Herpes simplex virus type-I and pyogenic granuloma: a vascular endothelial growth factor-mediated association?

Pyogenic granuloma (PG) is a vascular endothelial growth factor (VEGF)-related neoangiogenic process. Minor trauma, chronic irritation, certain drugs and pregnancy may favor PG. Viral triggers have not been reported up to date. A 52-year-old woman with hairy-cell leukemia presented because of a 3-month history of a giant pseudotumoral lesion on her left cheek. All prior antibacterial, antifungal and anti-inflammatory treatments had failed. Histology revealed PG with sparse and isolated epithelial cell aggregates. Immunohistochemistry (IHC) identified herpes simplex virus type-I (HSV-I) antigens in the nuclei and cytoplasm of normal-appearing as well as cytopathic epithelial cells, suggesting a chronic, low-productive HSV infection. No HSV-I signal was evidenced in the endothelial cells of the PG. Furthermore, IHC revealed VEGF in the HSV-I infected epithelial cells as well as within the PG endothelial cells. These results incited oral treatment with valaciclovir, and the PG promptly resolved after 2 weeks. These findings suggest that a chronic HSV-I infection might play an indirect, partial role in neoangiogenesis, presumably via HSV-I infection-related stimulation of keratinocytic VEGF production.

[Hereditary epidermolysis bullosa: clinical and ultrastructural analysis of 21 cases]

Hereditary epidermolysis bullosa (HEB) constitute a genodermatosis group with variable clinical severity. The aim of the study was to confront the diagnosis established by electron microscopy (EM), with the clinical presentation and evolution, genetic analysis and immunofluorescence, and to observe if there was concordance. Biopsies diagnosed as HEB in the last 15 years, were retrieved from the database of the C.H.U. Saint-Pierre EM lab. Each corresponding medical file was reviewed and the following data were recorded: date of birth, sex, age, age at biopsy, ultrastructural characteristics, degree of certainty regarding the EM diagnosis, family history, clinical lesions and their evolution as well as other diagnostic tests performed. 21 patients, aged 1 day to 26 year old were included. A HEB simplex was diagnosed in 10 cases, a junctional EBH in 5 cases and a dystrophic HEB in 6 cases. Immunofluorescence was requested in 4 cases. 7 patients benefited from a genetic analysis. Physical examination revealed hyperpigmented spots in 1 case. A patient with dystrophic HEB had a family history of symptoms restricted to the nails. 4 patients died. In conclusion, the accurate clinical diagnosis of the HEB sub-type is difficult because of the symptomatology heterogeneity. EM remains the gold standard for diagnosis even if immunofluorescence and genetic analysis should be more systematically considered.

[Differential diagnosis of onychomycosis]

Almost 50% of nail pathology is caused by onychomycosis. However, the nail has a limited reservoir of clinical expressions and many conditions may mimic onychomycosis. Its differential diagnosis should be known in order to avoid useless or even toxic treatments. When confronted with ungual alterations restricted to one or some nails, it is fair to evoke onychomycosis but one should keep in mind repeated traumata to the toenails, psoriasis and chronic paronychia on the fingernails. Involvement of a large number of nails, especially all twenty nails, should not first suggest a fungal infection but rather an inflammatory or systemic condition. It is mandatory to always sample the nail for mycological examination before prescribing any systemic treatment.

Nail biology and nail science

The nail plate is the permanent product of the nail matrix. Its normal appearance and growth depend on the integrity of several components: the surrounding tissues or perionychium and the bony phalanx that are contributing to the nail apparatus or nail unit. The nail is inserted proximally in an invagination practically parallel to the upper surface of the skin and laterally in the lateral nail grooves. This pocket-like invagination has a roof, the proximal nail fold and a floor, the matrix from which the nail is derived. The germinal matrix forms the bulk of the nail plate. The proximal element forms the superficial third of the nail whereas the distal element provides its inferior two-thirds. The ventral surface of the proximal nail fold adheres closely to the nail for a short distance and forms a gradually desquamating tissue, the cuticle, made of the stratum corneum of both the dorsal and the ventral side of the proximal nail fold. The cuticle seals and therefore protects the ungual cul-de-sac. The nail plate is bordered by the proximal nail fold which is continuous with the similarly structured lateral nail fold on each side. The nail bed extends from the lunula to the hyponychium. It presents with parallel longitudinal rete ridges. This area, by contrast to the matrix has a firm attachment to the nail plate and nail avulsion produces a denudation of the nail bed. Colourless, but translucent, the highly vascular connective tissue containing glomus organs transmits a pink colour through the nail. Among its multiple functions, the nail provides counterpressure to the pulp that is essential to the tactile sensation involving the fingers and to the prevention of the hypertrophy of the distal wall tissue, produced after nail loss of the great toe nail.

Reliability of Pseudomonas aeruginosa semi-automated rep-PCR genotyping in various epidemiological situations

The purpose of this study was to evaluate the possibility of using a semi-automated repetitive DNA sequences-based polymerase chain reaction (rep-PCR) for typing Pseudomonas aeruginosa isolates. rep-PCR profiles obtained by the DiversiLab system of 84 P. aeruginosa isolates from distinct epidemiological situations were obtained. rep-PCR groupings were in good agreement with the origin of these isolates. Linked rep-PCR profiles were observed for isolates recovered from a same family of cystic fibrosis (CF) patients, for the etiological agents of clustered cases of nosocomial infections, and for some isolates recovered from a same hospital room. rep-PCR and pulsed-field gel electrophoresis SpeI restricted genomic DNA (PFGE-SpeI) profiles were compared. In a few instances, rep-PCR revealed genetic divergences among isolates of a same group of PFGE-SpeI profiles. These divergences could reflect genetic drifts among closely related isolates, as illustrated by those observed between clinical and environmental isolates of a same group of PFGE-SpeI profiles. The interpretation of such differences will require further studies, but the rep-PCR analysis of P. aeruginosa diversity appeared to be an appropriate method to investigate infra-specific genetic relatedness.

Oral ulceration: an unusual manifestation of Churg-Strauss syndrome

Churg-Strauss Syndrome (CSS) is a relatively rare entity characterized by asthma, transient pulmonary infiltrates, eosinophilia and systemic vasculitis. Oral ulceration is a possible clinical manifestation of some systemic vasculitides, such as Wegener's granulomatosis (WG) or giant cell arteritis, but has never been reported with Churg-Strauss syndrome. We report the first observation of a palatine ulceration in a 15-year-old girl with Churg-Strauss syndrome.

Epidermoid carcinoma and perforating necrobiosis lipoidica: a rare association

We report the case of a 33-year-old patient who had had insulin-dependent diabetes mellitus (IDDM) since he was 11 months old, and who presented with major perforating necrobiosis lipoidica (PNL) complicated by a well-differentiated epidermoid carcinoma. PNL is a rare clinical form of NL, always associated with diabetes. Only seven cases have been reported to date in the literature, and to the best of our knowledge, an association of epidermoid carcinoma and PNL has never been described. The development of a tumoral transformation on a classical NL plaque has only been described 12 times. The presence of an epidermoid carcinoma on a weakened background with permanent ulceration suggests that early surgical excision of the tumour and of the NL followed by a skin graft might be the treatment of choice. Radiotherapy seems to be a poor therapeutic option.

Hyperkeratotic nail discoid lupus erythematosus evolving towards systemic lupus erythematosus: therapeutic difficulties

Nail changes occur in about 25% of systemic lupus erythematosus (SLE) cases. Onycholysis has been reported as the most frequent abnormality in SLE. Nailbed hyperkeratosis may be observed in both SLE and discoid lupus erythematosus (DLE). Involvement of the nail apparatus in DLE is extremely uncommon and never restricted to it. We report on a patient in whom the clinical features on the proximal nailfold were similar to those observed on the skin of a patient with typical DLE. This has, to the best of our knowledge, not yet been reported. The patient also exhibited a very distinctive prominent subungual hyperkeratosis. Interestingly, the patient developed biological alterations suggesting a systematization of the disease. Only a combination of systemic corticoids, retinoids and antimalarials was able to achieve nail improvement and this partial resistance to therapy may be explained by the very unusual subungual hyperkeratosis.

Periungual lipoma: About three cases

Lipomas are one of the most common benign soft tissue tumors. The usual development sites are the neck, the torso, and the legs. Lipomas of the nail unit are extremely rare. Only five cases have been reported up to now, four in subungual locations and one in the lateral nail fold. We report three cases of peri-ungual lipomas, one on the digit and two on the toes. Two of them exhibited the histological features of perisudoral lipomas.

[Acquired lymphangiectasias or mammary dermolytic blisters with spontaneous resolution]

INTRODUCTION

Spontaneous occurrence of hemorrhagic blisters on the lower side of the breasts is an unusual clinical presentation of acquired lymphangiectasia.

CASE REPORT

A 64 Year-old and a 85 Year-old woman had developed recurrent bleeding blisters in the sub-mammary region for several Months. Histological, immunohistochemical and electron microscopic examination revealed a subpapillary dermal bullous dehiscence, parallel to the epidermis, which was connected to lymphangiectasias of the superficial dermis. Their extreme dilatation and rupture were probably responsible for the clinical inflammatory and bleeding aspect of the lesions, which have not recurred after 1 and 3 Years, respectively.

DISCUSSION

The presence of subpapillary inflammatory lymphangiectasias might be responsible for recurrent dermal blister formation. The reason for the presence of these hemorrhagic lymphangiectasias, restricted to the sub-mammary location and their spontaneous regression after several flare-ups, remain unclear. The unusual clinical presentation of the lesions observed in these two women constitutes a differential diagnosis of acquired dermolytic blisters.