An unusual case of multiple grouped non-familial trichoepitheliomas

Trichoepitheliomas (TEs) are benign and rare adnexal hamartomas of the pilosebaceous units. Trichoepitheliomas could occur in the setting of an underlying genetic disorder with multiple TEs or as solitary non-hereditary TEs. We report a healthy 32-year-old woman with sporadic multiple clustered and non-segmental TEs without positive family history. There have been two other cases reported in the literature that had non-familial multiple TEs, one was facially disfiguring and the other was in a segmental pattern. Our case has been the only one reported in the English literature which has sporadic, multiple TEs clustered unilaterally and non-segmentally on the trunk.

Generalized fixed drug eruption to piperacillin/tazobactam and review of literature

Fixed drug eruption (FDE) is an adverse drug reaction characterized by the development of well-circumscribed, round, dusky erythematous macules and plaques on cutaneous or mucosal surfaces. The reaction occurs on the same mucosal or cutaneous site with subsequent exposures to the offending drug. Although FDE usually manifests as a single lesion, in rare instances, more than one lesion may arise and this is referred to as a generalized eruption. Herein, we present a 31year-old man with history of cystic fibrosis who developed a generalized fixed drug eruption to piperacillin/tazobactam (Zosyn, Pfizer). We discuss our patient's course and review causes and outcomes of generalized fixed drug eruptions in the literature.

Improving classification of melanocytic nevi: Association of BRAF V600E expression with distinct histomorphologic features

BACKGROUND

A subset of melanomas carrying a B-Raf proto-oncogene, serine/threonine kinase gene (BRAF) V600E mutation, which is the most common targetable mutation in melanoma, arise in association with a melanocytic nevus that is also harboring a BRAF V600E mutation. The detailed histomorphologic characteristics of nevi positive for BRAF V600E have not been systematically documented.

OBJECTIVE

To identify histomorphologic features correlating with BRAF V600E status in nevi.

METHODS

We retrospectively identified melanocytic nevi from our laboratory reporting system. We performed a histomorphologic analysis and analysis of BRAF V600E expression by immunohistochemistry.

RESULTS

Thirteen nevi (14.8%) were negative and 76 (86.4%) were positive for BRAF V600E. The nevi positive for BRAF V600E were predominantly dermal (predominantly dermal growth in 55.3% of nevi positive for BRAF V600E and 15.4% of nevi negative for BRAF V600E [P = .01]) and showed a congenital growth pattern (congenital growth pattern in 51.3% of nevi positive for BRAF V600E and 15.4% of nevi negative for BRAF V600E [P = .02]). Compared with nevi negative for BRAF V600E, those that were positive for BRAF V600E often exhibited predominantly nested intraepidermal melanocytes, larger junctional nests, abrupt lateral circumscription, and larger cell size. Architectural disorder and inflammatory infiltrates were seen more often in nevi negative for BRAF V600E. BRAF sequencing of a subset of nevi confirmed the immunohistochemical results.

LIMITATIONS

Limitations include the study's retrospective design and the small sample size of nevi negative for BRAF V600E.

CONCLUSIONS

BRAF V600E is associated with distinct histomorphologic features in nevi. These features may contribute to improving the accuracy of classification and diagnosis of melanocytic neoplasms.

Classic Ulcerative Pyoderma Gangrenosum Is a T Cell-Mediated Disease Targeting Follicular Adnexal Structures: A Hypothesis Based on Molecular and Clinicopathologic Studies

Background

Pyoderma gangrenosum (PG) is a debilitating ulcerative skin disease that is one of the most common associated diseases seen in patients with inflammatory bowel disease and rheumatoid arthritis. Although PG is classified as a neutrophilic dermatosis, its pathophysiology is poorly understood.

Objective

Use data obtained from patient-reported histories, immunohistochemistry, and gene expression analysis to formulate a hypothesis on PG pathophysiology.

Methods

Ten PG patients participated and answered questions about new ulcer formation. Skin biopsies of healed prior ulcers and adjacent normal skin were obtained from four patients for immunohistochemistry. Scars from healthy patients and patients with discoid lupus were used as additional controls. New onset PG papules were analyzed using immunohistochemistry and gene expression analysis via quantitative real-time PCR.

Results

All PG patients reported that healed sites of previous ulceration are refractory to re-ulceration. Simultaneous biopsies of healed and uninvolved skin triggered ulceration only in the latter. On immunohistochemistry, healed PG scars showed complete loss of pilosebaceous units, which were present in normal skin, and to a lesser extent in control scars, and discoid scars. Early PG papules showed perivascular and peripilosebaceous T cell infiltrates, rather than neutrophils. These early inflammatory events were dominated by increased gene expression of CXCL9, CXCL10, CXCL11, IL-8, IL-17, IFNG, and IL-36G and transcription factors consistent with Th1 phenotype.

Limitations

Small sample size was the main limitation.

Conclusion

We put forth the hypothesis that PG is a T cell response resulting in the destruction of pilosebaceous units.

Psoriasis or not? Review of 51 clinically confirmed cases reveals an expanded histopathologic spectrum of psoriasis

BACKGROUND

Psoriasis is usually diagnosed clinically, so only non-classic or refractory cases tend to be biopsied. Diagnostic uncertainty persists when dermatopathologists encounter features regarded as non-classic for psoriasis.

OBJECTIVE

Define and document classic and non-classic histologic features in skin biopsies from patients with clinically confirmed psoriasis.

METHODS

Minimal clinical diagnostic criteria were informally validated and applied to a consecutive series of biopsies histologically consistent with psoriasis. Clinical confirmation required 2 of the following criteria: (1) classic morphology, (2) classic distribution, (3) nail pitting, and (4) family history, with #1 and/or #2 as 1 criterion in every case RESULTS: Fifty-one biopsies from 46 patients were examined. Classic features of psoriasis included hypogranulosis (96%), club-shaped rete ridges (96%), dermal papilla capillary ectasia (90%), Munro microabscess (78%), suprapapillary plate thinning (63%), spongiform pustules (53%), and regular acanthosis (14%). Non-classic features included irregular acanthosis (84%), junctional vacuolar alteration (76%), spongiosis (76%), dermal neutrophils (69%), necrotic keratinocytes (67%), hypergranulosis (65%), neutrophilic spongiosis (61%), dermal eosinophils (49%), compact orthokeratosis (37%), papillary dermal fibrosis (35%), lichenoid infiltrate (25%), plasma cells (16%), and eosinophilic spongiosis (8%).

CONCLUSIONS

Psoriasis exhibits a broader histopathologic spectrum. The presence of some non-classic features does not necessarily exclude the possibility of psoriasis.

Severe pellagra masked by concurrent plaque psoriasis: a case report of a hidden diagnosis

Despite characteristic features, psoriasis can mimic other dermatologic conditions, such as seborrheic dermatitis, lichen simplex chronicus, and certain nutritional deficiencies such as pellagra. We present a patient with a longstanding history of severe plaque psoriasis who presented with disfiguring scaly plaques involving greater than 80% body surface area. The patient's disease was minimally responsive to multiple therapies. Repeat punch biopsies demonstrated parakeratosis, psoriasiform hyperplasia, and dilated blood vessels consistent with psoriasis. Given atypical clinical features and overall poor treatment response additional work up was obtained. A serum nutritional panel was consistent with niacin deficiency and the patient later revealed extensive alcohol intake. A diagnosis of concurrent pellagra was made and the patient was started on niacin supplementation and instructed to reduce alcohol intake, while continuing adalimumab and high potency topical steroids. Within two weeks, his disease had markedly improved. Pellagra presents characteristically with a photosensitivity dermatitis that may appear clinically and histologically similar to psoriasis. It is important to maintain an index of suspicion for a secondary pathology in treatment-resistant psoriasis.

Malignancy-associated Sweet syndrome: acute febrile neutrophilic dermatosis associated with recurrence of metastatic cervical cancer

We present a rare case of acute febrile neutrophilic dermatosis, also known as Sweet syndrome, associated with recurrence of metastatic cervical cancer. This report highlights similar reports and serves as an important reminder of the relationship between Sweet syndrome and cervical cancer. Increasing awareness of Sweet syndrome assists clinicians in recognizing characteristic findings and encourages evaluation of patients for new-onset or recurrent neoplastic disease. Additionally, we discuss the typical presentation of the syndrome, the proper workup and treatment, and a common pitfall encountered in the diagnosis of Sweet syndrome.

Granuloma inguinale in a 51-year-old man

Granuloma inguinale, or Donovanosis, is a rare, sexually transmitted ulcerative disease primarily affecting the genital area. In this report, we present a case of a 50-year-old man that was diagnosed with granuloma inguinale after a 2-month history of a penile ulcer. Histological analysis demonstrated the presence of Donovan bodies within macrophages, confirming the diagnosis. He was subsequently treated with trimethoprim/sulfamethoxazole with improvement in the ulcer. This case serves as a reminder to clinicians that although granuloma inguinale is rarely encountered in the US, it should still be suspected in patients with non-healing penile ulcers.

100% Complete response rate in patients with cutaneous metastatic melanoma treated with intralesional interleukin (IL)-2, imiquimod, and topical retinoid combination therapy: results of a case series

BACKGROUND

Patients with cutaneous melanoma metastases have experienced excellent responses to intralesional interleukin (IL)-2. This has led to its recent inclusion into the US National Comprehensive Cancer Network guidelines for management of cutaneous melanoma metastases. Despite this, intralesional IL-2 has not been highlighted in the US literature nor have US physicians adopted it.

OBJECTIVE

We sought to evaluate the effectiveness of intralesional IL-2 combined with topical imiquimod and retinoid for treatment of cutaneous metastatic melanoma.

METHODS

A retrospective case series of 11 patients with cutaneous metastatic melanoma were treated with intralesional IL-2 combined with topical imiquimod and retinoid.

RESULTS

A 100% complete local response rate with long-term follow-up (average of 24 months) was seen in all 11 patients treated with this proposed regimen. Biopsy specimens of treated sites confirmed absence of malignant cells. The most common treatment-related adverse event was rigors.

LIMITATIONS

Small number of patients, retrospective review of charts, and lack of a comparison group were limitations.

CONCLUSION

Intralesional IL-2 administered concomitantly with topical imiquimod and a retinoid cream is a promising therapeutic option for managing cutaneous melanoma metastases. The regimen was well tolerated and should be considered as a reasonable alternative to surgical excision.

Locally Advanced Spiroadenocarcinoma in the Regional Axilla of a Breast Cancer Patient: Hallmarks of Definitive Diagnosis and Management

Eccrine spiroadenocarcinoma is an extremely rare malignant eccrine gland tumor which may masquerade as other more common malignancies such as poorly differentiated squamous carcinoma or metastatic breast cancer. We report a case of an ulcerated axillary skin lesion with bulky adenopathy in a 77 year-old female with a prior history of ipsilateral triple negative breast carcinoma. The clear transition of benign spiradenoma to malignant carcinoma was essential to establishing a definitive diagnosis and treatment plan.

Labyrinthine artery aneurysm as an internal auditory canal mass

We present the first case report of a labyrinthine artery aneurysm masquerading as an internal auditory canal tumor. A 72-year-old woman presented with sudden onset right facial paralysis, facial pain, hearing loss, and vertigo. She demonstrated dense right-sided facial paralysis involving all branches of the facial nerve, left beating horizontal nystagmus, and anacusis of the right ear. Magnetic resonance imaging with contrast demonstrated a 6 × 7 mm peripherally enhancing lesion with lack of central uptake filling the right internal auditory canal. The patient elected to proceed with translabyrinthine approach to the internal auditory canal for definitive resection of the mass as well as to decompress the neural structures of the internal auditory canal in an attempt to recover neural function, particularly of the facial nerve. Intraoperatively, the internal auditory canal mass was resected with minimal difficulty, with intraoperative dissection notable for brisk bleeding at the medial base of the tumor just as the tumor was dissected off its medial fibrous attachments. Final pathology of the resected mass revealed a blood vessel with mucinous degeneration of the medial layer of the vessel wall, with immunohistochemical staining confirming the presence and structure of aneurysmal blood vessel.

Multicentric primary extramammary Paget disease: a Toker cell disorder?

Toker cells are epithelial clear cells found in the areolar and nipple areas of the breast, vulvar region, and other apocrine gland-bearing areas of the skin. Toker cells have been implicated in the pathogenesis of clear cell papulosis, cutaneous hamartoma with pagetoid cells, and rare cases of primary extramammary Paget disease (EMPD) but not in secondary EMPD with underlying adenocarcinoma. The pathogenesis of primary EMPD is not well defined. We report a case of multicentric primary EMPD with evidence of Toker cell proliferation and nonaggressive biologic behavior in a 63-year-old white man. A detailed description of the morphologic and biologic features of Toker cells and their possible carcinogenetic links also are discussed. Based on the observation and follow-up of our patient, we hypothesize that multicentric primary EMPD starts with Toker cell hyperplasia and can potentially evolve to carcinoma in the genital region.

Multimodal therapy of idiopathic pyoderma gangrenosum

A 13-year old girl was admitted to the University of California Davis Medical Center for evaluation and treatment of cutaneous bullae and ulcerations over her lower extremities that were refractory to antibiotic therapy and incision and drainage. Her disease continued to worsen with the appearance of multiple new bullae and the progression of old ones into deep ulcers with undermined borders. Biopsy revealed a neutrophilic dermatosis and diagnostic work-up was negative for infectious or autoimmune etiologies. Given her clinical presentation, biopsy results, and negative work-up, a diagnosis of pyoderma gangrenosum (PG) was made and she was started on immunosuppressive medications. The patient was started on a multidrug regimen of prednisone and cyclosporine but remission was not achieved until the addition of adalimumab. After the inflammatory component of her disease was under control, wound care measures were maximized to promote ulcer healing. Wound care measures included compression and debridement. Upon complete closure of all wounds she was successfully transitioned to mycophenolate mofetil monotherapy for maintenance therapy. This case emphasizes the need for combinational therapy to successfully treat severe cases of PG, which are often refractory to monotherapy with prednisone or cyclosporine. It also highlights the importance of appropriate wound care to achieve complete ulcer healing.

Unilateral nevoid telangiectasia syndrome (UNTS) associated with chronic hepatitis C virus and positive immunoreactivity for VEGF

Unilateral Nevoid Telangectasia Syndrome (UNTS) is characterized by superficial telangiectasias in a unilateral distribution. Vascular endothelial growth factor (VEGF) may play a role in the pathogenesis of UNTS in patients with underlying hepatic disease. We report a case of a patient with UNTS accompanied by chronic hepatitis C virus infection, with a normal serum estrogen profile and strong positive immunohistochemical staining of lesional skin with VEGF.

A case of Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) related to rufinamide

Drug Rash (or Reaction) with Eosinophilia and Systemic Symptoms (DRESS) is a potentially life-threatening hypersensitivity reaction to drugs characterized by rash, fever, lymphadenopathy, hematologic abnormalities, and involvement of internal organs. Initially coined in 1996, the term is used to refer to an idiosyncratic reaction to several drugs, the most common of which are carbamazepine, allopurinol, sulfasalazine, and phenobarbital. We report the first case of DRESS related to rufinamide in a ten year old boy with a history of a complex seizure disorder.

ADAM15 deficiency attenuates pulmonary hyperpermeability and acute lung injury in lipopolysaccharide-treated mice

ADAM15 is a disintegrin and metalloprotease recently implicated in cancer and chronic immune disorders. We have recently characterized ADAM15 as a mediator of endothelial barrier dysfunction. Whether this molecule contributes to acute inflammation has not been evaluated. The purpose of this study was to investigate the role of ADAM15 in mediating pulmonary microvascular leakage during acute inflammatory injury. Immunofluorescent staining and Western blotting revealed that the endothelium was the main source of ADAM15 in lung tissue. In a mouse model of acute lung injury induced by lipopolysaccharide (LPS), upregulation of ADAM15 was observed in association with pulmonary edema and neutrophil infiltration. The LPS-induced inflammatory injury, as demonstrated by bronchoalveolar lavage neutrophil count, lung wet-to-dry weight ratio, and myeloperoxidase activity, was significantly attenuated in Adam15(-/-) mice. Studies with primary cell culture demonstrated abundant ADAM15 expression in endothelial cells (ECs) of mouse lung but not in neutrophils. Deficiency of ADAM15 in ECs had no obvious effect on basal permeability but significantly attenuated hyperpermeability response to LPS as evidenced by albumin flux assay and measurements of transendothelial electrical resistance, respectively. ADAM15 deficiency also reduced neutrophil chemotactic transmigration across endothelial barriers in the presence or absence of formyl-methionyl-leucyl-phenylalanine (fMLP). Rescue expression of ADAM15 in Adam15(-/-) ECs restored neutrophil transendothelial migration. These data indicate that ADAM15 upregulation contributes to inflammatory lung injury by promoting endothelial hyperpermeability and neutrophil transmigration.

Congenital self-healing reticulohistiocytosis: concern for a poor prognosis

Congenital self-healing reticulohistiocytosis (CSHRH) is a rare type of Langerhans cell histiocytosis with potential for relapse and systemic involvement. Whereas CSHRH was traditionally considered a benign disease, there is an approximately 3 percent risk of mortality and a 10 percent chance of relapse. This article, using an extensive review of cases since Hashimoto and Pritzker first described the condition in 1973, highlights the various presentations of CSHRH and reveals high rates of relapse and systemic involvement in cases that specifically address features of CSHRH occurring within the first year of life. The findings from this review will highlight the importance of considering LCH in the differential diagnosis when evaluating a neonate with congenital skin eruptions. Timely diagnosis of CSHRH and treatment of systemic involvement may decrease the likelihood of adverse outcomes. These patients may require closer follow-up and monitoring than previously recommended, especially in the first year of life when relapses and systemic involvement occur most frequently.

Cervical carcinosarcoma: a case report

BACKGROUND

Carcinosarcomas are rare neoplasms of the female genital tract. They tend to be highly aggressive and are generally associated with a poor prognosis. Carcinosarcomas of the uterine cervix are extremely rare, with only approximately 35 cases previously reported in English.

CASE

A 68-year-old woman presented with cervical carcinosarcoma. She remained without evidence of recurrent disease for 18 months after surgical resection and pelvic radiation treatment.

CONCLUSION

In a review of all cases reported in the literature, it appears that cervical carcinosarcomas tend to present at an earlier stage than carcinosarcomas of the uterine corpus, therefore allowing early diagnosis and treatment. They may therefore be associated with a better overall prognosis than their counterparts in the corpus. Some studies have shown improved survival of patients of carcinosarcoma of the uterine corpus whose treatment included postoperative radiation and chemotherapy. Due to the better prognosis of cervical carcinosarcomas, we suggest studies to evaluate the role of aggressive, multimodal therapy, with the intent of obtaining a cure of cervical carcinosarcomas.

A rare lethal combination of premature closure of the foramen ovale and d-transposition of the great arteries with intact ventricular septum

We report an infant who presented with cyanosis after birth and was unresponsive to all resuscitative efforts. Emergent echocardiogram showed d-transposition of the great arteries (d-TGA) with an intact ventricular septum. Attempts to perform a bedside balloon atrial septostomy failed due to inability to traverse the atrial septum. Autopsy revealed d-TGA with intact atrial and ventricular septa and patent ductus arteriosus. Though no survivors have been reported for this rare lethal combination of lesions thus far in the literature, we speculate that recent advances in fetal treatment may soon be applicable to infants with this condition.

Primary clear cell adenocarcinoma of the rectovaginal septum treated with concurrent chemoradiation therapy: a case report

Primary clear cell adenocarcinoma of the rectovaginal septum is rare and typically emerges in the setting of endometriosis. We report a case of a 52-year-old woman with clear cell adenocarcinoma of the rectovaginal septum presenting with vaginal hemorrhage. Management with concurrent chemoradiation with cisplatin and paclitaxel is discussed. Six years following the completion of treatment, the patient is without evidence of disease or significant long-term toxicity.

Rhabdomyoblastic pulmonary lesions in a patient with Wilms tumor: choristomas or metastases?

New lesions that occur while patients are receiving treatment for malignant tumors may represent not only difficulties in arriving at the correct diagnosis, but also impact on subsequent therapeutic options. We encountered a patient developing new pulmonary lesions during and after receiving treatment for Stage II Wilms tumor (WT). The presence of mature rhabdomyoblasts in multiple biopsy specimens allowed rational decisions to be made regarding subsequent therapy. This and other published experiences suggest that patients with WT may develop choristomas or have tumors, which undergo cytodifferentiation. Methodologies are now available allowing differentiation of these two processes.

Fibrous Hamartoma of Infancy: A Case Report With Associated Cytogenetic Findings

A 2-month-old male infant presented with a subcutaneous mass on the left middle finger; the mass had been present since birth. This was treated with local excision, and there has been no recurrence. Histology revealed the typical features of a fibrous hamartoma. Cytogenetic studies revealed a reciprocal translocation, t(2;3)(q31;q21), as the sole abnormality. To our knowledge, this is the first report of the cytogenetic findings in fibrous hamartoma, and it suggests that this lesion represents a benign neoplasm.