Neurophysiologic and vascular studies in erythromelalgia: a retrospective analysis

Erythromelaigia is a poorly understood clinical syndrome characterized by painful, hot, red extremities. We assessed the frequency and types of abnormalities observed during tests of vascular, peripheral neurophysiologic, and autonomic function in patients with erythromelalgia.Methods Of" 163 charts of patients fulfilling the clinical diagnosis of erythromelalgia. 93 patients underwent vascular studies Five of them had detailed vascular studies in 10 affected lower extremities performed before and during symptoms, fifty-four patients underwent neurophysiologic testing, 27 had autonomic reflex screening (ARS). and two had recordings of peripheral autonomic surface potentials (PASP).Results. Measurements in the toes during symptoms revealed a mean temperature increase of 11.6 C (P = 0,00011 along with a laser flow increase from a mean of 6.8 mL/min per 100 g tissue to 76.5 mL/min per 100 g tissue (P<.0.0001). Baseline TcPO; in the feet decreased by 6.7 mmHg (P = 0.032) during symptoms. Twenty-one of 54 electromyographic recordings were abnormal: all fulfilled the criteria for axonal neuropathy. Seventeen of 27 ARSs and one PASP showed severe postganglionic sudomotor impairment; five of 17 additionally had peripheral adrenergic dysfunction.Conclusions During symptoms, an increase in flow and temperature is accompanied paradoxically by a decrease in oxygenation of the affected area; a high proportion of patients have a distal small fiber neuropathy with selective involvement of cutaneous sympathetic fibers; in addition, large fiber neuropathy is often present.

Clinical assessment and outcome in 70 patients with complaints of burning or sore mouth symptoms

OBJECTIVE

To review a series of patients with a burning or sore mouth for elucidation of associated conditions and treatment outcome.

MATERIAL AND METHODS

We retrospectively studied 70 consecutive patients with a burning or sore mouth who were encountered at a tertiary-care center between 1979 and 1992. Clinical and laboratory findings were summarized, and follow-up data were analyzed.

RESULTS

The study cohort of 56 women and 14 men had a mean age of 59 years. They had had a burning or sore mouth for a mean duration of 2.5 years. Multiple etiologic factors for the burning or sore mouth were present in 37% of the study subjects. The most frequently associated conditions were psychiatric disease (30%), xerostomia (24%), geographic tongue (24%), nutritional deficiencies (21%), and allergic contact stomatitis (13%). With a treatment course tailored to the suspected causal factor, 72% of the patients who had follow-up reported improvement.

CONCLUSION

With a directed investigation, one or more causes could be identified in most patients who had a burning or sore mouth. Successful management of these symptoms was possible in a majority of the patients.

Bullous pemphigoid presenting as generalized pruritus: observations in six patients

BACKGROUND

Bullous pemphigoid is a chronic immunobullous disease of the elderly. Classically, tense, pruritic blisters develop on normal or erythematous skin. These may be preceded by a prodromal pruritic, urticarial, or eczematous eruption. Occasionally, patients may develop generalized pruritus without blisters as a prodrome of bullous pemphigoid.

METHODS

The records of the patients were reviewed. Biopsy specimens were studied by light and immunofluorescence microscopy. Serum specimens were studied by indirect immunofluorescence techniques including the salt-split skin technique.

RESULTS

We studied six elderly patients presenting with generalized pruritus as the dominant or single presenting feature of early bullous pemphigoid. Two of the six had rare vesicles at presentation. All had excoriations and one each presented with minimal urticarial or eczematous papules. Routine skin biopsies were largely nonspecific. All patients had confirmation of their diagnosis by either indirect or direct immunofluorescence testing or both. All six patients had their disease completely controlled by their treatment.

CONCLUSIONS

The clinical presentation of the six patients in our series and the eight previously reported patients should be regarded as an unusual prodromal manifestation of bullous pemphigoid characterized by generalized pruritus without primary skin lesions. This presentation could be described as "pruritic pemphigoid," because it joins the remarkable clinical finding of generalized pruritus with the underlying diagnosis of bullous pemphigoid. Elderly patients with severe or persistent unexplained generalized pruritus merit immunofluorescence testing to exclude bullous pemphigoid as the cause of the generalized pruritus. Establishing an early diagnosis permits the prompt institution of effective therapy with dapsone or systemic corticosteroids with an excellent prognosis for complete control of the disease.

Clinicopathologic correlation of hypocomplementemic and normocomplementemic urticarial vasculitis

BACKGROUND

Urticarial vasculitis is characterized by persistent urticarial lesions with histologic evidence of leukocytoclastic vasculitis. Hypocomplementemic urticarial vasculitis (HUV) is a distinct clinical entity in a subset of patients with urticarial vasculitis.

OBJECTIVE

We examined presentation of urticarial vasculitis and factors predictive of connective tissue disease.

METHODS

The clinical, histologic, and immunologic characteristics of 132 patients with urticarial vasculitis seen at the Mayo Clinic were examined, and features of the hypocomplementemic patients were compared with those of the normocomplementemic patients.

RESULTS

Twenty-four patients (18%) had hypocomplementemia; all were female. Interstitial dermal neutrophilia was seen in 19 biopsy specimens (83%). On direct immunofluorescence (DIF) testing of lesional skin, 23 patients (96%) had a continuous strong granular deposition of immunoreactants along the basement membrane zone compatible with lupus erythematosus in addition to vascular fluorescence. Systemic lupus erythematosus (SLE) was present or occurred in 13 (54%). One hundred eight patients (82%) had normocomplementemia; 65 (60%) were female. Interstitial dermal neutrophilia was seen in 11 of 26 (42%) randomly selected biopsy specimens. On DIF, one patient (1%) had the lupus band. SLE occurred in three patients (3%).

CONCLUSION

Patients with HUV were more likely to be female, to have diffuse neutrophilia on biopsy specimens stained with hematoxylin and eosin, to have continuous strong granular deposition of immunoreactants along the basement membrane zone on DIF, and to have SLE than normocomplementemic patients. We submit that HUV represents a subset of SLE with shared clinical, laboratory, and immunologic features.

American Urological Association symptom index in the assessment of urethroplasty outcomes

PURPOSE

In men undergoing urethroplasty we used the American Urological Association (AUA) symptom index to assess the magnitude of symptoms and determine the validity of this index as an outcome assessment tool.

MATERIALS AND METHODS

The AUA symptom index was completed by individual interview of 50 men a mean of 41 years old who underwent urethral reconstruction. Symptom scores were then correlated with radiographic retrograde urethrograms and urinary flow rates to determine whether changes in the score were consistent with these other clinical indicators of success or failure.

RESULTS

Mean preoperative AUA symptom index score in all evaluable patients was 26.9 (maximum 35), indicating severely bothersome voiding symptoms. In patients with radiographic evidence of successful urethral reconstruction the average postoperative score was 5.1 (p <0.0001). In those with recurrent stricture after urethroplasty scores were essentially unchanged but after successful repeat urethroplasty the mean symptom index score decreased to 3.4 (p <0.0001). A statistically significant inverse correlation (r = -0.712, p <0.0001) was found between AUA symptom index scores and maximum urinary flow rates.

CONCLUSIONS

Patients with urethral strictures who are selected for formal urethroplasty have severe obstructive and irritative voiding symptoms. Results of the AUA symptom index correlate closely with conventional measures of urethroplasty outcome, such as radiographic retrograde urethrography and urinary flow studies. The AUA symptom index appears to have clinical validity as an adjunctive outcome assessment tool after urethroplasty.

Phenytoin-induced linear IgA bullous disease

Drug-induced linear IgA bullous disease most commonly occurs after exposure to vancomycin, but other medications may also trigger the eruption. We describe a 78-year-old man with linear IgA bullous disease related to treatment with phenytoin.

Diseases of the lips

The vermilion of the lips was conceptualized by Jean Darier as the semi-mucosa. The anatomy of the lips is transitional from skin to mucous membrane. This article emphasizes inflammatory diseases of the lips known as cheilitis. Angular cheilitis is a reactive process with several possible causes, including infections, mechanical, nutritional deficiency, and various dermatoses. Contact cheilitis may be caused by a primary irritant or a delayed hypersensitivity allergic reaction to contactants. Plasma cell cheilitis is a reactive periorificial mucositis. Exfoliative cheilitis is also a reactive process, probably secondary to factitious activity of the patient. Cheilitis glandularis is a chronic inflammatory disorder of the labial salivary glands and their ducts. There are three forms: simple, superficial suppurative, and deep suppurative. A premalignant potential is present in cheilitis glandularis. Cheilitis granulomatosa is one manifestation of orofacial granulomatosis. The granulomatous conditions of Melkersson-Rosenthal syndrome, sarcoidosis, and Crohn's disease may be associated with cheilitis granulomatosa or it may stand alone as Miescher's cheilitis. Actinic cheilitis is another premalignant form of cheilitis that is amenable to a variety of therapeutic modalities.

Recurrent aphthous stomatitis in the diagnosis of Behçet's disease

Recurrent aphthous stomatits (RAS) is also known as recurrent oral ulcers, recurrent aphthous ulcers, or simple or complex aphthosis. RAS is the most common inflammatory ulcerative condition of the oral mucosa in North American patients. RAS has been the subject of active investigation along multiple lines of research including epidemiology, immunology, clinical correlations and therapy. Clinical evaluation of the patient requires correct diagnosis of RAS and classification of the disease based on morphology (MIAU, MJAU, HU) and severity (simple versus complex). In order to properly diagnose and treat a patient with lesions of RAS, the clinician must exclude other causes of acute oral ulcers. Complex aphthosis and complex aphthosis variants associated with systemic disorders should be considered. The aphthous-like oral ulcerations of patients with HIV disease represent a challenging differential diagnosis. The association of lesions of RAS with hematinic deficiencies and gastrointestinal diseases provides an opportunity to identify a "correctable cause" which, with appropriate treatment, can result in a remission or substantial lessening of disease activity. Finally, when all of these factors are considered, the evaluation of the patient for Behçet's disease can be continued on firm grounds that one of the major criteria for the diagnosis of Behçet's disease has been met.

Recurrent aphthous stomatitis: clinical characteristics and associated systemic disorders

Recurrent aphthous stomatitis (RAS), commonly known as canker sores, has been reported as recurrent oral ulcers, recurrent aphthous ulcers, or simple or complex aphthosis. RAS is the most common inflammatory ulcerative condition of the oral mucosa in North American patients. One of its variants is the most painful condition of the oral mucosa. Recurrent aphthous stomatitis has been the subject of active investigation along multiple lines of research, including epidemiology, immunology, clinical correlations, and therapy. Clinical evaluation of the patient requires correct diagnosis of RAS and classification of the disease based on morphology (MiAU, MjAU, HU) and severity (simple versus complex). The natural history of individual lesions of RAS is important, because it is the bench mark against which treatment benefits are measured. The lesions of RAS are not caused by a single factor but occur in an environment that is permissive for development of lesions. These factors include trauma, smoking, stress, hormonal state, family history, food hypersensitivity and infectious or immunologic factors. The clinician should consider these elements of a multifactorial process leading to the development of lesions of RAS. To properly diagnose and treat a patient with lesions of RAS, the clinician must identify or exclude associated systemic disorders or "correctable causes." Behçet's disease and complex aphthosis variants, such as ulcus vulvae acutum, mouth and genital ulcers with inflamed cartilage (MAGIC) syndrome, fever, aphthosis, pharyngitis, and adenitis (FAPA) syndrome, and cyclic neutropenia, should be considered. The aphthous-like oral ulcerations of patients with human immunodeficiency virus (HIV) disease represent a challenging differential diagnosis. The association of lesions of RAS with hematinic deficiencies and gastrointestinal diseases provides an opportunity to identify a "correctable cause," which, with appropriate treatment, can result in a remission or substantial lessening of disease activity.

Synthesis and biological evaluation of the 1,5-diarylpyrazole class of cyclooxygenase-2 inhibitors: identification of 4-[5-(4-methylphenyl)-3-(trifluoromethyl)-1H-pyrazol-1-yl]benze nesulfonamide (SC-58635, celecoxib)

A series of sulfonamide-containing 1,5-diarylpyrazole derivatives were prepared and evaluated for their ability to block cyclooxygenase-2 (COX-2) in vitro and in vivo. Extensive structure-activity relationship (SAR) work was carried out within this series, and a number of potent and selective inhibitors of COX-2 were identified. Since an early structural lead (1f, SC-236) exhibited an unacceptably long plasma half-life, a number of pyrazole analogs containing potential metabolic sites were evaluated further in vivo in an effort to identify compounds with acceptable pharmacokinetic profiles. This work led to the identification of 1i (4-[5-(4-methylphenyl)-3-(trifluoromethyl)- H-pyrazol-1-yl]benzenesulfonamide, SC-58635, celecoxib), which is currently in phase III clinical trials for the treatment of rheumatoid arthritis and osteoarthritis.

Mucosal, genital, and unusual clinical variants of melanoma

To demonstrate the need for a through cutaneous and mucosal examination, we discuss and illustrate the spectrum of mucosal melanomas and unusual clinical variants of melanoma. Although cutaneous areas exposed to sunlight are most vulnerable, melanomas can occur in any site on the skin or mucous membranes. Pigmented nevi as well as mucosal and labial melanotic macules are lesions that simulate oral mucosal melanomas but are not associated with such a poor prognosis. In contrast, the 5-year survival rate for patients with malignant melanomas of the oral mucosa is only 5%. Similarly, the prognosis is poor for patients who have malignant melanomas of the vulva, vagina, male genitalia, or anorectal area; most patients with such lesions are 50 years of age or older. Subungual and plantar areas are common sites of malignant melanomas, and involvement of the eyelid margin portends a poor prognosis. Other rare variants-desmoplastic, amelanotic, and polypoid malignant melanomas-are associated with local recurrences and metastatic lesions. Early diagnosis is the key to proper treatment and improved survival rate for patients with these unusual variants of melanoma. Increased awareness of the wide variety of clinical features of melanoma should lead to earlier diagnosis.

Melkersson-Rosenthal syndrome and orofacial granulomatosis

The Melkersson-Rosenthal syndrome is a rare disorder of unknown etiology characterized by a triad of recurrent orofacial swelling, relapsing facial paralysis, and fissured tongue. Exacerbations and recurrences are common. The orofacial swelling is characterized by fissured, reddish-brown, swollen, nonpruritic lips or firm edema of the face. The facial palsy is indistinguishable from Bell's palsy. The fissured tongue is seen in one third to one half of patients and, although the least common manifestation, its presence assists in diagnosis. The classic triad is not seen frequently in its complete form; therefore, diagnosis is difficult. This is particularly true because monosymptomatic and oligosymptomatic variants are seen more commonly. Cheilitis granulomatosa of Miescher is an example of a monosymptomatic variant of the Melkersson-Rosenthal syndrome. The histologic findings of noncaseating, sarcoidal granulomas support the diagnosis. These granulomas are not invariably present, and their absence does not exclude the diagnosis of the Melkersson-Rosenthal syndrome. Thus, the Melkersson-Rosenthal syndrome is a disease with elements of orofacial granulomatosis. Orofacial granulomatosis is a clinicopathologic entity describing oral lesions with noncaseating granulomas. The spectrum of this entity includes patients with oral Crohn's disease, patients with oral lesions who will develop typical bowel symptoms of Crohn's disease in the ensuing months to years, patients with tooth-associated infections, patients with sarcoidosis, and patients with food or contact allergies. The value of the clinicopathologic construct of orofacial granulomatosis is to provoke the careful search for provocative causes for the reactive symptom complex of the Melkersson-Rosenthal syndrome.

Immunohistochemical analysis of proliferation and differentiation in organotypic cultures of cervical tumor cell lines

Researchers have previously demonstrated that organotypic cultures of cervical tumor cell lines exhibit morphological characteristics similar to the in vivo biopsies from which they were derived (Rader et al., 1990). Both the in vivo biopsy and organotypic culture appeared undifferentiated. We have extended these studies with immunohistochemical analysis using the proliferation and differentiation markers, proliferating cell nuclear antigen (PCNA) and involucrin, respectively, to evaluate in more detail the ability of cervical tumor cell lines to differentiate in organotypic culture. An HPV-immortalized keratinocyte cell line, PE-4, expressed PCNA in the lower half and involucrin in the upper half of the organotypic culture which is consistent with the characteristics of a preneoplastic lesion in vivo. The CC-1 cell line, derived from an invasive squamous cell carcinoma, appeared undifferentiated, but expressed involucrin in the upper half of the organotypic culture. This is the first observation of expression of a differentiation marker in an organotypic culture of a cervical tumor cell line. The other cervical tumor cell lines, SiHa and HeLa, derived from a squamous cell carcinoma, and an adenocarcinoma of the cervix, respectively, did not express detectable levels of involucrin or mucin. All three cervical tumor cell lines, CC-1, SiHa and HeLa, expressed PCNA throughout their entire thickness. The majority of nuclei in SiHa and HeLa cultures were PCNA-positive, while the CC-1 cell line exhibited a lower growth fraction.(ABSTRACT TRUNCATED AT 250 WORDS)

Melkersson-Rosenthal syndrome

Melkersson-Rosenthal syndrome is a triad of recurrent orofacial swelling, relapsing facial paralysis, and fissured tongue. However, the classic triad is not frequently seen in its complete form. Monosymptomatic and oligosymptomatic forms are more common. The histological findings of sarcoid-like granuloma in skin or mucosal biopsy specimens support the diagnosis. The course is chronic but benign. Treatment is difficult, but intralesional or systemic corticosteroids may be helpful.

Barium studies in esophageal cicatricial pemphigoid

BACKGROUND

Cicatricial pemphigoid (CP) (benign mucous membrane pemphigoid) is a rare, blistering disease of skin and mucous membrane. The disease rarely extends to involve the esophagus, and there are only a few cases reported in the radiological literature. The aims of this study were to document the frequency of esophageal involvement and to describe the findings on upper GI barium studies.

METHODS

A total of 197 patients with CP were seen at our institution from 1981 to 1991. The clinical and radiological findings of these patients were reviewed and compared with findings reported in the literature.

RESULTS

Esophageal involvement was documented in seven patients. Cervical esophageal webs were found in five of the seven patients. Two patients had single esophageal webs while three had multiple webs. Frank strictures of the esophagus were also seen in five patients. These were most common in the cervical esophagus, but strictures were also found in the mid and lower esophagus. Two of the strictures resulted in significant dysphagia and required multiple endoscopic dilatations. One of the dilatations was complicated by mucosal injury, and follow-up barium examination showed dissection of the esophageal mucosa from the cervical esophagus to the esophagogastric junction. One patient demonstrated intramural pseudodiverticulosis in the cervical esophagus. Functional disturbances demonstrated on barium studies included tracheal aspiration in two patients and nasopharyngeal reflux in three.

CONCLUSIONS

CP involves the esophagus in approximately 5% of cases. The hypopharynx and cervical esophagus are most commonly involved, but any portion of the esophagus may be involved, and multiple levels of involvement may be seen. Cervical esophageal webs, often multiple or complex, are the most common appearance on barium studies, but frank strictures are also found. Secondary manifestations of esophageal involvement include nasopharyngeal reflux, tracheal aspiration, and intramural pseudodiverticulosis.

Chilblain lupus erythematosus (lupus pernio): clinical review of the Mayo Clinic experience and proposal of diagnostic criteria

Five cases of chilblain lupus erythematosus were retrospectively reviewed regarding their clinical, histopathologic, serologic, and immunofluorescence findings. Ages at onset of chilblain lupus erythematosus varied from 26 to 73 years, with a female-to-male ratio of 3:2. Since other entities can be confused with this disorder, we propose the following diagnostic criteria. The two major criteria are skin lesions in acral locations induced by exposure to cold or a drop in temperature, and evidence of lupus erythematosus in the skin lesions by results of histopathologic examination or direct immunofluorescence study. The three minor criteria are coexistence of systemic lupus erythematosus or other skin lesions of discoid lupus erythematosus, response to anti-lupus erythematosus therapy, and negative results of cryoglobulin and cold agglutinin studies. We conclude that chilblain lupus erythematosus can be diagnosed and treated. Discoid lupus erythematosus lesions respond more quickly to treatment than chilblain lupus erythematosus lesions. Treatment with antimalarial agents, prednisone, pentoxifylline, or dapsone was of benefit to our patients.

The sensitivity and specificity of direct immunofluorescence testing in disorders of mucous membranes

BACKGROUND

Direct immunofluorescence testing is frequently used to diagnose inflammatory mucosal disorders, but its accuracy relative to histologic and clinical diagnosis has not been reported.

OBJECTIVE

Our purpose was to compare diagnoses made on the basis of direct immunofluorescence, histologic features, and clinical impression and define optimal immunofluorescence criteria.

METHODS

Direct immunofluorescence findings and diagnostic impressions for 500 unselected mucosal biopsy specimens were recorded, as were the histologic diagnosis, initial clinical impression, and final diagnosis made on the basis of all studies and follow-up. Sensitivity and specificity were calculated for each parameter by diagnosis and site.

RESULTS

Direct immunofluorescence testing was superior for diagnosing pemphigus and pemphigoid and was slightly inferior to histologic evaluation for diagnosing lichen planus. Optimal criteria were IgG and C3 intercellular substance staining for pemphigus, linear C3 basement membrane zone deposits for pemphigoid, and shaggy fibrinogen basement membrane zone staining plus IgM cytoids for lichen planus. Direct immunofluorescence testing was diagnostic for several extraoral mucosal biopsy specimens.

CONCLUSION

Direct immunofluorescence is a valuable diagnostic tool for diseases of the oral mucosa and other mucosal sites.

Orofacial manifestations of Melkersson-Rosenthal syndrome. A study of 42 patients and review of 220 cases from the literature

We investigated orofacial manifestations in 42 patients with Melkersson-Rosenthal syndrome who were examined at our institution between 1965 and 1990. Patient histories and histologic and clinical findings were reviewed in detail. These data were compared with the oral findings in 220 cases that were reported in the literature between 1965 and 1990. There were 28 females in our study. The age at onset of signs and symptoms varied widely with a mean of 33.8 years. Most frequent initial signs were labial edema, facial swelling, and Bell's palsy. During the course of the disease, 75% of all patients had labial swelling, 50% had facial edema, and 33% had Bell's palsy. Swelling, erythema, or painful erosions that affected the gingiva, buccal mucosa, palate, or tongue were common intraoral symptoms. A comparison with patients reported in the literature revealed a similar frequency of extraoral symptoms but more prevalent intraoral symptoms in our patients.

Oral lesions in systemic lupus erythematosus. Do ulcerative lesions represent a necrotizing vasculitis?

BACKGROUND

It has been suggested that oral lesions in patients with systemic lupus erythematosus (SLE) may be grouped clinically as erythema, discoid lesions, or oral ulcerations. Oral ulcerations have been said to foretell a severe systemic disease flare and the proposal that oral ulcers represent a mucosal vasculitis has been suggested to explain this hypothesis.

OBJECTIVE

Our objective was to test the hypothesis that oral ulcers in patients with SLE result from vasculitis.

METHODS

We studied 10 patients with American College of Rheumatology (ACR) criteria for a diagnosis of SLE who had oral lesions of lupus (six prospectively and four retrospectively) clinically and by routine and immunofluorescence microscopy. Biopsy specimens were reviewed in a single-blinded fashion.

RESULTS

In our patients, no oral lesion, regardless of morphology, demonstrated vasculitis histologically. All lesions demonstrated an interface mucositis.

CONCLUSION

Our data strongly contradict the hypothesis that leukocytoclastic vasculitis explains a possible unproven correlation between oral ulceration and disease flares in patients with SLE.

Common lesions of the oral mucosa. A guide to diseases of the lips, cheeks, tongue, and gingivae

Canker sores and cold sores are common, relatively banal diseases of the oral mucosa and lips, occurring most often in young persons. Some otherwise healthy patients may have a more severe variant, such as major aphthous ulcers, recurring lesions of aphthous stomatitis, or acute herpetic gingivostomatitis. Other patients may present with severe recurrent herpes simplex labialis or chronic oral candidiasis, and in these patients an immunodeficiency state must be considered.