Cyclosporine treatment for dermatomyositis/polymyositis

We report one case of dermatomyositis and one case of polymyositis and scleroderma in which the patients' condition improved after treatment with cyclosporine (cyclosporine A). Both patients' conditions were unresponsive to systemic steroid therapy. The addition of cyclosporine to the regimen enabled us to taper the steroid dosage; the lesions resolved and the results of laboratory tests returned to normal. In nine of thirteen studies of dermatomyositis treated with cyclosporine reported in the literature, definite benefit was achieved and no serious toxicity was noted.

Chordoma involving the skin: an immunohistochemical study of 11 cases

Immunohistochemical properties were studied in 16 lesions from 11 patients with chordoma involving the skin. There were nine men and two women ranging from 21 to 62 years old (mean, 42.6). The initial tumor was sacrococcygeal in 10 cases and nasopharyngeal in 1 case. Three lesions represented a direct extension from the primary tumor to the skin, and 13 lesions were examples of local recurrences in the skin. Immunohistochemically, all lesions showed positivity for keratin, whereas 14 lesions were positive for vimentin and 12 for protein S-100. Epithelial membrane antigen was positive in four instances and carcinoembryonic antigen was negative in all studies. No significant difference was observed between the immunoprofile of cases of direct extension and those of local recurrences. Overall, the remarkable triple positivity for keratin, vimentin, and protein S-100 was observed in 11 lesions from eight different cases (73%). This study confirmed the utility of immunohistochemistry in the differential diagnosis of chordoma from tumors with similar histologic characteristics encountered in the skin.

Alpha-fetoprotein in patients with hepatocellular carcinoma after transcatheter arterial embolization

To assess the usefulness of alpha-fetoprotein (AFP) in monitoring treatment effects of transcatheter arterial embolization (TAE) in hepatocellular carcinoma (HCC) patients, a total of 31 sets of AFP levels after TAE in 21 HCC patients were analysed by linear regression between logarithmic AFP levels and days. Eleven sets of AFP data with poor linear declination were accompanied with poor TAE results except in one patient who had chronic hepatitis with acute exacerbations. Twenty sets of data with good linear declination in the first month after TAE indicated good TAE results. Seven of them showed no evidence of tumour recurrence nor elevated AFP levels within a follow-up of 6 months. The mean, standard deviation and range of half-lives of AFP in the non-recurrent group were 5.0, 1.6 and 2.9-7.2 days, respectively. The others experienced late tumour recurrence that was detected by rebound of AFP levels except one who had another non-AFP-secreting HCC. Thus, the results might be used as a reference in monitoring the treatment effects of TAE and the timing selection of repeated TAE.

Dermatologic manifestations of human immunodeficiency virus infection

Human immunodeficiency virus (HIV) infection and the acquired immunodeficiency syndrome (AIDS) have become major health problems in the United States, and patients with manifestations of these diseases are seen by physicians in all areas of medicine. Cutaneous manifestations develop in as many as 92% of HIV-positive persons. Familiarity with these manifestations facilitates early diagnosis and enhances the care of HIV-infected patients. The spectrum of mucocutaneous disorders in these patients includes an acute exanthem, multiple infections, neoplastic processes, and miscellaneous disorders. Herein we review the most common and the most specific dermatologic manifestations associated with HIV infection, which often are atypical, more severe, or less responsive to treatment than the corresponding diseases encountered in non-HIV-infected persons.

Malignant lymphoma and leukemia with prominent ulceration: clinicopathologic correlation of 33 cases

BACKGROUND

The clinical and pathologic findings in patients with malignant lymphomas who presented with prominent cutaneous ulcers are described.

OBJECTIVE

Our purpose was to determine the histologic findings, type, and prognosis of lymphomas with cutaneous ulcers.

METHODS

Thirty-three patients (20 with cutaneous T-cell lymphomas, 10 with other non-Hodgkin's lymphomas, and 3 with leukemia) were retrospectively studied.

RESULTS

All patients had a poor prognosis; 23 died within 9 months after the onset of the ulcers. Patients with non-Hodgkin's lymphoma had a worse prognosis, had a higher incidence of systemic involvement, and more often had ulcers as an initial manifestation of lymphoma than did the patients with cutaneous T-cell lymphoma. The histopathologic findings ranged from a nonspecific inflammatory infiltrate to ulcers with marked adjacent epidermal epidermotropism to ulcers with an angiocentric infiltrate.

CONCLUSION

A variety of lymphomas may cause cutaneous ulceration. Adequate sampling of these ulcers is necessary for diagnosis. The average life expectancy after ulcer formation is 21 months.

Relationship between fatty liver, alanine aminotransferase, HBsAg and hepatitis C virus

A community health survey of 923 residents aged 30 years or more was performed in Putai Township of Taiwan. To elucidate the relationships between hepatitis C virus (HCV) and surrogate tests for non-A, non-B hepatitis in hyperendemic areas of hepatitis B virus (HBV) serum levels of alanine aminotransferase (ALT), triglycerides, cholesterol, hepatitis B surface antigen (HBsAg) and antibody to HCV (anti-HCV) were examined. Glucose tolerance tests and the history of diabetes treatment were used to define the diabetes status. Fatty liver was diagnosed by sonography. The prevalence of anti-HCV was 2.6% (95% confidence interval, 1.6-3.6%). Elevated ALT and fatty liver were significantly associated with anti-HCV in univariate analysis. Anti-HCV was not an associated factor for fatty liver after adjusting for serum triglycerides and cholesterol, sex, body mass index and diabetes status through multiple logistic regression. However elevated ALT was still associated with anti-HCV after adjusting for serum triglycerides, sex, body mass index, HBsAg and age through multiple linear regression. The anti-HCV prevalence was similar between HBsAg-positive and negative subjects. Aggregation of HCV infection was found among spouses. It was concluded that elevated ALT and intimate contact with HCV carriers might be associated factors for HCV infection, and that HBV infection and fatty liver were not related to HCV infection in Taiwan.

Marjolin's ulcer: immunohistochemical study of 17 cases and comparison with common squamous cell carcinoma and basal cell carcinoma

Formalin-fixed, paraffin-embedded biopsy specimens of 17 cases of squamous cell carcinoma of Marjolin's ulcer (SCC-MU), 6 cases of common SCC (SCC), and 5 cases of basal cell carcinoma (BCC) were stained with three monoclonal antikeratin antibodies (CAM 5.2, MAK-6, and MA-903), a monoclonal antivimentin antibody (V9), and a polyclonal anticarcinoembryonic antigen antiserum (A115). Neoplastic cells of SCC-MU, SCC, and BCC showed consistently negative staining for CAM 5.2. A wide range of reactivity, from negative to diffuse strong positivity, among neoplastic cells of SCC-MU and SCC was noted with MAK-6. Alternatively, neoplastic cells of SCC-MU, SCC, and BCC consistently showed diffuse moderate to strong reactivity with MA-903. These findings imply that SCC-MU has largely high-molecular-weight keratins. They also showed a wide range of reactivity with V9. However, neoplastic cells of five of the six SCC and five cases of BCC were negative for V9. These findings suggest that neoplastic cells of SCC-MU contain vimentin in higher frequency than in the more usual SCC.

Palisading granulomas caused by infectious diseases

We recently encountered a palisading granuloma in which an infectious cause was not considered until special stains revealed hyphae and tissue culture revealed organisms of phaeohyphomycosis. A review of more than 2,500 cases of various granulomas revealed 11 cases of palisading-type granuloma caused by infection, including phaeohyphomycosis, nontuberculous mycobacteriosis, papulonecrotic tuberculid, tuberculoid syphiloderm, cat-scratch disease, sporotrichosis, cryptococcosis, and coccidioidomycosis. Infectious disease should be considered in the differential diagnosis of palisading granuloma. Special stains for bacteria, fungi, and acid-fast bacilli should be performed in biopsy specimens that have a palisading granuloma pattern with central necrosis, especially in immunosuppressed patients.

Clinical utility of pulsed Doppler in the detection of arterioportal shunting in patients with hepatocellular carcinoma

Ninety-seven patients with hepatocellular carcinoma had duplex scanning from the patent or residual portal lumen and comparative angiography. Duplex ultrasonography identified five of nine patients with angiographic evidence of arterioportal shunting. Furthermore, Doppler results indicated the presence of the shunt in one patient without angiographic evidence. Duplex scanning from the portal lumen may be useful in the detection of arterioportal shunting. This procedure can be used to evaluate the hemodynamic change of the recipient portal vein under natural physiologic conditions. However, small shunts without hepatofugal portal blood cannot be detected by this procedure.

Value of immunohistochemistry in the diagnosis of leukemia cutis: study of 54 cases using paraffin-section markers

A grave prognosis is usually associated with leukemic skin infiltrates (leukemia cutis). However, some leukemic skin infiltrates are clinically similar to reactive non-leukemic infiltrates in patients with leukemia; thus it is of great importance to distinguish them. Fifty-four cases which were thought clinically to be leukemia cutis underwent immunophenotyping with a panel of nine T, B, monocytic, and macrophage markers using paraffin sections. Immunohistochemistry helped identify 44 cases with leukemia cutis and 10 with reactive infiltrates. In all cases of leukemia cutis, the staining patterns of skin infiltrates were concordant with cell type in the bone marrow. Furthermore, the panel of markers was usually helpful in distinguishing reactive from leukemia infiltrates, especially in cases with chronic lymphatic leukemia. Immunohistochemistry is a valuable adjunct in histopathologic differentiation of skin infiltrates in most cases of leukemia. With formalin-fixed, paraffin-embedded biopsies, we recommend that CD45 (LCA), CD45RO (UCHL-1), CD3, CD20 (L-26), CD43 (Leu-22), CD68 (KP-1), lysozyme, and chloroacetate esterase be considered in cases of systemic leukemia with cutaneous papules and nodules that prove difficult to interpret with routine section.

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.

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.