Successful treatment of an extended leg ulcer in systemic sclerosis

We report the successful surgical treatment of a large and painful leg ulcer associated with systemic sclerosis (scleroderma). In addition, there was a long occlusion of the superficial femoral artery, and ankle systolic blood pressure was 80 mmHg (ankle-brachial-index 0.65). All conservative treatments including systemic antibiotics, nifedipine, intravenous iloprost, intravenous penicilline G and hyperbaric oxygen failed. Pain was intolerable and below-knee amputation was considered. In a first attempt to save the limb, the patient underwent femoropopliteal bypass surgery. Despite a successful outcome of the bypass operation and normalization of the ankle blood pressure, the large wound remained recalcitrant and extremely painful. A second attempt to save the limb consisted of complete debridement of all sclerotic tissue down to the fascia and split skin grafting. The graft took in over 90% of the surface and the remaining wound healed spontaneously. Large leg ulcers in systemic sclerosis can become limb threatening. Radical debridement combined with a split skin graft seems to be a promising way to avoid amputation.

[Dapsone in granulomatous rosacea]

We report on two patients with granulomatous rosacea and another patient with granulomatous perioral dermatitis who responded well to dapsone. Dapsone has a pharmacological double function as both an antibiotic and an antiphlogistic drug. Before the introduction of isotretinoin, dapsone had its place in the treatment of severe acne. To date, its use in granulomatous rosacea has not been described. When hematologic parameters are monitored, dapsone is considered a safe and cost-effective drug, especially in countries where isotretinoin is not readily available. However, the definite value of dapsone in granulomatous rosacea should be established by a controlled study.

[Tufted hair folliculitis]

A case of tufted hair folliculutis presenting as circumscribed, tender and inflamed areas in the occiput with residual tufted follicles in a 28-year old man is reported. Tufted hair folliculitis is a characteristic localized scarring bacterial folliculitis of the scalp due to Staphylococcus aureus. Histopathological studies reveal perifollicular inflammation around the upper portions of the follicles sparing the hair root level. Within areas of inflammation, several follicles converge toward a common follicular duct with a widely dilated opening. Currently, tufted hair folliculitis is considered a variant of folliculitis decalvans of Quinquaud. Staphylococcal infection is believed to be an initial causative factor, and underlying differences in follicular anatomy or host response may be important in determining which reaction pattern occurs in an affected individual. The development of atrophy with loss of adnexal structures (in folliculitis decalvans) or of hair tufts (in tufting folliculitis) may depend upon the depth and destructive potential of the inflammatory process. The therapeutic approach is problematic; prolonged treatment with oral antibiotics may stabilize the disease, but good and at times more definitive results (as in the presented case) have been reported after radical surgical excision of the involved areas.

Effect of time of day and duration into shift on hazardous exposures to biological fluids

OBJECTIVE

To determine whether hospital employee biological hazardous exposure rates varied with time of day or increased with time interval into shift.

METHODS

This was a retrospective occurrence report review conducted at a university hospital with an emergency medicine residency program. Health care worker biological hazardous exposure data over a 30-month period were reviewed. Professional status, date, time, and type of exposure (needlestick, laceration, splash), time interval into shift of exposure, and hospital location of exposure were recorded. Hourly employee counts and risky procedure counts were matched by location with each reported exposure, to determine hourly rates of biological hazardous exposures.

RESULTS

Analysis of 411 recorded exposures demonstrated that more people were exposed between 9:00 AM and 11:00 AM (p < 0.05), yet the exposure risk did not vary significantly when expressed as the number of exposures per worker or per procedure. Of the 393 exposures with data describing time interval into shift when the exposure occurred, significant numbers of exposures occurred during the first hour and at shift's end [when corrected for exposures per worker (p < 0.05) or exposures per procedure (p < 0.05)].

CONCLUSION

While the number of exposures are increased in the AM hours, the exposure rate (as a function of workers or procedures) does not vary with time of the day. However, the exposure rate is increased during the first hour and last 2 hours of a shift. Efforts to increase worker precautions at the beginning and end of shifts are warranted.

Influence of ethanol on in vitro growth of human mammary carcinoma cell line MCF-7

We have shown that ethanol in concentrations of 0.0001%-10% significantly enhances 3H-thymidine uptake in cultured human mammary carcinoma cell line MCF-7. Methanol only enhances 3H-thymidine uptake in a concentration of 0.01%.

[Treatment guidelines for venous leg ulcers: causal therapy initiation and local wound treatment]

Treatment of leg ulcers should consider two aspects, i.e. the exact underlying condition (main cause and contributing factors) and local conditions. Compression therapy remains the corner-stone of the therapeutic concept. A compression of 35 mmHg at the distal calf improves insufficient venous function. A systolic ankle pressure of < or = 80% of blood pressure (ankle-arm-index < or = 0.8) requires reduction of compression therapy. At an ankle pressure below 80 mmHg compression should not be used. If superficial reflux is the major cause of chronic venous insufficiency, vein stripping should be considered. Contributing diseases like heart insufficiency, anemia or diabetes may require general medical care. Local contributing factors like reduced mobility of the ankle joint and lymphostasis may require physical therapy, and calcification of the wound bed should be excised. Local treatment considers ulcer bed and border. The ulcer bed needs debridement and moist wound care. Infection is treated with systemic antibiotics, according to the antibiogram. Tetanus immunization is required for all leg ulcer patients. Some centers report good results with endoscopic subfascial decision of perforator veins, paratibial fasciotomy and excision of fibrous tissue. Local application of recombined growth factors is currently under clinical evaluation. Adjuvant pharmacotherapy plays a minor role in the treatment of venous leg ulcers. An efficient treatment of the underlying cause combined with optimal wound care are the key to therapeutic success.

Periodic quasi-orthogonal spline bases and applications to least-squares curve fitting of digital images

Presents a new covariant basis, dubbed the quasi-orthogonal Q-spline basis, for the space of n-degree periodic uniform splines with k knots. This basis is obtained analogously to the B-spline basis by scaling and periodically translating a single spline function of bounded support. The construction hinges on an important theorem involving the asymptotic behavior (in the dimension) of the inverse of banded Toeplitz matrices. The authors show that the Gram matrix for this basis is nearly diagonal, hence, the name "quasi-orthogonal". The new basis is applied to the problem of approximating closed digital curves in 2D images by least-squares fitting. Since the new spline basis is almost orthogonal, the least-squares solution can be approximated by decimating a convolution between a resolution-dependent kernel and the given data. The approximating curve is expressed as a linear combination of the new spline functions and new "control points". Another convolution maps these control points to the classical B-spline control points. A generalization of the result has relevance to the solution of regularized fitting problems.

Uremic small-artery disease with medial calcification and intimal hyperplasia (so-called calciphylaxis): a complication of chronic renal failure and benefit from parathyroidectomy

BACKGROUND

Uremic small-artery disease with medial calcification and intimal hyperplasia can lead to life-threatening skin necrosis or acral gangrene. It is a distinct complication of chronic renal failure that must be differentiated from soft-tissue calcification. An increased calcium-phosphate product and secondary hyperparathyroidism are the main underlying conditions. The benefit of parathyroidectomy is controversial.

OBJECTIVE

This article is based on a literature search to determine prognostic factors and, in particular, the benefit of parathyroidectomy.

METHODS

The literature on uremic small-artery disease (so-called calciphylaxis) was reviewed (full data set: 104 cases, including five of our own). The therapeutic benefit of parathyroidectomy and the relation between prognostic predictors (localization, dialysis, and transplant) and outcome were analyzed. The relation between diabetes and acral gangrene was also examined. Further epidemiologic data on the reviewed group of patients were established.

RESULTS

Thirty-eight of 58 patients who underwent parathyroidectomy survived compared with 13 of 37 patients who did not undergo parathyroidectomy (p = 0.007, n = 95). Forty of 53 patients with distal localization of necrosis survived compared with 11 of 42 patients with proximal pattern (p < 0.00001; n = 95). Dialysis and kidney transplantation followed by immunosuppression showed no relation to disease outcome. No association was found between diabetes and acral gangrene (p = 0.50).

CONCLUSION

Uremic small-artery disease is a distinct complication of chronic renal failure. Its recognition and early diagnosis should allow more effective treatment. In our retrospective study parathyroidectomy was significantly related to survival. Only a randomized, controlled, prospective trial (parathyroidectomy vs conservative treatment of secondary hyperparathyroidism) can establish the value of parathyroidectomy in uremic small-artery disease.

Benzidine stain for the histochemical detection of hemoglobin in splinter hemorrhage (subungual hematoma) and black heel

Minor nail trauma may cause bluish discoloration of the nail, while tangential skin trauma on the heel can result in a so-called black heel. To rule out melanoma in such clinical situations, a biopsy is needed to reveal homogeneous eosinophilic masses deposited under the nail plate or within it (transepidermal elimination). Most dermatopathologists attempt to demonstrate the presence of hemoglobin in these eosinophilic masses with Prussian blue stain, which typically remains negative. In our experience, these traumatically induced blood deposits are always situated in avascular spaces, devoid of degrading phagocytes. Consequently, a histochemical stain for these deposits should be directed specifically toward hemoglobin, not hemosiderin. In the dermatopathologic literature, the various techniques to detect hemoglobin deposits in tissue sections are not well-known. We would like to emphasize benzidine stain, a highly selective and efficient method to demonstrate the presence of hemoglobin deposits in histologic sections. To date, benzidine stain has not been utilized to characterize splinter hemorrhage (subungual hematoma). Of concern, the use of benzidine in histopathology laboratories is restricted because this agent is a known carcinogen, while the non-mutagenic derivative, 3,3',5,5'-tetramethylbenzidine, does not stain histologic sections. Patent blue V, a completely different and less specific agent, stains hemoglobin an intense blue-green.

Relapsing eosinophilic perimyositis

Relapsing eosinophilic perimyositis is a rare entity. Only 11 cases have been reported in the literature. We describe a patient with relapsing myopathy, peripheral blood eosinophilia and cutaneous manifestations, who had histopathological features of eosinophilic perimysial inflammation. His disease responded to moderate doses of glucocorticosteroids, and pursued an apparently benign course. Serum levels of eosinophilic cationic protein correlate with disease activity, and may be helpful in monitoring treatment. The features of this case are compared with those of other hypereosinophilic syndromes. It appears to be part of the spectrum of eosinophilic myositis.

Airborne irritant contact dermatitis from metal dust adhering to semisynthetic working suits

2 workers at an aircraft factory were employed in a plasma sparying unit. Soon after they were equipped with new semisynthetic working suits, they started to complain of pruritic eruptions after heavy exposure to metal dust. They noted that the dust was not as easily blown off the clothes by pressurized air as previously. Clinical findings consisted of discrete macular and papular lesions, partly follicular, on the ventral and medial thighs. Atopy score, IgE level and a standard series of prick tests ruled out atopic disposition. Patch tests revealed no reactions. A diagnosis of occupational airborne irritant contact dermatitis from metal dust was therefore made. To elucidate the role of the working suit, extensive physical investigations of the physical properties of the textile were performed. Microscopic pictures at low magnification showed more dust particles on the semisynthetic working suit, compared to the former pure cotton suit. This impression could not be confirmed by particle count because of too uneven particle distribution at higher magnification. Hairiness of the 2 textiles was low and ruled out irritation by the semisynthetic textile itself. No difference in electrostatic properties between the 2 working suits could be established either. Both textiles showed high static electrical propensity. When use of the semisynthetic overall was discontinued, the patients reported no recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

[Skin changes in kidney diseases and in chronic kidney insufficiency]

Skin symptoms in renal disease occur in a series of rare inherited or acquired diseases affecting the kidneys as well as the skin (amyloidosis, vasculitis, angiokeratoma diffusum corporis Fabry) (table 1). Chronic renal failure, regardless of its origin, often causes important skin symptoms, such as pruritus, the typical complexion with elastosis seen in uremic patients, porphyria cutanea uremica, metastatic calcifications, skin necrosis due to uremic small arteries disease with medial calcification and intimal hyperplasia, perforating dermatoses, nail lesions and symptoms of the oral mucosa (table 2). The following article reviews the pathogenesis and the limited possibilities of treatment for skin symptoms in chronic renal failure.

[Lupus erythematosus discoid-like dermatosis in a carrier of septic granulomatosis]

We present a clinically atypical case of discoid lupus erythematosus in the mother of a boy with chronic granulomatous disease. In this disorder, the phagocytes are unable to produce superoxide anion to degrade incorporated microorganisms. In addition to a discoid lupus erythematosus-like skin disease, recurrent stomatitis aphthosa, hidradenitis suppurativa and Raynaud phenomenon are markedly associated with heterozygote carriers of chronic granulomatous disease. Based on this conspicuous association, diverse models concerning the pathogenesis of lupus erythematosus are discussed.

Disulfite-induced acute intermittent urticaria with vasculitis

Recognition of sulfite sensitivity by the practicing dermatologist has become increasingly important. A wide spectrum of anaphylactoid reactions can occur after ingestion of sulfite additives in foods and medications. We report the case of a 47-year-old man with severe acute intermittent urticaria. A placebo-controlled oral challenge test with 50 mg sodium disulfite resulted in an acute urticaria attack. A biopsy taken 5 h after the appearance of the urticaria demonstrated a leukocytoclastic vasculitis with eosinophilia. Avoiding foods and drugs containing sulfites is often difficult due to its widespread use. Therefore, the patient should be equipped with a medical emergency kit.