included independent lesions and photographs of different lesions of the same patient. Statistical analysis used chi2-test, estimation of the percentage interobserver agreement, and kappa-values.

RESULTS

The diagnosis of non-aphthous ulcer (71.8%) was significantly held in comparison with the diagnosis of oral aphthous ulcer (28.2%; P<0.001). To differentiate aphthous ulcer from non-aphthous ulcer, physicians significantly used three clinical criteria. The diagnosis of non-aphthous ulcer were significantly associated with the absence of yellow-based ulceration (P<0.001), with the linear shape (P=0.006) and the absence of inflammatory halo (P=0.003).

CONCLUSION

Oral nicorandil-induced lesions are not aphthous ulcers. We propose that at this stage of our knowledge, oral nicorandil-induced ulcer is the most suitable terminology.

Ivermectin-responsive Demodex infestation during human immunodeficiency virus infection. A case report and literature review

We report the case of a 56-year-old HIV-seropositive man who presented a facial Demodex infection developed 2 months after initiation of highly active antiretroviral therapy. The Demodex infection was confirmed by scrapings and histopathologic examination and by the dramatic response to antiparasitic treatment with oral ivermectin associated with 5% permethrin cream.