Primary effusion lymphoma with skin involvement

Primary effusion lymphoma (PEL) was once defined as a body cavity-based lymphoma without identifiable contiguous tumour mass, but is now recognised as an independent clinicopathological entity. The case of a 67-year-old Japanese woman with PEL is reported, in which the clinical findings showed a pericardial effusion and multiple erythema on the hypogastrium and inguinal region. The histopathological findings showed a diffuse infiltration of large neoplastic B cells from the dermis to the subcutis. After the disappearance of pericardial effusion without any treatment, she received several rounds of chemotherapy to resolve the skin eruption, but she finally died from multiple organ failure. No tumour mass was observed during the course of her disease.

Evidence for polyclonal infection of Epstein-Barr virus in a patient with primary cutaneous anaplastic large cell lymphoma

We report a case of CD30 + primary cutaneous anaplastic large cell lymphoma. The lymphoma cells were shown to express the Epstein-Barr virus (EBV)-encoded small RNAs by in situ hybridization and to have EBV genomes by PCR, whereas no monoclonal band was detected by Southern blot analysis using the EBV terminal repeat probe. These data suggested polyclonal infection by EBV, which provides evidence that EBV plays little part in the pathogenesis of this tumour even in the infected cases.

Extramammary Paget's disease with superimposed herpes simplex virus infection: immunohistochemical comparison with cases of the two respective diseases

We describe an extremely rare case of genital Paget's disease with superimposed herpes simplex virus (HSV) infection. We also describe immunohistochemical comparison of this lesion with 19 cases of genital Paget's disease and 12 cases of skin lesions caused by HSV or varicella-zoster virus. The Paget cells expressed simple epithelial keratins (CK7 and CK19) and carcinoembryonic antigen (CEA), but did not express stratified epithelial keratins (CK1, CK2e, CK10, CK5/8, CK14). Conversely, the virus-infected keratinocytes were positive for stratified epithelial keratins but negative for simple epithelial keratins and CEA. In the present case, simple epithelial keratins, stratified epithelial keratins, CEA and HSV were heterogeneously expressed in the ballooning and multinucleated giant cells. These results suggest that these cells were derived from keratinocytes and Paget cells and that the production of many multinucleated giant cells resulted from the virus-mediated cell fusion between Paget cells and neighbouring keratinocytes.

An immunohistochemical and ultrastructural study of syringocystadenoma papilliferum

BACKGROUND

Syringocystadenoma papilliferum is a benign hamartomatous tumour of the skin. The histogenesis of this tumour is still controversial. There have been few reports regarding immunohistochemical investigations using only a limited range of antibodies and ultrastructural studies on this rare tumour.

OBJECTIVES

To elucidate the immunohistochemical and ultrastructural properties of this tumour.

METHODS

We investigated the immunohistological patterns of 12 different anticytokeratin (CK) antibodies and several other markers in five cases of this tumour, comparing them with the patterns in adult sweat glands. One of these cases was also evaluated ultrastructurally.

RESULTS

The luminal columnar cells of the tumour were mostly positive for CK7 and more than 70% were positive for CK19. These cells showed the heterogeneous expression of CK1/5/10/14, CK14 and CK5/8. These patterns were also observed in the luminal cells in the secretory or the ductal portion of the adult sweat glands. The basal cuboidal cells of the tumour almost constantly expressed CK1/5/10/14, CK5/8, CK14 and CK7 (except for one case), similar to the patterns of basal cells in the transitional portion and myoepithelial cells in the sweat glands. However, the basal tumour cells expressed CK19 and vimentin heterogeneously, and alpha-smooth muscle actin focally (three cases). Ultrastructurally, the constituent epithelial cells were mainly divided into three types: luminal cells, basal cells and clear cells. The luminal tumour cells bore features of the secretory or ductal luminal cells of sweat glands, although they were somewhat immature in appearance. The basal tumour cells were fundamentally basaloid in nature. The clear cells were undifferentiated or primitive in appearance, suggesting stem or progenitor cell properties. Transitional forms between the clear cells and the other two cell types were also identified.

CONCLUSIONS

The tumour epithelium was composed of several cell types demonstrating various developmental stages from the primitive clear cells to the basal cells demonstrating a tendency to differentiate toward basal cells in the apocrine transitional portion or myoepithelial lineage, or luminal cells toward the ductal or secretory epithelium. These results support the classical concept that syringocystadenoma papilliferum is a hamartomatous tumour that arises from pluripotent cells.

Proteus syndrome

A case of Proteus syndrome is presented, in which severe hemihypertrophy of the left trunk and left lower extremity, scoliosis, endometriosis and huge bizarre-shaped body tumors were observed. Up to 22.6 kg of tumorous tissue was excised. This syndrome was first described in 1983. The name Proteus comes from a Greek mythical sea god who was able to change his body form freely. This syndrome has numerous features including hemihypertrophy, macrodactyly, various subcutaneous masses, scoliosis and other minor abnormalities. Although diagnostic criteria have been established for Proteus syndrome, which is very difficult to differentiate from other congenital hamartomatous syndromes, more case reports are needed to define such a rare disorder. Our patient is the 6th Japanese case in the English literature.

Enhanced expression of endothelin-1 and endothelin-converting enzyme-1 in acute hypoxic rat aorta

Deeply anesthetized male Wistar rats were perfused by Hanks' balanced salt solution bubbled with either 95%air and 5%CO2 (normoxic group) or 95%N2 and 5%CO2 (hypoxic group) from the thoracic aorta for 30 min, and the isolated abdominal aortae from both groups were used for electron microscopy, immunocytochemistry of endothelin (ET)-1 and ET-converting enzyme (ECE)-1, and in situ hybridization of preproET-1 mRNA. A remarkable increase in the number of Weibel-Palade (WP) bodies, storage sites of ET-1 and ECE-1, occurred in the hypoxic group when compared to the normoxic group. Immunoreactivities for ET-1 and ECE-1, and signals for preproET-1 mRNA were seen along the endothelia of both groups, but the intensities were significantly elevated in the hypoxic group. The increase in the number of ECE-1 immunoreactive gold particles was noticed especially in WP bodies in the hypoxic group. These findings indicate the enhancement of preproET-1 synthesis in the aortic endothelial cells as well as the acceleration of ET-1 processing in increased WP bodies in such cells in an experimentally hypoxic condition of the rat aortae.

[A case of autoimmune progesterone dermatitis]

A 41-year-old Japanese woman came to our clinic complaining of multiple edematous erythemas on the trunk and legs. The eruptions recurred periodically in association with the menstrual cycle. She had received oral progesterone therapy between 24 and 34 years of age. There were no abnormal values found in the routine and hormonal examinations, including progesterone and estrogen levels in serum and urine. After an intradermal skin test with progesterone, she had no reaction after 20 minutes but a positive reaction after 48 hours.

[Three cases of occupationally induced herpetic whitlow in health care workers]

Herpetic whitlow is one of the herpes simplex virus (HSV) infections, and is known as an occupational disease. In Japan, however, there have been only a few reports of this disease. Recently, we experienced three cases of herpetic whitlow in health care workers. They presented painful vesicles on the right ring finger, the left thumb and the left index finger, respectively. All of them were considered to have been infected by HSV when they were engaged in mouth care of inpatients. We reviewed these three cases from the aspect of occupational medicine, and propose the following three points for preventing this serious nosocominal infection to health care workers: 1) re-education and enlightenment for the workers regarding hazardous behavior of HSV, 2) keeping the hands and fingers free from skin impairments, and 3) early diagnosis and treatment for herpetic whitlow of health care professionals to prevent further nosocominal infection.

[Six cases of occupational skin diseases caused by cement: considerations from the aspect of occupational dermatology]

Cement, in particular Portland cement, is now widely used in the field of civil engineering and the construction industry. High alkalinity of wet cement and its tiny content of water-soluble chromate can cause occupational skin diseases. In this paper, we report four cases of contact dermatitis by cement and two cases of cement burn. The occupation of the patients included two plasterers, a truck driver, a manufacturer of cement ware and two construction workers. Skin of the hands and fingers of the cement dermatitis cases was dry and fissured, and had hyperkeratotic papules and erythemas or acute exudative eczematous lesions. In one of these cases, the eczematous lesions spread to the face, extremities and trunk. All cases resulted in a positive patch testing for sodium dichromate. The cement burn cases developed severe necrotic ulcers on the leg and/or foot following prolonged contact with wet cement inside their boots. Patch testing was negative for chromate. A field trip to a construction worksite showed that method of working as well as worker's clothing at present could not thoroughly protect the skin. Therefore we concluded that better protective clothing and gloves should be used and that working conditions be improved. Most skin diseases caused by cement occur among workers at small-scale enterprises. Therefore it is desirable that regional occupational health centers, which were established to promote the health care system for workers at small-scale enterprises, take prompt measures to avoid the skin diseases.

Six cases of metastatic malignant melanoma with apparently occult primary lesions

We report here six cases of malignant melanoma in which metastatic lesions were detected first. Of these, two cases showed some peculiar features: one exhibited widespread subcutaneous bleeding, probably due to venous rupture, and the other case had a rare primary lesion on the penis. In the Japanese literature, there have been 46 cases of malignant melanoma in which metastatic lesions were detected prior to the initial ones. The preferential site for metastasis was the lymph node (32 cases). The primary lesion was unknown in 35 patients. The outcomes were available for 36 of the 46 patients; 23 died, including 18 who died within two years.

Comparison of three in vitro assay systems used for assessing cytotoxic effect of heavy metals on cultured human keratinocytes

The cell viability assay using cultured cells is of great advantage to elucidate the biological effect of potentially toxic substances. Recently, a novel assay system, Tetracolor One cell proliferation assay (Seikagaku Co., Tokyo, Japan), has been developed. In this report, we compare the results of the Tetracolor One assay regarding the cytotoxic effect of three heavy metal salts on cultured adult keratinocytes to those of the neutral red dye uptake assay and the MTT eluted stain assay. In this study, these three methods showed almost similar results. Compared to the other two methods, however, the Tetracolor One assay, which requires only one-step procedure before spectrophotometric measurement, is easier to use, and errors in measurement, which may be produced through the multistep procedure, are much less in this assay. Therefore, we believe that the Tetracolor One assay system is useful for assessing the cytotoxic effect of heavy metals on cultured human keratinocytes.

[Occupationally induced nitric acid and sulfuric acid burns: an analysis of 2 patients from the aspect of occupational health]

We report two patients who suffered from acid burns while working in chemical factories. Case 1: a 44-year-old man who received burn induced by nitric acid on the face and extremities. Despite his protecting facial mask, he was exposed to nitric acid on his face through a gap between the mask and skin surface. Nitric acid was also sprinkled on his scalp which was not covered by a helmet or a protecting device. In addition, he suffered from acid burn on the right scapular region, the right upper arm, and the lower extremities through the work clothes. Case 2: a 26-year-old man who suffered from sulfuric acid burn on the forearms. Both patients were accidentally exposed to acids while they filled tanks with the acids through a hose. Following the manual of the factories, they washed the exposed skin with water for more than 15 minutes after the exposure. Although they recovered without any serious sequel, there remained partial deep tissue destruction of the skin. We reviewed these two cases from the aspect of industrial medicine, and proposed the following three points for improvement in the workplace to prevent accidental acid burns. 1) re-education or enlightenment activities for the well-experienced workers to avoid negligence to the danger of strong acid. 2) recommendation to take a complete shower to avoid overlooking of unaware acid injury. 3) improvement in the protecting facial mask. In addition, clinicians who examine acid-burn patients should not pass over the presence of deep ulcers lying behind the thick crust on the injured area.

[A case of pemphigus foliaceus associated with bullous impetigo successfully treated with tetracycline and nicotinamide]

A 50-year-old Japanese woman visited our clinic, complaining of generalized erythema with painful erosions and bullae. The histopathological findings of the skin lesion suggested development of impetigo. Gentamycin-resistant Staphylococcus aureus was detected by the bacterial culture examination from the impetiginous bullae. A direct immunofluorescence study of the lesion showed an intercellular deposition of IgG and C3 in the upper epidermis. We diagnosed this case as pemphigus foliaceus associated with bullous impetigo. A combined oral administration of tetracycline (200 mg/day) and nicotinamide (1200 mg/day) for 3 weeks was successful. In Japan, patients with moderate to severe symptoms of pemphigus foliaceus are usually treated with oral steroid therapy. To our knowledge, however, there is no reported pemphigus case which has been successfully treated only with tetracycline and nicotinamide.

Immunohistochemical analysis of metallothionein expression in malignant melanoma in Japanese patients

Recently, Zelger et al. found that metallothionein expression in melanoma is a useful prognostic indicator in white patients. In this study, we evaluated metallothionein expression in patients with melanoma as a prognostic indicator. We studied the tumors of 44 patients with cutaneous melanoma seen in our clinic from July 1988 to August 1998. Twenty-five neoplasms were metallothionein-positive, and 19 were metallothionein-negative. Only 9 (37.5%) of 24 cases of level I through III melanoma were positive for metallothionein, but 16 (80%) of 20 level IV and V cases were positive. Eight (40%) of 20 cases of "thin" melanoma (thickness: < or = 1.5 mm) were metallothionein-positive, and 17 (70.8%) of 24 cases of "thick" melanoma (thickness: > 1.5 mm) were metallothionein-positive. These results indicate a strong correlation of metallothionein expression with the level of invasion and tumor thickness in melanoma. The survival distribution function curve (Kaplan-Meier) for metallothionein expression showed a much better survival rate in the metallothionein-negative group than in the metallothionein-positive group.

[Occupational contact dermatitis in women]

In work in which women predominate, the highest rate of the occupational contact dermatitis is seen among hairdressers and medical nursing staffs. Twelve such cases are presented and several points regarding the diagnosis and treatments are discussed. The patients were five hairdressers, two dental technicians, two nurses and three woman divers. A patch test was useful in identifying the allergens or irritants in most cases.

Sweat gland toxicity induced by bis (tributyltin) oxide: an ultrastructural and X-ray microanalysis study

Acute toxicity of bis (tributyltin) oxide in the sweat glands in the rat footpad was investigated by electron microscopy and an energy-dispersive X-ray microanalyzer. Male Wistar rats received an intramuscular injection of 0.5 ml/kg bis (tributyltin) oxide. After 6-8 h, swelling of mitochondria appeared in the secretory cells of the sweat glands. After 12 h, the secretory cells began to show intracytoplasmic edema. After 16-20 h, secretory cells in some sweat glands showed marked hydropic degeneration with swollen cytoplasm. Using X-ray microanalysis, tin peaks were preferentially obtained from the swollen mitochondria of the affected secretory cells. Mitochondria dysfunction due to the toxic effects of bis (tributyltin) oxide induced changes in the secretory cells of rat sweat glands. After 24-48 h, the secretory portion of the sweat glands contained three types of cells: degenerating dark cells, regenerating cells carrying injured mitochondria, and light cells which were morphologically very similar to the cells in the transitional portion of the sweat gland. These light cells appeared to differentiate into active secretory cells after settling down in the secretory portion. Based on these observations, we concluded that the cells in the transitional portion could play an important role at least as reserve cells against secretory cell toxicity. In association with the regenerating process of the damaged secretory portions, increased mitotic activities were seen in different areas of all the dermal sweat ducts. The above-mentioned morphological observations for cell damage and subsequent regeneration and renewal ofsecretory cells in sweat gland intoxication have not been reported so far.