The role of hepatitis B and C viruses in hepatocellular carcinoma in a hepatitis B endemic area. A case-control study

To investigate the role of hepatitis B (HBV) and C viruses (HCV) in hepatocellular carcinoma (HCC) in an HBV endemic area and elucidate the interaction of these two viruses, a case-control study of 128 patients with HCC and 384 age-matched and sex-matched control subjects was done. The positive rates of hepatitis B surface antigen (HBsAg, 77.3%, 99 of 128) and anti-HCV (19.5%, 25 of 128) in patients with HCC were significantly higher than in control subjects (P less than 0.001). Both HBsAg and anti-HCV were important risk factors for HCC (relative risks, 13.96 and 27.12, respectively), and the risk for HCC was elevated significantly to 40.05 (95% confidence interval, 12.57 to 127.6) when HBsAg and anti-HCV were considered simultaneously. These results suggested that HBV and HCV were associated highly with HCC in an HBV endemic area and that these two viruses might contribute independent but synergistic effects to the pathogenesis of HCC.

Mycetoma: infection with tumefaction, draining sinuses, and "grains"

Mycetoma is a tumorous infection of skin and subcutaneous tissue. It is caused by either actinomycotic bacteria or eumycotic fungi. The three cardinal features are tumefaction or the appearance of indolent inflammatory nodules and secondary fibrosis, formation of sinus tracts and fistulas that may have the ability to penetrate deep tissue, and the presence of grains or granules in the affected tissue and discharge. Although mycetoma is relatively uncommon in the United States, increasing mobility and changes in demographic characteristics should lead to a greater awareness of this disease. Characteristic histopathologic findings and microbiological identification establish the diagnosis. Consequently, when evaluating what might seem like an ordinary skin or fungal infection, we must widen our differential diagnosis to include mycetoma. Effective treatments for actinomycetoma are available, whereas eumycetoma is often difficult to treat.

Mid dermal elastolysis with wrinkling. Report of two cases and review of the literature

BACKGROUND

We observed two patients who had mid dermal elastolysis with wrinkling.

OBJECTIVE AND METHODS

We reviewed the pertinent features of the four cases reported in the literature and of our two cases. We also compared mid dermal elastolysis with other disorders of acquired elastolysis, such as postinflammatory elastolysis and cutis laxa, anetoderma, and (regular) cutis laxa.

RESULTS

Our two patients with mid dermal elastolysis with wrinkling were middle-aged, white women. Physical examination showed widespread wrinkling, erythematous patches (macules), and papules. Histologic examination showed patchy loss of elastic tissue limited to the mid dermis. In one of our patients, elastolytic skin lesions appeared on areas not covered by a two-piece swimsuit. She used to sunbathe frequently. In our other patient, skin lesions were also more prominent on exposed areas.

CONCLUSION

We speculate that sun exposure is one of the main causative factors of mid dermal elastolysis with wrinkling.

Panniculitis

An accurate assessment of subcutaneous lesions can be made by joining the differential diagnoses generated by clinical and histologic features. Anatomic location of lesions, presence or absence of ulceration, occurrence of lipoatrophy, history of trauma, association with immunologic or metabolic disorders, and age of the patient are important clinical data to consider in conjunction with the microscopic features. Individual histologic features such as calcification, cytophagic histiocytes, pseudocysts, lymphoid nodules, and crystals should be evaluated in conjunction with the inflammatory infiltrate (i.e., granulomatous, neutrophilic, lymphocytic, or combined); presence and type of necrosis (e.g., basophilic, hyaline, lobular, or septal); and presence and extent of sclerosis. For optimal management of patients, it is important to consider the differential diagnosis generated by the dominant histologic features as well as the clinical and histologic abnormalities.

Purpura simplex (inflammatory purpura without vasculitis): a clinicopathologic study of 174 cases

Purpura simplex manifests clinically as macular purpuric and petechial pigmented, golden, annular, or lichenoid lesions. These subtypes have been termed Schamberg's purpura, lichen aureus, Majocchi's purpura, and Gougerot-Blum purpura. Histologically, there is inflammation and hemorrhage without fibrinoid necrosis of vessels. One hundred seventy-four cases were retrospectively reviewed. In some patients, the eruption was related to medications. Treatment was usually of limited benefit. Fifty-eight of 87 patients (67%) who had follow-up data did eventually have clearing of lesions. Because of the clinical and histologic similarities among the subtypes, the inclusive term purpura simplex is favored.

The subsequent risk of internal cancer with Bowen's disease. A population-based study

OBJECTIVE

To address the subsequent risk of internal cancer in a population-based cohort of patients with Bowen's disease.

DESIGN

Incident cases of skin cancers other than malignant melanoma occurring in a defined population were classified as basal cell carcinoma, squamous cell carcinoma, or Bowen's disease. Through medical records, all patients were followed up for the development of subsequent internal cancer until they died, moved from Rochester, Minn, or January 1, 1986, whichever came first. Incidence rates of skin cancer and subsequent cancer were computed; the subsequent rate of internal cancer was compared with that prevailing in the community.

PATIENTS

Enrolled were all permanent residents in the population base of Rochester, Minn, who developed basal cell carcinoma (n = 657), squamous cell carcinoma (n = 169), or Bowen's disease (n = 71) on the basis of pathologic examination and clinical presentation from 1976 through 1984.

MAIN OUTCOME MEASURE

The relative risk of subsequent internal cancer among patients with Bowen's disease compared with that of the population base from which they arose was 1.1 (95% confidence limits, 0.5, 1.6).

RESULTS

Annual incidence rates, adjusted to the 1980 US white population, were 14.9 per 100,000 for Bowen's disease, 38.8 for squamous cell carcinoma, and 146 for basal cell carcinoma. The estimated relative risk for subsequent cancer was 0.9 (95% confidence limits, 0.5, 1.6) among patients with squamous cell carcinoma and 1.0 (95% confidence limits, 0.7, 1.3) for patients with basal cell carcinoma. These risks were not significantly different for various durations of follow-up or for sun-exposed vs sun-protected sites.

CONCLUSIONS

We find no evidence in these population-based cohort data of and increased risk of subsequent internal cancer associated with Bowen's disease or other forms of nonmelanomatous skin cancer.

Cutaneous manifestations of cryoglobulinemia: clinical and histopathologic study of seventy-two patients

In the 72 cases of cryoglobulinemia reviewed, erythematous to purpuric macules or papules were present in 92%. Infarction, hemorrhagic crusts, and ulcers were present in 10% to 25% of the patients and were relatively more common in type I cryoglobulinemia than in the other types. Postinflammatory hyperpigmentation was noted in 40%. Lesions on the leg were common in all types of cryoglobulinemia; however, lesions on the head and mucosal surfaces suggested type I cryoglobulinemia. Histopathologic features were classified as vasculitis in 50%, inflammatory or noninflammatory purpura in 15%, noninflammatory hyaline thrombosis in 10%, and postinflammatory sequelae in 10%. Noninflammatory hyaline thrombosis was relatively more frequent in type I. Thus erythematous to purpuric lesions on the legs and leukocytoclastic vasculitis are the common cutaneous findings in cryoglobulinemia. Type I cryoglobulinemia is suggested by noninflammatory hyaline thrombosis, cutaneous infarction, hemorrhagic crusts, skin ulcerations, and lesions of the head and neck and of oral or nasal mucosa.

Eosinophils in lupus panniculitis and morphea profunda

The extent of eosinophils in skin biopsy and peripheral blood specimens of patients with lupus panniculitis and morphea profunda was determined by studying 37 biopsies from 33 patients with lupus panniculitis and 55 biopsies from 53 patients with morphea profunda. Specimens from 8 (24%) of 33 patients with lupus panniculitis showed eosinophils, and 13 (25%) of 53 patients with morphea profunda had eosinophils in the subcutaneous tissue. In all cases, the diagnosis of lupus panniculitis or morphea profunda was established on the basis of other, more characteristic histologic features; the presence of eosinophils was incidental and not a diagnostic criterion. Occasional cases of lupus panniculitis or morphea profunda had numerous eosinophils. However, in most of the specimens, eosinophils were absent or observed in small numbers. Only 3% of patients with lupus panniculitis showed an increase in the number of eosinophils in the peripheral blood, whereas 47% of patients with morphea profunda had peripheral eosinophilia. The degree of hyaline necrosis in lupus panniculitis or of sclerosis in morphea profunda did not correlate with the number of eosinophils present in the biopsy specimen or peripheral blood.

Rheumatic manifestations in myelodysplastic syndromes

The myelodysplastic syndromes are characterized by ineffective hematopoiesis with possible transformation to acute nonlymphocytic leukemia. We describe a patient with refractory anemia with excess blasts with unusual rheumatic manifestations of vasculitis, migratory synovitis, arthralgias, and myalgias. A retrospective review over a 6-month period of 162 patients with myelodysplastic syndromes found 16 patients (10%) with several rheumatic manifestations. We divided these manifestations into 4 different categories: cutaneous vasculitis, "lupus-like syndrome," neuropathy, and patients with both a rheumatic disease and a myelodysplastic syndrome. There were 7 with cutaneous vasculitis including leukocytoclastic vasculitis and other individual cases of urticarial vasculitis and panniculitis; 3 with lupus-like manifestations with histological evidence of an inflammatory process; 3 with neuropathic manifestations including peripheral neuropathy, mononeuritis with foot drop, and chronic inflammatory demyelinating polyneuropathy; and 3 patients in which their myelodysplastic syndrome was diagnosed after their rheumatic disease was known, including rheumatoid arthritis. Sjögren's syndrome and mixed connective tissue disease. The class with refractory anemia with excess blasts had 9 patients with rheumatic manifestations but also had the largest number of patients in the study (46/162 or 29%). Three of the 16 patients died, all from the refractory anemia with excess blasts class, reflecting the known mortality in this group of patients. We believe there is a significant association between myelodysplastic syndromes and rheumatic manifestations.

Cutaneous botryomycosis

We report four cases of cutaneous botryomycosis. The predisposing factors included alcoholism, diabetes, and trauma. Clinically, the patients had nodules, suppurative plaques, or ulcers. In two cases, Staphylococcus aureus was cultured. In one case Neisseria species was cultured and in another a coagulase-negative Staphylococcus and Corynebacterium species were the only organism cultured. All patients responded to systemic antibiotic therapy.

Bullous lesions in cutaneous lupus erythematosus

Seventeen patients with cutaneous lupus erythematosus (LE) were observed to have bulla formation. Their clinical, histopathologic, and immunopathologic findings are reported. All biopsy specimens studied revealed moderate to severe vacuolating degeneration of the basal cell layer as well as lymphocytic inflammatory infiltrate involving the dermoepidermal junction. Immunoglobulins or C3 (or both) was deposited in the basement membrane zone in eight of nine patients in whom direct immunofluorescence study was performed. We believe that the immune reaction in the papillary dermis and the severe vacuolating degeneration in the basal cell layer result in the separation of epidermis and dermis, and thus bullous formation, in some patients with LE. This phenomenon can be observed not only in systemic LE but also in subacute cutaneous LE and discoid LE.

Nontuberculous mycobacterial infections of the skin. Report of fourteen cases and review of the literature

This study comprised 14 patients from whose skin nontuberculous mycobacteria were recovered. Most clinical manifestations were relatively nonspecific. Various histopathologic patterns were observed in 22 biopsy specimens. Recurrences were common and prolonged treatment was often necessary. Culture of tissue remains the definitive diagnostic procedure. Cutaneous lesions can be the first or only site of nontuberculous mycobacteriosis.

Abdominal sonographic screening in a single community

A health survey, on adults aged 30 years or more, was carried out at 3 villages on the southwest coast of Taiwan. A total of 923 cases (42.6%) of the 2,166 population participated in the survey. The estimated total population prevalence rates were as follows: no gross lesion (60.5%), fatty liver (25.2%), biliary stone (5.2%), gall bladder polyp (1.9%), hepatic hemangioma (1.4%), liver cyst (0.9%) and renal cyst (2.9%). The prevalence rates of gall bladder polyp and renal cyst were higher in men, while that of fatty liver was higher in women. There was an increase in the prevalence with age for fatty liver in females. The results might be a reference about the above findings among Chinese in Taiwan.

Multicentric cloacogenic carcinoma: report of a case with anogenital pruritus at presentation

A case of multicentric cloacogenic carcinoma of the perianal skin and vulva in a 79-year-old woman is presented, and the embryologic basis for the multicentricity is discussed. Histologically, cloacogenic carcinoma can be differentiated from other small cell neoplasms that affect the area. Cloacogenic carcinoma should be considered a rare cause of anogenital pruritus. It is important to perform an early biopsy of anogenital lesions that do not respond to conventional therapy.

Subungual leukemia cutis

A 79-year-old man had generalized humping of the nails and subungual tumors involving several fingers and the left big toe. Findings on histologic study of the tumor, together with the pattern on the peripheral blood smear, established the diagnosis of chronic lymphocytic leukemia. To the best of our knowledge, this is the first reported case of chronic lymphocytic leukemia involving the subungual area. The authors' observation emphasizes the importance of taking a biopsy specimen in the differential diagnosis of subungual tumors.

Clinicopathologic study of cutaneous plasmacytoma

Eight patients with skin tumor lesions composed of dense, predominantly plasma cell infiltrates were studied. Primary cutaneous plasmacytoma can be reactive (polyclonal) or neoplastic (monoclonal). In four of the patients skin lesions were associated with multiple myeloma. Specific skin lesions usually consisted of reddish or purple nodules located on the trunk. In one case the cutaneous lesions developed at the site of previous herpes zoster. Histologically, the cutaneous plasmacytic infiltrate was mainly diffuse and monomorphous. Most of the plasma cells were mature, but in some cases immature immunoblasts and mitoses were observed. Serum immunoelectrophoresis findings correlated with the monoclonality or polyclonality of the plasmacytoma. Presence or absence of systemic involvement cannot be predicted from the appearance of clinical lesions or from maturity of plasma cell infiltration in the skin.

Risk factors for gallstones among Chinese in Taiwan. A community sonographic survey

A health survey of adults aged 30 years or more was carried out in southwest Taiwan to determine the prevalence of gallstones and to study risk factors associated with gallstones. Blood samples were collected and abdominal sonographic examination and anthropometric measurements were performed on a total of 923 people. The 40 gallstone cases detected resulted in a prevalence of 4.3%. The risk factors explored included age, sex, hepatitis, obesity, hyperlipidemia, and diabetes mellitus (DM). Age and DM were the only significant factors associated with gallstones in our study. With a reference group of 30-39-year-olds as a comparison, multiple logistic regression analysis showed a trend effect with odds ratios of 1.73, 3.74, and 6.32 for age groups of 40-49, 50-59, and 60 or above, respectively. The odds ratio for DM was as high as 2.59. However, sex, body weight index, chronic hepatitis B, and hyperlipidemia were not significantly associated with gallstones.

Noonan's syndrome with extensive verrucae

We report the case of a patient with multiple findings characteristic of Noonan's syndrome, including a severe lymphedema present since early infancy, hypertelorism, low-set and prominent ears, broad facies, low posterior hairline, high arched palate, broad short neck, slightly short stature, and moderate dental malocclusion. In addition, extensive verrucae planae, verrucae vulgares, and condylomata acuminata occurred and were refractory to conventional therapy. To our knowledge, this is the first report of an association of Noonan's syndrome with extensive verrucae. We speculate that it is related to immunodeficiency as a consequence of loss of immunoglobulins and lymphocytes from intestinal lymphangiectasia. Cutaneous findings and other physical anomalies reported in patients with Noonan's syndrome are reviewed.

Autosomal dominant granulomatous arthritis, uveitis, skin rash, and synovial cysts

In 1985, Blau reported a family with 11 members in four generations affected by granulomatous arthritis, iritis, skin rash, and periarticular synovial cysts. We report a second family with these abnormalities, thereby confirming this syndrome as a distinct familial entity with transmission compatible with autosomal dominant inheritance. Affected members in our family included a mother and two daughters. Disease onset was at 10 months to 8 years of age. Each had uveitis, symmetric polyarthritis, and synovial cysts overlying the ankle and wrist joints. In addition, both daughters had an intermittent generalized erythematous papular rash that on biopsy revealed noncaseating granulomatous infiltration. All three patients improved during alternate-day steroid therapy. Recognition of this disorder as distinct from other, more common causes of arthritis is important because of the apparent autosomal dominant transmission and because of the excellent responses to low-dose steroid therapy.