Diffuse intraepidermal deposition of immunoreactants on direct immunofluorescence: a clue to the early diagnosis of epidermal necrolysis

BACKGROUND

Toxic epidermal necrolysis is a distinctive disorder that is readily identified clinically and histologically in advanced cases. Early on, however, toxic epidermal necrolysis may be difficult to identify. Some consider fixed drug eruption a limited form of toxic epidermal necrolysis.

METHODS

Direct immunofluorescence was performed on biopsy material of erythematous skin lesions.

RESULTS

Diffuse deposition of immunoreactants in the midmalpighian layer was noted. This finding has not been encountered in other disorders studied in our immunopathology laboratory.

CONCLUSIONS

Diffuse immunoreactant deposition in the mid-epidermis should suggest a diagnosis of epidermal necrolysis either from toxic epidermal necrolysis or fixed drug eruption. Additional cases will need to be assessed to document the usefulness of this pattern for prospective diagnosis.

Lichen planus associated with neoplasia: a cell-mediated immune response to tumor antigens?

BACKGROUND

Individual case reports have suggested an occasional association of lichen planus with internal malignancy.

OBJECTIVE

Our purpose was to describe five patients with a neoplastic disease in whom lichen planus developed.

METHODS

Serologic and immunopathologic studies were conducted.

RESULTS

No evidence of autoantibody production characteristic of paraneoplastic pemphigus was found, and antibodies reactive with basal cell keratinocytes were not detected.

CONCLUSION

Lichen planus may be rarely induced by neoplasia. A cell-mediated immune reaction possibly causes this phenomenon.

Ki-1-positive anaplastic large-cell lymphoma can mimic benign dermatoses

BACKGROUND

Regressing atypical histiocytosis is a recently described disease characterized by recurrent nodules or ulcers. The cutaneous lesions appear abruptly and then regress only to return in a manner reminiscent of lymphomatoid papulosis. Immunophenotypic analysis has revealed that most cases are a form of anaplastic large-cell Ki-1-positive (CD30+) lymphoma.

OBJECTIVE

We describe two patients with Ki-1-positive anaplastic large-cell lymphoma that had clinical and pathologic features of regressing atypical histiocytosis and mimicked benign dermatoses (pyoderma gangrenosum and morphea), causing a delay in confirming the true diagnosis. A third case that was readily recognized as a lymphoma is also presented.

METHODS

The clinical and histopathologic findings were recorded. In addition, T-cell receptor gene rearrangement and immunophenotyping were determined in the index case.

RESULTS

The index patient and second patient were diagnosed as having Ki-1-positive anaplastic large-cell lymphoma by immunophenotyping and underwent cyclophosphamide, doxorubicin, prednisone, and vincristine (CHOP) chemotherapy with complete remission. The patient detected by chart review died of her disease without receiving antineoplastic therapy; disseminated lymphoma was diagnosed at autopsy. Studies on paraffin-embedded tissue were consistent with Ki-1-positive anaplastic large-cell lymphoma.

CONCLUSION

Regressing atypical histiocytosis may clinically resemble some benign dermatoses. Recent evaluation of these cases has shown that many represent a form of Ki-1-positive anaplastic large-cell lymphoma. Multiple skin biopsy specimens with immunophenotyping and gene rearrangement studies are required to arrive at the diagnosis.

Malignant melanoma arising in a blue nevus with features of pilar neurocristic hamartoma

A 65-year-old man presented with a history of a giant blue plaque of the parietal scalp since childhood. Biopsy revealed a cellular blue nevus. The blue nevus was observed for 10 years and thought to be unchanged until a new adjacent lesion was noted. Biopsy of the new lesion revealed metastatic malignant melanoma. A wide excision was performed of the original lesion which revealed malignant melanoma arising in a blue nevus. Areas within the blue nevus were consistent with a pilar neurocristic hamartoma, whereas other areas were consistent with a common blue nevus. Subsequent satellite metastases developed, with early metastases resembling blue nevi except for the absence of a stromal component and the presence of hyperchromatic nuclei. Later metastases were typical of metastatic melanoma. This case illustrates the uncommon evolution of malignant melanoma from a blue nevus. The histological features and relationship between melanoma, blue nevus, and pilar neurocristic hamartoma are reviewed.

Pretibial mucin. Histologic patterns and clinical correlation

BACKGROUND AND OBJECTIVE

We identified several patients with a histologic diagnosis of pretibial myxedema in whom thyroid disease was not found. The purpose of this study was to investigate if histologic characteristics can distinguish between pretibial mucinosis secondary to Graves' disease and that unassociated with thyroid disease.

METHODS

Biopsy specimens interpreted as compatible with pretibial myxedema were reviewed; these included 12 cases of pretibial mucinosis with documented Graves' disease, and six cases of pretibial mucinosis without evidence of Graves' disease. Ten specimens interpreted as compatible with stasis dermatitis were also evaluated for histologic characteristics, including the possible presence of mucin.

RESULTS

Features that distinguish between pretibial mucinosis associated with Graves' disease and pretibial mucinosis without Graves' disease included preservation of a zone of normal-appearing collagen in the superficial papillary dermis (12/12 with Graves' disease, 0/6 without), mucin deposition in the reticular dermis (12/12 with Graves' disease, 0/6 without), lack of mucin deposition in the superficial papillary dermis (11/12 with Graves' disease, 1/6 without), angioplasia (2/12 with Graves' disease, 6/6 without), and the presence of hemosiderin (2/12 with Graves' disease, 6/6 without). Mucin deposition in the papillary dermis was found in six of 10 specimens interpreted as stasis dermatitis.

CONCLUSIONS

There are patients with pretibial mucinosis in whom there is no thyroid disease. Specimens from patients without Graves' disease have features of stasis dermatitis in addition to mucinosis. We conclude that pretibial mucinosis may result from stasis or Graves' disease and that histologic differences allow for accurate differentiation.

Vascular nodules and plaques resembling chronic mucocutaneous candidiasis in a patient with a low interleukin 2 level

A 21-year-old woman had a lifelong history of widespread friable vascular nodules and plaques. Her condition had previously been diagnosed as chronic mucocutaneous candidiasis because of her clinical appearance. Routine studies of immune function were performed in addition to a comparison of cytokine secretion in mononuclear leukocytes of our patient and normal controls. Interleukin 2 secretion by phytohemagglutinin-stimulated mononuclear leukocytes was deficient when compared with six healthy donors (< 300 pg/ml vs 2108 +/- 336 pg/ml). Interleukin 2 deficiency may be a causative factor in cases of unusual vascular proliferation. Treatment with methotrexate, which increases interleukin 2 activity and inhibits neovascularization in vitro, was helpful in our patient.

Indirect immunofluorescence on rat bladder transitional epithelium: a test with high specificity for paraneoplastic pemphigus

BACKGROUND

Paraneoplastic pemphigus is a blistering disease with specific serum immunoprecipitation findings. Although immunoprecipitation studies allow accurate diagnosis, they are time-consuming, expensive, and not readily available. In contrast, indirect immunofluorescence (IIF) testing of serum on transitional rat bladder epithelium is a simple and inexpensive method available to any immunopathology laboratory.

OBJECTIVE

Our purpose was to determine the specificity of positive IIF on rat bladder epithelium for paraneoplastic pemphigus.

METHODS

The IIF findings in four index cases of paraneoplastic pemphigus were compared with the findings in 47 patients with a variety of malignant neoplasms and no associated blistering disease as well as 49 patients with vesiculobullous or lichenoid disease but no neoplasia.

RESULTS

IIF was negative in all patients with neoplasia and no blistering disease and negative in all but one of the patients with vesiculobullous or lichenoid disease without neoplasia (98.9% specificity).

CONCLUSION

IIF on transitional rat bladder epithelium appears to be a highly specific test for paraneoplastic pemphigus. Because of its simplicity and inexpensiveness, we suggest that IIF be performed on transitional epithelium in any suspected case of paraneoplastic pemphigus.

Persistent annular erythema of infancy

Annular erythema of infancy is an uncommon, nonpruritic, figurate erythema that begins in the first year of life. Biopsy specimens reveal a perivascular and interstitial lymphocytic infiltrate with numerous eosinophils. The cause of the disorder is unknown, but a hypersensitivity response to unrecognized antigens is suspected. The disorder is self-limited, but may last for many months. In our patient the eruption continued 19 months after its onset.

Paraneoplastic pemphigus. A distinct autoimmune vesiculobullous disorder associated with neoplasia

A vesiculobullous disease termed paraneoplastic pemphigus with distinct autoantibodies was newly described in 1990. All reported cases have occurred in patients with a history of neoplasia, including lymphoma, chronic lymphocytic leukemia, poorly differentiated sarcoma, and benign thymoma. As in pemphigus vulgaris, intraepithelial clefts with acantholysis are noted histopathologically, and intercellular binding of immunoreactants is seen with direct immunofluorescence studies of mucous membrane and skin biopsies. However, immunoreactants may also be found along the basement membrane zone in paraneoplastic pemphigus. Indirect immunofluorescence using rat bladder epithelium as substrate shows an intercellular pattern that appears to be highly specific for paraneoplastic pemphigus. We report a patient with non-Hodgkins lymphoma of 8 years duration who developed severe erosive stomatitis and lichenoid dermatitis after receiving chemotherapy for a relapse of lymphoma. Her case illustrates the typical features of the disorder described as paraneoplastic pemphigus. Neoplasia-associated pemphigus may be a more precise term for this disorder because the course of the blistering eruption does not always parallel the course of the underlying cancer. The clinical features, histopathologic findings, and immunofluorescence findings of this unique syndrome are reviewed.

Symptomatic zinc deficiency in a one-year-old child precipitated by changing from formula to cow's milk

The case of a one-year-old girl with symptomatic zinc deficiency is presented. She had been misdiagnosed as having impetigo and/or candidiasis and had been treated with topical antifungal agents and both oral and topical antibiotic agents without success during the four months before she presented. Zinc replacement led to rapid improvement. Her nutritional history suggests that weaning from formula to cow's milk precipitated her eruption. The clinical findings, differential diagnosis, and treatment of zinc deficiency are reviewed.

Paraneoplastic pemphigus: a report of three cases including one long-term survivor

BACKGROUND

Paraneoplastic pemphigus is a newly described autoimmune disease characterized by painful mucosal ulcerations and polymorphous skin lesions in association with an underlying neoplasm. All reported patients with an associated malignant neoplasm have had a poor prognosis.

OBJECTIVE

We present three new cases of paraneoplastic pemphigus associated with a malignant neoplasm and further characterize this disease.

METHODS

We used clinical criteria, histologic and immunopathologic examinations, and immunophenotyping to characterize this disease. In addition, we performed immunoprecipitation studies with extracts of radiolabeled human keratinocytes to characterize the antigens to which patient serum binds.

RESULTS

All three patients had clinical, histologic, and immunopathologic findings that were strongly suggestive of paraneoplastic pemphigus. Their sera immunoprecipitated a complex of four polypeptides from human keratinocyte extracts with molecular weights of 250, 230, 210, and 190 kd, confirming the diagnosis of paraneoplastic pemphigus. The 250, 230, and 210 kd antigens comigrated with desmoplakin I, the 230 kd bullous pemphigoid antigen, and desmoplakin II, respectively. Lymphocyte immunophenotyping revealed large populations of monoclonal CD19+, CD5+ B cells in two cases. Although two of the patients died, one patient is alive and well 2 years after the diagnosis of paraneoplastic pemphigus.

CONCLUSION

We report three cases of paraneoplastic pemphigus. One patient is alive and well 2 years after diagnosis, which suggests that a subgroup of patients may have a more benign course.

Angiotropic lymphoma: malignant angioendotheliomatosis

Malignant angioendotheliomatosis is an angiotropic lymphoma that may present with clinical findings suggestive of thrombophlebitis or vasculitis. Examination of a biopsy specimen with special stains for leukocyte common antigen establishes the diagnosis. Although malignant angioendotheliomatosis is usually fatal, early treatment with chemotherapeutic agents is helpful. We review the characteristics and treatment of this uncommon disorder and present an illustrative case.