Histopathology of peripheral nerves in cutaneous herpesvirus infection

Cutaneous herpesvirus infection is a common viral disorder manifest by epidermal and/or mucosal vesicle formation. Though it is believed that the virus most likely resides in regional sensory ganglia following primary infection and that cutaneous involvement represents reactivation of a latent infection, the histopathology of cutaneous nerves in sites of disease has not been well characterized. In order to assess and characterize the pathologic changes of these nerves, we retrospectively examined 54 cases of cutaneous and mucosal herpesvirus infection as defined by the presence of diagnostic multinucleate epithelial giant cells that demonstrated viral cytopathic effect. Dermal nerves were evaluable in 48 of 54 cases. All cases showed perineural inflammation that consisted of a dense mixed lymphocyte-polymorphonuclear cell infiltrate. Twenty-six cases exhibited intraneural infiltrations accompanied by Schwann cell hypertrophy with nuclear eosinophilia and pyknosis. Frank neuronal necrosis was present in 21 cases, with viral cytopathic effect evident within neurons of four cases. The degree of peri- and intraneural inflammation correlated with the severity of the inflammatory response within the dermis in most cases; however, in eight cases there was inflammatory involvement of neurovascular structures distant from and out of proportion to dermal and epidermal changes. Immunoperoxidase staining using a polyvalent antibody to human herpesvirus was performed in two cases and demonstrated viral antigen within nerve twigs. This pattern of peripheral nerve twig inflammation, along with the occurrence of more distant neural involvement, may prove to have diagnostic implications and serve as a clue in the recognition of cutaneous herpesvirus infection, particularly in cases with subtle or absent epidermal alteration. Furthermore, the presence of inflammation within and around nerves as well as degenerative changes suggest that nerve twigs are not passive conduits for viral spread but may be directly involved in infection.

Diagnosis and treatment of infectious diseases in HIV-infected hosts

Treatment of infectious diseases in patients with HIV infection is of primary importance in patient care. Viral, bacterial, parasitic, and fungal pathogens all may affect these patients. It is essential that accurate diagnoses be made and appropriate therapy be administered as early as possible.

Atypical fibroxanthoma with osteoclast-like multinucleated giant cells

Atypical fibroxanthoma is a malignant fibrohistiocytic neoplasm that develops most commonly on sun-exposed skin of elderly individuals. A number of different variants have been described, ranging from a purely spindle cell type to a xanthomatous form. We recently observed an unusual variant of atypical fibroxanthoma in which there were numerous osteoclast-like multinucleated giant cells. Histologically, there was a diffuse spindle cell neoplasm in the dermis exhibiting fibrohistiocytic differentiation associated with inflammatory cells. The neoplastic spindle cells were markedly pleomorphic and many were in mitosis, some being tripolar and tetrapolar. In addition to these features, which are common in atypical fibroxanthoma, there were numerous multinucleated giant cells scattered throughout the lesion with features resembling normal osteoclasts. Epithelioid cells with features of histiocytes were seen in association with these cells. No osteoid was observed, however, that suggested monocyte-macrophage differentiation. The histologic appearance of this lesion was reminiscent of the giant cell variant of malignant fibrous histiocytoma, also termed malignant giant cell tumor of soft parts. Thus, osteoclast-like giant cells may be seen in atypical fibroxanthoma. These cells probably represent multinucleated histiocytes rather than true osteoclasts. It is important to recognize this variant to avoid confusion with other malignant soft tissue neoplasms.

Long-term efficacy and safety of Jessner's solution and 35% trichloroacetic acid vs 5% fluorouracil in the treatment of widespread facial actinic keratoses

BACKGROUND

Few studies have examined the long-term efficacy of fluorouracil (FU) or chemical peels for the treatment of actinic keratoses (AK). Our earlier work examined the efficacy and safety of a medium-depth chemical peel compared with the standard regimen of topical FU in the treatment of widespread facial AK through 12 months.

OBJECTIVES

To determine long-term efficacy of both treatments by extending our observations through 32 months.

METHODS

Fifteen patients with severe facial actinic damage were treated on the left side with a single application of Jessner's solution and 35% trichloroacetic acid and on the right side with twice daily applications of 5% FU cream for 3 weeks. Parameters evaluated at 1, 6, 12, and 32 months included counts of visible AK, random skin biopsies from both treatment areas, development of intercurrent neoplasms, and surveys assessing sun exposure.

RESULTS

Eight patients were available for reevaluation at 32 months. Both treatment sides showed a reduction in mean number of AK at 12 months followed by an increase in mean AK number between 12 and 32 months. Improvements in biopsies of clinically actinically damaged skin were seen in keratinocytic atypia, hyperkeratosis, parakeratosis, and inflammation at all treatment times during the study with both treatments. Three squamous cell carcinomas developed in the patients after initial treatment; one developed on the side treated with the peel, and two developed on the side treated with fluorouracil. Surveys failed to demonstrate an association between sun exposure and clinical response.

CONCLUSION

Based on these findings, patient with widespread actinic keratoses treated with medium-depth chemical peel or with 5% FU should be reevaluated yearly or every 1.5 years for reappearance of AK and retreatment.

Acquired cutis laxa associated with a plasma cell dyscrasia

Acquired cutis laxa (generalized acquired elastolysis) is characterized by skin laxity often with systemic involvement of the lungs, aorta, gastrointestinal tract, and pelvic organs. Although there have been many speculations regarding its pathogenesis, the etiology of this condition is still unclear. We describe a patient with generalized acquired cutis laxa associated with a plasma cell dyscrasia. Immunofluorescence studies were used to evaluate the pathogenesis of the elastolysis. Lesional skin was examined by direct and indirect immunofluorescence techniques for evidence of deposition of immunoglobulins on elastic fibers in the dermis. Direct immunofluorescence revealed deposition of IgG on elastic fibers in the dermis. Some patients with acquired cutis laxa have underlying lymphoreticular disorders such as plasma cell dyscrasia and may have immunoglobulins deposited on dermal elastic fibers. Immune-mediated mechanisms may play a major role in the pathogenesis of acquired cutis laxa in at least some cases.

Calciphylaxis with histologic changes of pseudoxanthoma elasticum

Calciphylaxis is a rare condition of widespread calcification of tissues and blood vessels with accompanying vascular thrombosis and ischemic necrosis. Most cases develop in association with hyperparathyroidism in patients with chronic renal failure. Pseudoxanthoma elasticum (PXE) is a hereditary condition of abnormal elastic tissue structure that leads to widespread abnormalities of the skin, retina, and visceral organs. Histologic changes of PXE have been observed as coincidental findings in several conditions such as following trauma to the skin manifest as isolated plaques often in scars. We observed histologic findings of PXE in a patient with chronic renal failure who developed fatal calciphylaxis. Complete evaluation failed to reveal evidence of systemic findings of PXE. Histologic changes of PXE may be seen in patients with calciphylaxis as a coincidental finding. Rapidly developing soft tissue calcification may lead to the expression of the characteristic histopathologic findings of PXE without evidence of classic clinical manifestations of PXE. Calciphylaxis should be added to the list of disorders that may lead to microscopic PXE-like changes.

Localization of human herpes-like virus type 8 in vascular endothelial cells and perivascular spindle-shaped cells of Kaposi's sarcoma lesions by in situ hybridization

Kaposi's sarcoma (KS) is a neoplasm that develops as multifocal lesions characterized by a histological picture that includes irregularly shaped vascular spaces surrounded by perivascular and interstitial spindle-shaped cells, extravasated erythrocytes, and an inflammatory mononuclear cell infiltrate. Recently, the DNA sequences of a novel human gamma-herpesvirus-like (HHV-8) agent have been detected by polymerase chain reaction in KS associated with acquired immune deficiency syndrome (AIDS-KS), classical KS, and African endemic KS. The present study was done to identify the specific cells within KS tumors that contain the viral DNA. Fourteen skin biopsy specimens, including three classical KSs, six AIDS-KSs, three normal skin specimens, and two common warts from healthy individuals, were examined by polymerase chain reaction for the presence of the HHV-8 DNA sequences. HHV-8 DNA were present in all nine KS specimens but not detectable in the five non-KS tissue samples. Using in situ hybridization, we found the HHV-8 DNA sequences to be predominantly localized to the nuclei of endothelial cells lining the vascular slits and some perivascular spindle-shaped cells, in two of three KS and four of six AIDS-KS tissue sections examined. The HHV-8-positive cells of KS specimens were concurrently shown to also be positive for factor-VIII-related antigen by immunohistochemical staining. The presence of the DNA of HHV-8 in the nuclei of KS cells further supports the possibility that this agent may play a role in the pathogenesis of this tumor.

Mucocutaneous neoplasms in patients with human immunodeficiency virus infection

Neoplastic disorders of the skin are commonly encountered in patients with human immunodeficiency virus infection. As patients survive longer, they are at ever increased risk to acquire one of a number of different malignant neoplasms of the skin. These may be of many different types including epithelial, lymphoreticular, vascular, smooth muscle, and melanocytic. Because of the immunocompromised status of these patients, many of these disorders behave in more aggressive fashions and require more aggressive treatment.

Clinical and histologic spectrum of human T-cell lymphotropic virus type I-associated lymphoma involving the skin

BACKGROUND

Adult T-cell leukemia/lymphoma (ATL) is associated with infection with human T-cell lymphotropic virus type I (HTLV-I).

OBJECTIVE

The objective was to describe the clinical, histopathologic, and immunologic features in three patients with ATL involving the skin.

METHODS

Clinical histories and skin biopsy specimens were reviewed. Immunophenotypic studies were performed on peripheral blood lymphocytes (three patients) and on skin biopsy specimens (one patient).

RESULTS

Serologic testing in each patient was positive for HTLV-I. Specific cutaneous lesions of ATL were diverse. Histologic features included markedly epidermotropic lymphoid infiltrates and dermal aggregates of lymphocytes and macrophages resembling granulomas. One patient died 3 months after diagnosis; the other two are alive with residual lymphoma.

CONCLUSION

A spectrum of clinical, histologic, and immunophenotypic features are seen in ATL involving skin. Those cases with a chronic course may resemble mycosis fungoides clinically and histologically. Serologic testing for HTLV-I is recommended in all patients with cutaneous lymphoma from endemic areas and in those with other risk factors for HTLV-I infection.

Expression of transforming growth factor beta and transforming growth factor beta receptors on AIDS-associated Kaposi's sarcoma

Several humoral growth factors may contribute to the development and growth of AIDS-associated Kaposi's sarcoma (KS). They are either provided by chronically activated cells of the immune system or in an autocrine/paracrine manner by the neoplastic cells themselves. Transforming growth factor beta(TGF-beta) may directly enhance the growth of KS cells and tumor matrix formation. To mediate a signal both TGF-beta receptors type I and type II (TbetaR-I and TbetaR-II) have to be expressed. We investigated the expression of TGF-beta, TGF-beta receptors types I and II, and endoglin, a nonsignaling-type TbetaR-III, by means of immunohistochemistry on skin biopsies from patients with AIDS-related KS. We found that the TGF-beta ligand was expressed by KS cells in 9 of 11 samples. TbetaR-II was strongly expressed in 10 of 12 samples, but none of the investigated tumor samples stained for TbetaR-I. Endoglin was weakly expressed on all KS lesions and stained the endothelium of tumor-associated vessels in 92% of the samples. These findings show that most KS lesions have the ability to produce TGF-beta and that KS cells maintain a high expression of TbetaR-II in the absence of TbetaR-I, which may allow KS to escape growth inhibitory effects of endocrine or paracrine TGF-beta.

Cutaneous vasculitis and rheumatoid factor positivity as presenting signs of hepatitis C virus-induced mixed cryoglobulinemia

BACKGROUND AND DESIGN

Hepatitis C virus (HCV) infection is associated with mixed cryoglobulinemia, which can cause a vasculitis affecting various organs. To determine the prevalence of cutaneous vasculitis in patients infected with HCV, information concerning a series of 408 HCV antibody-positive outpatients was analyzed. Patients with a skin eruption were evaluated by a dermatologist for objective evidence of cutaneous vasculitis, and the sensitivity of cryoglobulins was compared with that of rheumatoid factor activity as a serologic marker of mixed cryoglobulinemia in these patients.

RESULTS

Cutaneous vasculitis was identified in 10 of 408 HCV-infected patients (prevalence of at least 2%). The vasculitis was manifested as palpable purpura in eight patients, livedo reticularis in one patient, and urticaria in one patient. The skin eruption was a major presenting feature in each of the 10 patients and even led to the discovery of occult HCV infection in two patients. Histologic examination revealed leukocytoclastic vasculitis in six patients and necrotizing arteritis consistent with polyarteritis nodosa in two patients. All 10 patients had chronic active hepatitis and exhibited rheumatoid factor activity. Variable features attributable to mixed cryoglobulinemia included arthropathy, central nervous system abnormalities, and glomerular disease. Serum cryoglobulins were detected in only four patients.

CONCLUSIONS

Practitioners should be alert to the possibility of HCV infection in patients presenting with palpable purpura, livedo reticularis, or urticaria, in which the underlying histologic features are those of leukocytoclastic vasculitis or necrotizing panarteritis. Positive serologic test results for HCV antibody and rheumatoid factor in such patients virtually confirm the diagnosis of HCV-induced mixed cryoglobulinemia.

Sclerotic primary cutaneous leiomyosarcoma

We describe the case of a painful primary cutaneous leiomyosarcoma that developed on the back of a 54-year-old white male over a 6-year period. The lesion had been sampled by punch technique and had been originally diagnosed as cutaneous sclerosis. Histologic examination of excisional tissue revealed a diffuse spindle cell neoplasm in the dermis that extended into the subcutis. There was extensive sclerosis and sparse cellularity in the deep portion and in several zones throughout the tumor. Immunostaining for desmin was negative, although stains for vimentin and smooth muscle actin were both strongly positive. Sclerotic cutaneous leiomyosarcoma should be recognized as a distinct but unusual variant of leiomyosarcoma that may be difficult to diagnose because of extensive sclerosis. Lesions may be painful and should be considered in the differential diagnosis of painful cutaneous neoplasms of the skin.

A comparison of the efficacy and safety of Jessner's solution and 35% trichloroacetic acid vs 5% fluorouracil in the treatment of widespread facial actinic keratoses

BACKGROUND AND DESIGN

We compared the efficacy and safety of a medium-depth chemical peel with those of the standard regimen of topical fluorouracil in the treatment of widespread facial actinic keratoses (AK). Fifteen patients with severe facial actinic damage and similar numbers of AK on both sides of the face were treated on the left side with a single application of Jessner's solution and 35% trichloroacetic acid and on the right side with twice daily applications of 5% fluorouracil cream for 3 weeks. Evaluations were conducted before treatment and at 1, 6, and 12 months after treatment. Visible AK were counted, random skin biopsies performed, adverse effects monitored, and patients questioned about preference and perception of efficacy.

RESULTS

Both treatments reduced the number of visible AK by 75% and produced equivalent reductions in keratinocyte atypia, hyperkeratosis, parakeratosis, and inflammation, with no significant alteration of preexisting solar elastosis and telangiectasia. Except for erythema that lasted 3 months in one patient, no untoward side effects were observed with the chemical peel. The majority of patients preferred the peel over fluorouracil because of the single application and less morbidity.

CONCLUSION

The medium-depth peel induced by Jessner's solution and 35% trichloroacetic acid is a useful alternative therapeutic option for widespread facial AK, particularly for poorly compliant patients, because it equals fluorouracil in efficacy while being superior in terms of the convenience of a single application with little associated morbidity.

Papulonodular mucinosis associated with systemic lupus erythematosus: possible mechanisms of increased glycosaminoglycan accumulation

BACKGROUND

The mechanism for the production of papulonodular mucinosis in patients with lupus erythematosus (LE) is not known.

OBJECTIVE

Our purpose was to determine whether fibroblasts in a patient with LE and papulonodular mucinosis produced more mucin than normal fibroblasts and whether this mucin production could be stimulated by the patient's serum.

METHODS

Skin fibroblasts from a patient with systemic LE and massive papulonodular mucin deposition, as well as normal fibroblasts, were incubated in the presence of serum from the patient or from a healthy volunteer. The production of glycosaminoglycan by fibroblasts was analyzed.

RESULTS

Fibroblasts from the patient produced more glycosaminoglycan than did normal fibroblasts. Glycosaminoglycan production was increased in all cells when incubated in the presence of the patient's serum.

CONCLUSION

Cutaneous mucin deposition in patients with papulonodular LE skin lesions is associated with increased glycosaminoglycan production by dermal fibroblasts. Our preliminary observations suggest glycosaminoglycan production by these fibroblasts appears to be stimulated by a factor, (or factors) in the patient's serum that is yet to be identified.

Cutaneous clues to HIV infection: diagnosis and treatment

The skin is one of the most important organs involved in patients with HIV infection. Because it is the one most readily evaluated by inspection, it is essential that clinicians be expert in the recognition of skin disorders that herald the presence of HIV disease or a change in the immune status of one already known to be infected. In this article, the most important cutaneous disorders in patients with HIV infection are discussed with special emphasis on those that can be used to assess prognosis or detect the presence of an opportunistic infection.