Belimumab for the Treatment of Early Diffuse Systemic Sclerosis: Results of a Randomized, Double-Blind, Placebo-Controlled, Pilot Trial

OBJECTIVE

To assess the safety and efficacy of treatment with belimumab in patients with early diffuse cutaneous systemic sclerosis (dcSSc) treated with background mycophenolate mofetil (MMF).

METHODS

In this 52-week, investigator-initiated, single-center, double-blind, placebo-controlled, pilot study, 20 patients with dcSSc recently started on MMF were randomized 1:1 to additionally receive belimumab at 10 mg/kg intravenously or placebo. We assessed safety, efficacy, and differential gene expression.

RESULTS

In the belimumab group, the median modified Rodnan skin thickness score (MRSS) decreased from 27 (interquartile range [IQR] 26.5, 31) to 18 (IQR 11, 23) (P = 0.039). In the placebo group, the median MRSS decreased from 28 (IQR 22, 28) to 21 (IQR 14, 25) (P = 0.023). The median change in MRSS was -10 (IQR -13, -9) in the belimumab group and -3.0 (IQR -15, -1) in the placebo group (P = 0.411). There were no significant differences between the groups in the number of adverse events (AEs). A significant decrease in expression of B cell signaling and profibrotic genes and pathways was observed in patients with improved MRSS in the belimumab group but not in the placebo group.

CONCLUSION

Patients in both treatment groups experienced significant improvements in MRSS. The median difference was greater in the belimumab group but did not achieve statistical significance in this small pilot study. AEs were similar between the groups. Changes in gene expression were consistent with mechanism of action and showed that clinical response to treatment with belimumab is associated with a significant decrease in profibrotic genes and pathways. Additional studies are needed to determine the role of belimumab in the treatment of dcSSc.

Pediatric pustular psoriasis responsive to cyclosporine bridged to etanercept: A treatment approach

Pustular psoriasis occurs rarely in children but can present with acute toxicity requiring inpatient admission. For the best approach, medical providers should have an evidence based and systematic treatment algorithm in their armamentarium. Toillustrate this point, we describe a 13-year-old girl who was admitted with generalized pustular psoriasis and who responded dramatically to "wet wrap" therapy and cyclosporine bridged to etanercept. Using this case example, we highlight the three most important considerations in any patient with new onset pustularpsoriasis: avoidance of disease complications, acute "rescue" therapy, and maintenance therapy.

Pityriasis lichenoides-like drug reaction: A clinical histopathologic study of 10 cases

BACKGROUND

Lymphomatoid drug reactions can mimic endogenous T and B cell lymphoproliferative diseases.

OBJECTIVES

We present a novel form of cutaneous drug reaction with features of pityriasis lichenoides (PL), a recognized form of T cell dyscrasia.

METHODS

Ten cases were studied where a cutaneous eruption exhibiting semblance to PL within a few weeks to months after starting a particular drug.

RESULTS

The patient cohort comprised 7 females and 3 males with the mean age of 60 years. Widely distributederythematous cutaneous lesions were present in 6 cases whereas a more localized distribution was seen in three cases. The most frequently implicated drugsassociated with the eruption were antidepressants and statins. Histologic examination showed a morphologic picture identical to PL including marked epitheliotropism of mildly atypical lymphocytes, psoriasiform epidermal hyperplasia, dyskeratosis, hemorrhage, and a thick parakeratotic scale. Therewas a significant reduction in the expression of CD7 and CD62L amid the T cells. Regression of the eruption occurred in all cases excluding one.

CONCLUSION

Thefindings conform the categorization of this process as a form of T-cell dyscrasia albeit one that is reversible, dependent on the drug withdrawal. The limitationof our study includes the retrospective design of the study.

Eruptive Keratoacanthoma-Like Discoid Lupus Erythematosus

Hypertrophic discoid lupus erythematosus can resemble keratoacanthoma histomorphologically. We describe a unique case of eruptive keratoacanthomatous scaly papules in a 56-year-old woman with discoid lupus erythematosus. We review the literature and conclude by discussing important histologic features and useful immunostains to consider when attempting to discern the underlying identity and pathogenicity of such lesions.

Resolution of a steroid-resistant, hypereosinophilic immune diathesis with mepolizumab and concomitant amelioration of a mixed thrombotic microangiopathy

The anaphylatoxins produced by an unbridled complement cascade in atypical hemolytic uremic syndrome (aHUS) can alter the leukocyte environment in tissues and peripheral blood, causing clinically significant eosinophilia. While the membrane attack complex and C5a anaphlatoxin can be suppressed with anti-C5 biologics, the production of C3a is still capable of driving a destructive hypereosinophilic syndrome in spite of anticomplement therapy. The side-effects of glucocorticoids in treating hypereosinophilic syndrome limit their therapeutic index in long-term treatment and this behooves the use of alternative strategies. While use of the anti-IL-5 antibody, mepolizumab, has been reported for treatment of primary hypereosinophilic syndromes off-label, its usage in the setting of complement-driven thrombotic microangiopathy has not been attempted. We report mepolizumab's rapid resolution of a glucocorticoid-resistant hypereosinophilic syndrome that caused multi-organ dysfunction in a patient with a complex immune diathesis. The patient's long standing TTP/aHUS disease activity, shown to have direct correlation with his eosinophil count, improved with anti-IL-5 therapy, suggesting a reciprocal enhancement between the conditions.

Atrophying pityriasis versicolor as an idiosyncratic T cell-mediated response to Malassezia: A case series

BACKGROUND

Atrophying pityriasis versicolor (PV), first described in 1971, is a rare variant in which lesions appear atrophic.

OBJECTIVE

We sought to determine the pathophysiology of atrophying PV.

METHODS

A retrospective chart review identified 6 cases of atrophying PV. In all cases, routine light microscopy, an elastic tissue stain, and immunohistochemical assessment for the expression of CD3, CD4, CD8, GATA3 and CXCR3 was performed.

RESULTS

All cases demonstrated hyperkeratosis with intracorneal infiltration by pathogenic hyphal forms as well as epidermal attenuation and papillary dermal elastolysis. A supervening, mild-to-moderate, superficial lymphocytic infiltrate was noted and characterized by a focal CD8⁺ T cell-mediated interface dermatitis along with a mixed T-cell infiltrate composed of GATA3⁺ and CXCR3⁺ T cells.

LIMITATIONS

Small sample size and the loss of some patients to follow-up.

CONCLUSION

Atrophying PV represents the sequelae of a mixed helper T-cell (T_H1 and T_H2) idiosyncratic immune response to Malassezia and can present as a protracted dermatosis that may clinically mimic an atypical lymphocytic infiltrate. T_H1 cytokines can recruit histiocytes, a source of elastases, and upregulate matrix metalloproteinase activity, which may contribute to epidermal atrophy.

Onychopapilloma Presenting as Leukonychia: Case Report and Review of the Literature

Onychopapilloma is a benign tumor of the nail bed and distal matrix and is the most common cause of localized longitudinal erythronychia. Here, we describe a case of onychopapilloma presenting as longitudinal leukonychia of the left 4th fingernail in a 71-year-old female. To date, this is only the ninth described case of onychopapilloma presenting as longitudinal leukonychia. We review the literature on the reported cases and provide evidence that longitudinal leukonychia as the presenting sign for onychopapilloma is becoming increasingly recognized in clinical practice.

Recurrent adult onset Henoch-Schonlein Purpura: a case report

Henoch-Schonlein purpura is an immunoglobulin A (IgA)-immune complex mediated leukocytoclastic vasculitis that classically manifests with palpable purpura, abdominal pain, arthritis, and hematuria or proteinuria. The condition is much more predominant in children (90% of cases) and commonly follows an upper respiratory infection. We present a case of recurrent Henoch-Schonlein purpura (HSP) complicated by nephritis in an adult female initially categorized as IgA nephropathy (IgAN). We review the pathophysiologic basis of HSP nephritis as the variant of HSP accompanied by renal involvement and its pathogenetic commonality with IgA nephropathy.

Treatment of metastatic cutaneous Crohn disease with certolizumab

Metastatic Crohn disease is a rare cutaneous manifestation of Crohn disease characterized by granulomatous lesions discontinuous with the diseased areas of the gastrointestinal tract. We report a case of a 32-year-old woman with history of Crohn disease who was admitted for treatment of cellulitis after presenting with a tender erythematous plaque of the left calf. Microbiological tests including tissue cultures were negative. A skin biopsy revealed granulomatous dermatitis consistent with metastatic cutaneous Crohn disease. Owing to concomitant perianal fistulas and abscesses and prior infusion reaction to infliximab, the patient was treated with certolizumab, a pegylated tumor necrosis factor (TNF) inhibitor combined with methotrexate resulting in complete resolution of the skin lesion. This case emphasizes the importance of recognizing this rare skin manifestation of Crohn disease and adds certolizumab as one of TNF inhibitors useful in the treatment of metastatic cutaneous Crohn disease.

Schizophrenia through the carers' eyes: results of a European cross-sectional survey

Schizophrenia is a serious mental disorder affecting approximately 29 million people worldwide. The ideal treatment and care of patients with schizophrenia should be provided by a multidisciplinary 'team' involving psychiatrists, nurses and other healthcare professionals, together with carers and patients. In light of the key role carers play in the care of patients with schizophrenia, the present survey was designed to assess the opinions of family members and friends of patients with schizophrenia across Europe and to ascertain their attitudes towards the illness, medication and adherence to medication. Among carers participating in this survey, there was widespread awareness of the issues involved in supporting patients with schizophrenia and the importance of their role in improving poor adherence to medication. Three differences in opinion emerged between the views of carers and psychiatrists; psychiatrists rely more on the patient themselves when assessing adherence than carers would recommend; in contrast to psychiatrists, many carers believe the illness itself contributes to non-adherence; two thirds of carers think that schizophrenia medication damages health (higher than estimated by psychiatrists). The findings from the present survey, taken together with the results from the Adherencia Terapéutica en la Esquizofrenia surveys of psychiatrists and nurses, support the need for a collaborative approach to the issue of treatment nonadherence. In particular, healthcare professionals should recognize the valuable contribution that family carers can make to improve treatment adherence and consequently clinical outcomes for patients with schizophrenia. Schizophrenia carries a significant burden for families providing care. The Adherencia Terapéutica en la Esquizofrenia (ADHES) carers' survey was designed to assess the opinions of family and friends of patients with schizophrenia across Europe and ascertain their attitudes towards the illness, medication and adherence to medication. A questionnaire-based cross-sectional survey of 138 carers across 16 European countries. Interpretation of results was based on a descriptive comparison of responses. Carers recognized the importance of medication to help patients get better (76%) and improve their quality of life (76%) and relationships (74%). Sixty-seven per cent believed medication damages general health. Sixty-five per cent reported that treatment adherence was a burden for patients. Thirty-eight per cent indicated that it was a daily struggle to get patients to take their medication. Fifty per cent perceived that medication administered every few weeks rather than daily was quite/very important. Ninety-three per cent agreed on the importance of family support to boost adherence, with education and information deemed important for families and patients. Carers rely less on the patient themselves when assessing adherence than psychiatrists. The burden faced by carers and patients in taking medication provides an opportunity for healthcare professionals to provide support in a multidisciplinary 'team' involving psychiatrists, nurses and carers.

Nilotinib (Tasigna™) in the treatment of early diffuse systemic sclerosis: an open-label, pilot clinical trial

Introduction

Tyrosine kinase inhibitors (TKI) are medications of interest in the treatment of Systemic Sclerosis (SSc) because of their ability to inhibit pathways involved in fibrosis. In this open-label pilot trial, our objectives were to assess the safety, efficacy, and molecular change associated with treatment of patients with diffuse cutaneous (dc)SSc with the TKI nilotinib (Tasigna™).

Methods

Ten adult patients with early dcSSc were treated with nilotinib. Primary endpoints were safety and change in modified Rodnan Skin Score (MRSS) after 6 months. Lesional skin biopsies at baseline, 6 and 12 months of treatment were assessed by histopathology, immunohistochemistry, and DNA microarray.

Results

Patients had early and active dcSSc with median disease duration of 0.7 years (range 0.5, 1.7) and increasing MRSS in the month prior to baseline (mean +2.9, p=0.02). Seven out of ten patients completed 6 and 12 months of treatment. Seventy-one adverse events (AEs) including 2 serious AEs were observed, and 92 % of AEs were grade 1-2. Two patients discontinued the medication due to mild QTc prolongation. MRSS improved by a mean of 4.2 points (16 %) at 6 months and by 6.3 points (23 %) at 12 months in the 7 completers, p=0.02 and 0.01, respectively. Patients with a decrease in MRSS >20 % from baseline at 12 months (classified as improvers) had significantly higher expression of transforming growth factor beta receptor (TGFBR) and platelet-derived growth factor receptor beta (PDGFRB) signaling genes at baseline than non-improvers, and the expression of these genes significantly decreased in improvers post-treatment.

Conclusion

Nilotinib was well tolerated by the majority of patients in this study, with tolerability limited primarily by mild QTc-prolongation. Significant MRSS improvement was observed in these early, active patients, but is not conclusive of treatment effect given the open-label study-design and small number of patients in this pilot study. Improvers had higher levels of expression of genes associated with TGFBR and PDGFRB signaling at baseline, and a significant decrease in the expression of these genes occurred only in patients with higher MRSS improvement. The findings of this pilot study warrant more conclusive evaluation.

Trial registration

Clinicaltrials.gov NCT01166139, July 1, 2010.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-015-0721-3) contains supplementary material, which is available to authorized users.

Cutaneous lymphocyte antigen expression loss and PD1 positivity in early cutaneous lesions of rapidly progressive mycosis fungoides

Key Clinical Message

It's important to assess cases both clinically and pathologically for factors potentially predictive of an aggressive clinical course. We concluded that the relative immunosuppressive effects of PD1 may contribute to tumor progression while the lack of staining for cutaneous lymphocyte antigen may be an additional factor facilitating distant extracutaneous migration.

Reed syndrome: an atypical presentation of a rare disease

Reed syndrome, also known as Multiple Uterine and Cutaneous Leiomyomas (MCUL), is an autosomal dominant defect in the fumurate hydrase gene, leading to a predisposition of leiomyomas of the skin and uterus. Patients with Reed syndrome may present with cutaneous leiomyomas, uterine leiomyomas and/or leiomyosarcomas. A 37-year-old woman presented to the dermatology clinic with several subcutaneous nodules. Punch biopsy was performed and the diagnosis of angioleiomyosarcoma with supervening degenerative changes was made. Medical history was positive for uterine leiomyomas. These concomitant findings led to the diagnosis of Reed syndrome. At the present time, genetic counseling is a suggested screening parameter for patients with multiple cutaneous leiomyomas. The superficial nature of these lesions and the low staging made surgical excision the preferred and actual treatment method. Adjunct radiation and chemotherapy have not been shown to provide clear benefit of survival. Owing to an association with renal cell carcinoma, a referral for nephrology consultation is also recommended.

Imatinib mesylate (Gleevec™) in the treatment of diffuse cutaneous systemic sclerosis: results of a 24-month open label, extension phase, single-centre trial

OBJECTIVES

We aimed to assess the long-term safety and tolerability of imatinib in diffuse cutaneous systemic sclerosis (dcSSc).

METHODS

In this open-label, single-arm, extension-phase clinical trial, patients continued imatinib for 24 months following 12 months of initial treatment.

RESULTS

Seventeen patients were enrolled. Forty of 92 adverse events (AE) and 0/6 serious (S) AEs were possibly related to medication. The MRSS decreased from a median of 21 to 16, (p=0.002).

CONCLUSIONS

This study demonstrates long-term safety and tolerability of imatinib in a substantial proportion of patients with dcSSc. This is important in evaluating the relevance of this therapy in a chronic disease such as SSc.

Bowel-associated dermatosis - arthritis syndrome in a patient with ulcerative colitis: an extraintestinal manifestation of inflammatory bowel disease

Bowel-associated dermatosis - arthritis syndrome (BADAS) is a neutrophilic dermatosis characterized by cutaneous lesions that begin as erythematous macules and progress to vesiculopustular eruptions. It has been described in patients with inflammatory bowel disease as well as those who have undergone various intestinal surgeries. Pathologically, the lesions show features of vasculitis without fibrinoid necrosis. In a patient with diagnosed inflammatory bowel disease, these neutrophilic dermatoses should be viewed as external signals of bowel inflammation. Management requires long-term treatment of the underlying disease. We report a case of BADAS in a patient with ulcerative colitis in which the skin lesions were associated with increased colonic inflammation.

A case of generalized eruptive histiocytosis in a 23-year-old man

Generalized eruptive histiocytosis (GEH) is an exceedingly rare type of Factor XIIIA-positive histiocytopathy, characterized by symmetric distribution of red-brown papules on the trunk, proximal extremities, and face. It is diagnosed by the integration of the clinical features, light microscopic findings, and phenotypic profile. Herein, we report an unusual presentation of GEH in a 23-year-old man, who had a striking papular and erythrodermic component to his lesions.

Cutaneous thrombogenic vasculopathy associated with bevacizumab therapy

Bevacizumab, a humanized monoclonal antibody against vascular endothelial growth factor (VEGF), is an angiogenesis inhibitor used to treat a variety of cancers, including lung, colon, cervical, ovarian, and renal cancers as well as glioblastoma. A significant adverse effect associated with its use is one of thromboembolic events. We report a case of a 74-year-old male with diagnosis of glioblastoma multiforme treated with partial resection, radiation, temozolomide, and bevacizumab. He presented to a plastic surgeon with a several week history of asymptomatic crusted hemorrhagic ulcers and purpuric patches on the lower legs shortly following the initiation of bevacizumab. A biopsy showed an occlusive pauci-inflammatory thrombogenic vasculopathy associated with ischemic epidermal and dermal changes and accompanied by extensive vascular C5b-9 (complement C5b-9 membrane attack complex) deposition. Bevacizumab has been associated with thrombotic complications including atypical hemolytic uremic syndrome and arterial and venous thrombosis. C5b-9 may be the factor most important in the mechanism of vascular thrombosis given the extent of deposition in our index case. Thrombotic events in the skin associated with bevacizumab therapy are without precedent and dermatologists should be aware of this potential complication.

Double-positive CD4(+)CD8(+) Sézary syndrome: an unusual phenotype with an aggressive clinical course

Sézary syndrome (SS) is a rare, aggressive form of cutaneous T-cell lymphoma. When patients die from SS, it frequently is due to the sequela of the profound endogenous immunosuppression that is typical of this condition. Most cases of SS represent neoplasms of mature postthymic CD4(+) T cells. We present a case of SS that exhibited an unusual double-positive phenotype in which the neoplastic T cells demonstrated CD4 and CD8 expression. The patient's clinical course was unusually aggressive with rapid clinical demise occurring less than 1 year from the initial cutaneous eruption. Our patient had documented involvement of the skin, peripheral blood, and lymph nodes. We also review other anecdotal reports of postthymic T-cell lymphomas manifesting as a double-positive phenotype primarily in the context of adult T-cell leukemia and T-cell lymphoma. The evolution of the postthymic double-positive T-cell phenotype, especially with regard to SS, and the benign lymphocyte counterpart also is discussed.

Identification of the PTPN22 functional variant R620W as susceptibility genetic factor for giant cell arteritis

OBJECTIVE

To analyse the role of the PTPN22 and CSK genes, previously associated with autoimmunity, in the predisposition and clinical phenotypes of giant cell arteritis (GCA).

METHODS

Our study population was composed of 911 patients diagnosed with biopsy-proven GCA and 8136 unaffected controls from a Spanish discovery cohort and three additional independent replication cohorts from Germany, Norway and the UK. Two functional PTPN22 polymorphisms (rs2476601/R620W and rs33996649/R263Q) and two variants of the CSK gene (rs1378942 and rs34933034) were genotyped using predesigned TaqMan assays.

RESULTS

The analysis of the discovery cohort provided evidence of association of PTPN22 rs2476601/R620W with GCA (PFDR=1.06E-04, OR=1.62, CI 95% 1.29 to 2.04). The association did not appear to follow a specific GCA subphenotype. No statistically significant differences between allele frequencies for the other PTPN22 and CSK genetic variants were evident either in the case/control or in stratified case analysis. To confirm the detected PTPN22 association, three replication cohorts were genotyped, and a consistent association between the PTPN22 rs2476601/R620W variant and GCA was evident in the overall meta-analysis (PMH=2.00E-06, OR=1.51, CI 95% 1.28 to 1.79).

CONCLUSIONS

Our results suggest that the PTPN22 polymorphism rs2476601/R620W plays an important role in the genetic risk to GCA.

Human rhinovirus infections of the lower respiratory tract in hematopoietic stem cell transplant recipients

BACKGROUND

Human rhinoviruses (HRVs) are a common cause of upper respiratory infection (URI) in hematopoietic stem cell transplant (HSCT) recipients; yet, their role in lower respiratory illness is not well understood.

METHODS

We performed a retrospective chart review of HSCT recipients with HRV infection from the time molecular detection methods were implemented at our institution in 2008. Factors associated with proven or possible HRV pneumonia at the first HRV detection were evaluated by univariate and multivariate analysis. We then characterized all episodes of proven and possible HRV pneumonia from the initial HRV infection through a 1-year follow-up period.

RESULTS

Between 2008 and 2011, 63 HSCT recipients had ≥1 documented HRV infections. At first HRV detection, 36 (57%) patients had HRV URI and 27 (43%) had proven or possible HRV pneumonia; in multivariate analysis, hypoalbuminemia (odds ratio [OR] 9.5, 95% confidence interval [CI] 1.3-71.7; P = 0.03) and isolation of respiratory co-pathogen(s) (OR 24.2, 95% CI 2.0-288.4; P = 0.01) were independently associated with pneumonia. During the study period, 22 patients had 25 episodes of proven HRV pneumonia. Fever (60%), cough (92%), sputum production (61%), and dyspnea (60%) were common symptoms. Fifteen (60%) episodes demonstrated bacterial (n = 7), fungal (n = 5), or viral (n = 3) co-infection. Among the remaining 10 (40%) cases of HRV monoinfection, patients' oxygen saturations ranged from 80% to 97% on ambient air, and computed tomography scans showed peribronchiolar, patchy, ground glass infiltrates.

CONCLUSIONS

HRV pneumonia is relatively common after HSCT and frequently accompanied by bacterial co-infection. As use of molecular assays for respiratory viral diagnosis becomes widespread, HRV will be increasingly recognized as a significant cause of pneumonia in immunocompromised hosts.

Generalized spinous follicular lichen nitidus with perifollicular granulomas

The first report of spinous follicular lichen nitidus with perifollicular granulomas was by Madhok and Winkelmann in 1988. Since this report, a few cases of follicular or periappendageal lichen nitidus have been described, in a more localized form or without perifollicular granulomas. We describe a 5-year-old girl with the rare generalized spinous follicular variant of lichen nitidus with perifollicular granulomas.

Interleukin 1 receptor antagonist deficiency presenting as infantile pustulosis mimicking infantile pustular psoriasis

BACKGROUND

Deficiency of interleukin 1 receptor antagonist (DIRA) is a recently described autoinflammatory syndrome of skin and bone caused by recessive mutations in the gene encoding the interleukin 1 receptor antagonist. Few studies have been published about this debilitating condition. Early identification is critical for targeted lifesaving intervention.

OBSERVATIONS

A male infant, born to nonconsanguineous Puerto Rican parents, was referred for management of a pustular eruption diagnosed as pustular psoriasis. At 2 months of age, the infant developed a pustular eruption. After extensive evaluation, he was confirmed to be homozygous for a 175-kb genomic deletion on chromosome 2 that includes the IL1RN gene, commonly found in Puerto Ricans. Therapy with anakinra was initiated, with rapid clearance of skin lesions and resolution of systemic inflammation.

CONCLUSIONS

Recent identification of DIRA as a disease entity, compounded by the limited number of reported cases, makes early identification difficult. It is critical to consider this entity in the differential diagnosis of infantile pustulosis. Targeted therapy with the recombinant human interleukin 1 receptor antagonist anakinra can be lifesaving if initiated early. A high carrier frequency of the 175-kb DIRA-associated genomic deletion in the Puerto Rican population strongly supports testing infants presenting with unexplained pustulosis in patients from this geographic region.

Characterization of Spin on Glass Using Thermo Analytical Techniques and Ftir Spectroscopy

The curing of a commercial ethoxymethyl-phosphosiloxane at different temperatures and under various gas ambients was characterised using NMR, thermoanalytical techniques, and FTIR spectroscopy. DSC (Differential Scanning Calorimetry) and DTG (Differential Thermo Gravimetry) were employed to characterize the reactions that occur during thermal treatments in O2 or N2 atmospheres. FTIR spectroscopy and CP (Cross Polarization) 133C - NMR were used to detect the presence of the hydroxyl and organic groups in the cured samples. The experimental results identified three different temperatures (400,580,700°C) that define important stages of the curing reaction. In particular, for annealing at temperatuires up to 580°C in 02, DSC, DTG and FTIR spectra showed the elimination of the organic groups. However, when the annealing was carried out in N2 up to 700°C, these groups are retained.

Delayed and recurring blisters in the donor graft site of a burn patient

A 79-year-old woman presented for evaluation of non-healing skin graft donor sites. The patient underwent split thickness skin graft repair two-and-a-half years ago as a consequence of severe burns from a fire that affected 10 to 15 percent of her body. Donor sites included her thighs and flanks. After initial healing, intermittent and paroxysmal, eroded and crusted, erythematous plaques have continued to arise at various donor sites. Normal skin has remained uninvolved. Histopathologic analysis showed a poor basement membrane zone. The patient's findings represented delayed and recurring blistering in the donor graft site that is uncommonly observed in burn patients.