[Malignant acanthosis nigricans associated with cholangiocarcinoma]

INTRODUCTION

Acanthosis nigricans is a dermatosis characterized by the presence of a hyperpigmented, velvety cutaneous thickening in the flexural areas, especially axillary and inguinal fossas, and lateral faces of the neck. AN is usually a benign condition but can sometimes reveal an internal malignancy corresponds to a cutaneous paraneoplasic syndrome. Literature shows a predominant association with gastric adenocarcinoma. Here, we report a rare association between AN and cholangiocarcinoma.

CASE REPORT

We report a 43-year-old woman who presented an extensive AN associated to a tripe palms syndrome and florid cutaneous papillomatosis. She consulted in dermatology because of the itchiness of the lesions as well as for esthetics reasons. Complementary investigations enabled to diagnose a cholangiocarcinoma without visceral metastasis and she was treated by tumor resection and chemotherapy. Consequently, a slight improvement of the skin condition and the disappearance of pruritus were observed.

CONCLUSION

AN should be considered as cutaneous sign either of malignancy or endocrinopathy and therefore requires further investigations. The existence of extensive lesions, pruritus, tripe palms syndrome, florid cutaneous papillomatosis or mucous lesions, associated to an AN is a sign of malignancy should be investigated urgently the early diagnosis of which can lead to a better prognosis.

[Non-tuberculous mycobacterial cervical adenitis in children: 2 cases]

BACKGROUND

Cervical lymphadenitis is the most common manifestation of infection with nontuberculous mycobacteria (NTM) in immunocompetent children. Nevertheless, it is poorly known by dermatologists. Its incidence, which is currently increasing since the cessation of BCG vaccination in 2007, raises several issues regarding its pathophysiology, diagnosis and management.

PATIENTS AND METHODS

We report two cases of NTM adenitis: one in a 2-year-old girl vaccinated with BCG and one in an unvaccinated 22-month-old boy, in whom a misleading presentation led to delayed diagnosis. The condition progressed to fistula formation and the diagnosis was finally made on systematic cultures of lymph node samples. The time to diagnosis was 2 and 4months, respectively. The girl was treated with erythromycin for 3 weeks and with clarithromycin for 3 weeks; the boy received clarithromycin for 7 weeks and underwent complete surgical excision.

DISCUSSION

NTM adenitis preferentially affects girls under 4 years and occurs more frequently in winter and spring. First, the other differential diagnoses, including tuberculosis, must be ruled out by chest radiography. The diagnosis is oriented by the clinical picture, a positive TST and resistance to conventional antibiotics. However, it is only certified by systematic culture or PCR of lymph node biopsies, with screening for atypical mycobacteria being specified. The decrease in child protection by BCG vaccination coincides with the current increase in NTM infections, of which the most frequent is Mycobacterium avium complex (MAC) for cervical adenitis. The reference treatment is surgery. However, alternative treatments (incomplete excision, antibiotics, watchful waiting, etc.) should be considered where surgery fails or there is excessive risk of injury to a branch of the facial nerve.

CONCLUSION

Atypical mycobacterial adenitis in immunocompetent children has become an increasingly common infection since the abandonment of BCG vaccination. Improved knowledge of this disease would result in complete surgical excision at an early stage with a lower rate of aesthetic sequelae.

[Metameric macular and papular skin mastocytosis]

BACKGROUND

Mastocytosis is characterised by the presence of abnormal quantities of mastocytes in one or more organs. Although it occurs in systemic forms of mastocytosis, isolated skin involvement is the predominant presentation, particularly in children, in the form of more or less extensive though non-systematic lesions. Herein, we report a case of maculopapular cutaneous mastocytosis that is unusual in terms of its metameric topography.

PATIENTS AND METHODS

A 16-year-old youth presented with an erythematous maculopapular rash of 18 months' duration and involving pruritic inflammatory episodes strictly localised in segment T8 to the left. The skin biopsy showed a significant increase in the number of dermal mastocytes (CD117+). No KIT mutations were found in the skin lesions nor in the unimpaired skin of the opposite side. Further investigations ruled out systemic mastocytis.

DISCUSSION

Herein, we report a case of cutaneous mastocytosis that is unusual in terms of its metameric disposition. There have been only two previous reports of segmental cutaneous mastocytis. The two pathological hypotheses involved precessional dermatitis that renders the skin surface susceptible to homing, and somatic mosaicism (type 1) with local mastocyte proliferation.

Early Detection of Schistosoma Egg-Induced Pulmonary Granulomas in a Returning Traveler

We report the case of a French traveler who developed acute pulmonary schistosomiasis 2 months after visiting Benin. He presented with a 1-month history of fever, cough, and thoracic pain. Initial investigations revealed hypereosinophilia and multiple nodular lesions on chest computed tomography scan. Lung biopsies were performed 2 months later because of migrating chest infiltrates and increasing eosinophilia. Histological examination showed schistosomal egg-induced pulmonary granulomas with ova exhibiting a prominent terminal spine, resembling Schistosoma haematobium. However, egg shells were Ziehl-Neelsen positive, raising the possibility of a Schistosoma intercalatum or a Schistosoma guineensis infection. Moreover, involvement of highly infectious hybrid species cannot be excluded considering the atypical early pulmonary oviposition. This case is remarkable because of the rarity of pulmonary schistosomiasis, its peculiar clinical presentation and difficulties in making species identification. It also emphasizes the need to consider schistosomiasis diagnosis in all potentially exposed travelers with compatible symptoms.

[Acral myxoinflammatory fibroblastic sarcoma: a report of two cases]

Acral myxoinflammatory fibroblastic sarcoma is a rare low-grade malignant soft tissue tumor, usually observed in the extremities of middle-aged adults. We report two cases which occurred in the thumb and knee of middle-aged women. Both tumors showed a multinodular architecture, with cellular areas, occasional foci of hyalinized fibrosis, and hypocellular areas with a myxoid background. Various neoplastic cells were identified including spindled or rounded epithelioid cells and occasional bizarre giant cells, morphologically mimicking Reed-Sternberg cells or ganglion cells. Tumor cells were strongly immunoreactive for vimentin, and variably positive for CD68 and CD34. Both tumors were completely resected and patients were free of disease without any further treatment after a mean follow-up of 14 months.

[Pemphigus vulgaris and intraepithelial neoplasia localized to the vagina]

BACKGROUND

Involvement of the vaginal mucosa in pemphigus vulgaris is a rare occurrence. Here we report an original case that resulted in discovery of intra-epithelial neoplasia at the same site.

PATIENTS AND METHODS

A 63 year-old woman was followed for 18 years for pemphigus vulgaris treated with prednisone, initially in combination with azathioprine. An erosive lesion was discovered in the pouch of Douglas during routine gynecological examination and demonstrated the histological features of pemphigus, despite remission of the disease at other sites. In spite of resumption of azathioprine and prednisone, the vaginal lesion continued to spread. A further biopsy revealed intra-epithelial vaginal neoplasia together with images of suprabasal cleavage and acantholysis. Surgical removal was carried out.

DISCUSSION

Intra-epithelial carcinoma associated with pemphigus vulgaris has been described in rare cases in the cervix but never in the vagina.

Presence of renin, angiotensinogen, angiotensin II in the lamb anterior pituitary gland: immunocytochemical study after cryoultramicrotomy

The presence of renin, angiotensin I-converting enzyme and angiotensin II detected by immunocytochemistry in the adult male rat anterior pituitary has suggested the existence of a pituitary renin-angiotensin system. To establish another mammalian experimental model we have investigated the presence of renin, angiotensinogen, angiotensin I-converting enzyme, and angiotensin II II in five normal lamb anterior pituitaries by immunocytochemistry after cryoultramicrotomy. Renin, angiotensinogen and angiotensin II immunoreactivities were observed only in cytoplasmic granules of lactotrophs, and the three proteins were found co-localized with prolactin in the same granules by double immunolabelling. No immunoreactive angiotensin I-converting enzyme was observed. These results suggest an activation of renin in the cytoplasmic granules of lactotrophs leading to a local synthesis of angiotensin II. Thus, the lamb anterior pituitary may provide a good experimental model for investigating the possible autocrine action of a local renin-angiotensin system on prolactin release in the human pituitary.

A case of temporal arteritis with intrahepatic arterial involvement

We report a case of temporal arteritis associated with anicteric cholestasis. Serial sections of a transthoracic needle biopsy of the liver revealed giant-cell arteritis in medium-sized hepatic arteries and cholangitis in adjacent bile ducts. The literature reveals that similar pathologic features have only exceptionally been observed in liver biopsies. These lesions may account for liver function disturbances commonly seen in temporal arteritis or polymyalgia rheumatica.