Alpha 1-antitrypsin deficiency panniculitis: a histopathologic and immunopathologic study of four cases

Four cases of alpha 1-antitrypsin deficiency associated with panniculitis were reviewed. The following histopathologic characteristics were typically present: (a) large areas of normal panniculus adjacent to severe necrotic panniculitis; (b) acute panniculitis--masses of neutrophils causing necrosis and replacing fat lobules; (c) chronic inflammation and hemorrhage at the periphery of acute panniculitis; (d) focal collection and proliferation of histiocytic cells and lipophages; (e) secondary leukocytoclastic vasculitis in areas of necrosis and lymphocytic vasculitis in areas of severe inflammation, but no evidence of primary vasculitis; (f) phlebothrombosis; and (g) in partial (heterozygous) deficiency, pronounced lipophages and giant-cell replacement of fat cells. Endarteritis obliterans was noted. Direct immunofluorescence study showed C3 deposition in the blood vessels of the panniculus or dermis (or both) in all four cases, and IgM was present in the blood vessels of three. Weak granular deposits of IgM or C3 were seen at the epidermal basement membrane zone in two cases. C3 in endothelial cells of the blood vessels was detected in one case. In general, the immunoreactants in the blood vessels were not dense and probably represent secondary vasculitis. We conclude that all patients with severe panniculitis and ulceration should have alpha 1-antitrypsin levels determined. A deep excisional biopsy specimen with abundant panniculus tissue is required for histopathologic diagnosis.

Argyria

The distinctive blue-gray discoloration that occurs in argyria is due to deposition of silver and a silver-induced increase in melanin. Argyria is pronounced in areas of sun exposure and in the lunulae of the fingernails. Skin biopsy confirms the diagnosis by demonstrating tiny brownish granules in connective tissue surrounding sebaceous glands, in perineural tissue and in arteriolar walls. Pigmentation is permanent but benign. While the incidence of argyria is declining, its recognition remains important.

Panniculitis associated with severe alpha 1-antitrypsin deficiency. Treatment and review of the literature

Panniculitis associated with homozygous severe alpha 1-antitrypsin deficiency was documented in three women hospitalized for painful cutaneous and subcutaneous ulcerations (severe panniculitis with spontaneous ulceration and drainage of clear or serosanguineous fluid). None had a history of trauma or infection. One patient responded rapidly and completely to treatment with dapsone. One patient, who had more extensive disease, failed to respond to prednisone plus dapsone; infusions of alpha 1-proteinase inhibitor concentrate led to resolution of her panniculitis. One patient who had severe and extensive panniculitis and pleural effusions failed to respond to corticosteroids but did well when both dapsone and infusions of alpha 1-proteinase inhibitor concentrate were added to her treatment program.

"Syndrome myxoma": a subset of patients with cardiac myxoma associated with pigmented skin lesions and peripheral and endocrine neoplasms

From January 1954 to December 1985 cardiac myxoma was diagnosed in 75 patients at the Mayo Clinic. The clinical presentation was typical in 70 cases and was referred to as "sporadic myxoma". Forty four other cases of cardiac myxomas (five from the Mayo Clinic) presented with a combination of distinctive clinical features and these cases are described as "syndrome myxoma". The patients with syndrome myxoma were younger (mean age, 25 vs 56 years) and had unusual skin freckling (68%), associated benign non-cardiac myxomatous tumours (57%), endocrine neoplasms (30%), and a high frequency of familial cardiac myxoma (25%) and familial endocrine tumours (14%). The two types of cardiac tumour were different (syndrome vs sporadic): atrial location, 87% vs 100%; ventricular location, 13% vs 0%; single tumour, 50% vs 99%; multiple tumours, 50% vs 1%; and recurrent tumour, 18% vs 0%. It is concluded that patients with syndrome myxoma represent a distinctive subgroup in which there are important clinical, surgical, and genetic implications. More importantly, syndrome myxoma appears to be only one expression of a much larger disease entity.

Histopathologic and immunopathologic study of pyoderma gangrenosum

Sixty-three patients with pyoderma gangrenosum were seen and studied at the Mayo Clinic from 1971 to 1980. Biopsies from the erythematous border or necrotic edge of the pyoderma gangrenosum lesions usually demonstrated a characteristic pathogenic morphologic evolution. The early lesions revealed mild to moderate perivascular lymphocytic infiltrate associated with endothelial swelling. The fully developed lesions demonstrated necrosis in addition to a dense lymphocytic infiltration surrounding as well as involving the blood vessels. Extravasation of erythrocytes and thrombosis sometimes were seen. Ulceration, infarction, and abscess formation were found in the later stages of evolution. Direct immunofluorescence results were positive in the blood vessels of 36 of 65 (55%) specimens. IgM, C3, and fibrin were found in the papillary and reticular dermal vessels. IgG and IgA were only occasionally present. Pyoderma gangrenosum appears to be a reactive process that is manifested as a vasculitis. Biopsy material from the advancing active erythematous border has early characteristic dermatopathologic findings of lymphocytic vasculitis. Cutaneous vascular immune deposits suggest an immune pathogenesis of either an immune complex disease or lymphocytotoxic reaction.

Cutaneous myxomas. A major component of the complex of myxomas, spotty pigmentation, and endocrine overactivity

Cutaneous myxoma(s) occurred in 22 (54%) of 41 patients with the complex of myxomas, spotty pigmentation, and endocrine overactivity. Of the 16 patients who had cardiac myxoma(s), the cutaneous tumor(s) was (were) detected in 13 (81%) of them prior to diagnosis of the cardiac neoplasm. Thus, the cutaneous tumor may herald a potentially fatal cardiac neoplasm (and other important conditions as well). Clinical features of the lesion were as follows: early appearance (mean age, 18 years); multicentricity (71% of patients); small size (usually less than 1 cm in diameter); widespread distribution but with predilection for certain sites (eyelids, ears, nipples); and tendency for recurrence. Pathologic features included the following: location in dermis, subcutis, or both; sharp circumscription (sometimes encapsulation); hypocellularity; abundant myxoid stroma; prominent capillaries; lobulation (larger lesions); and occasional presence of an epithelial component.

Bullous morphea profunda

A deep sclerotic process developed on the shins of a 58-year-old man, and eosinophilic fasciitis or morphea profunda was suspected clinically. Bullae later arose on the plaques, and histologic examination of a skin biopsy specimen revealed sclerosis and inflammation of the deep dermis, panniculus, and fascia, with subepidermal edema causing formation of bullae. No lymphatic obstruction or vasculitis was seen. Two plaques of typical morphea on the penis were noticed 10 months later. The patient had no peripheral or tissue eosinophilia, hypergammaglobulinemia, hematologic abnormality, or history of exertion before the onset of the disease. The sclerotic process involved more than the fascia. In describing this deeper variant of morphea, the term "morphea profunda" appears to be more appropriate than "eosinophilic fasciitis."

Diagnostic criteria for Sweet's syndrome

Five patients with Sweet's syndrome with typical clinical and histologic features were reviewed. Attention is drawn to the possible association of drug use, venipuncture and insect bite, resection of colon, exacerbation of sinusitis, and acute myelocytic leukemia with the onset of the skin eruptions in our patients. The question of whether Sweet's syndrome is just a reactive phenomenon or a specific entity is raised. Our opinion is that Sweet's syndrome is a reaction to many different antigens. However, characteristic clinical and histologic features are present to allow a definite diagnosis of Sweet's syndrome. We propose two major criteria and four minor criteria for the diagnosis of Sweet's syndrome. Findings in patients must fulfill both of the major criteria and at least two of the minor criteria to allow a diagnosis of Sweet's syndrome.

The clinical diagnosis of Reiter's syndrome. Ophthalmic and nonophthalmic aspects

The histories of 113 patients with Reiter's syndrome were reviewed to obtain information regarding the sequence of the clinical signs and symptoms, laboratory findings, and progression of disease. Rheumatologic manifestations occurred in 98% of the patients, genitourinary manifestations in 74%, ophthalmic manifestations in 58%, and mucocutaneous manifestations in 42%. Four major criteria and six categories of minor criteria for the diagnosis of Reiter's syndrome, based on the frequency and specificity of the various manifestations of the disease, are proposed. The ophthalmic and nonophthalmic features are important to appreciate because the ophthalmologist is frequently at the pivotal point in suggesting or supporting the diagnosis.

Adult-onset urticaria pigmentosa and systemic mast cell disease

The records of 32 patients with adult-onset urticaria pigmentosa were analyzed to determine if any clinical or pathologic findings could distinguish urticaria pigmentosa associated with systemic mast cell disease from urticaria pigmentosa with no clinical evidence of systemic mast cell disease. Thirteen patients had biopsy-proven systemic mast cell disease, and 19 had no documentation of systemic mast cell disease after at least 20 years of follow-up. Generally, urticaria pigmentosa with systemic mast cell disease could not be differentiated from urticaria pigmentosa with skin involvement only. Although most patients in both groups had mast cells in a perivascular location, four patients had dense infiltrates filling the papillary dermis. Two of these patients had biopsy-proven systemic mast cell disease, and two had clinical symptoms that could have been produced by systemic mast cell disease, although the diagnosis was not proved by biopsy. The presence of dense infiltration by mast cells in urticaria pigmentosa with cytologic atypia may correlate with the presence of systemic mast cell disease.

Angioimmunoblastic lymphadenopathy

Angioimmunoblastic lymphadenopathy often begins with constitutional symptoms, such as fever, malaise, and weight loss. Most patients have generalized lymphadenopathy, and about 40 per cent have skin lesions with maculopapular erythema, purpura, urticaria, or exfoliative erythroderma. Lymph-node biopsy specimens demonstrate the most characteristic histopathologic features: extensive effacement of lymph nodal architecture; a pleomorphic population of immunoblasts, plasma cells, lymphocytes, and eosinophils; interstitial deposits of eosinophilic material; and prominent vascular proliferation, with "arborization" of small vessels. The pathogenesis of angioimmunoblastic lymphadenopathy is still unknown, but its histopathologic features and laboratory findings strongly suggest that it is an immunologically mediated disorder. Some clinical and laboratory evidence supports the possibility that angioimmunoblastic lymphadenopathy is a benign reactive or proliferative process, whereas other studies suggest that it might be a malignant disease. In some patients, it can develop into immunoblastic sarcoma or other types of malignant lymphoma or leukemia. It is probably reasonable to consider angioimmunoblastic lymphadenopathy a prelymphomatous state of immunoblastic sarcoma.

Chronic idiopathic anhidrosis

We describe the cases of eight patients with chronic idiopathic anhidrosis. These patients were heat intolerant and became hot, flushed, dizzy, dyspneic, and weak but did not sweat when the ambient temperature was high or when they exercised. Four patients had preganglionic sudomotor lesions and in the remaining 4 the lesion appeared to be postganglionic. The patients did not have orthostatic hypotension, other evidence of generalized autonomic failure, or symptomatic somatic neuropathy. One patient regained thermoregulatory sweat function and no patient's condition progressed to generalized autonomic failure. Chronic idiopathic anhidrosis appears to be distinctly different from other autonomic neuropathies that tend to carry much poorer prognoses.

Adnexal carcinomas of the skin. II. Extraocular sebaceous carcinomas

Extraocular sebaceous carcinomas are uncommonly seen neoplasms, and have been confused in the past with basal cell carcinomas showing sebaceous differentiation. In contrast to the latter tumors, however, sebaceous carcinomas have a distinct risk of aggressive behavior. This study presents clinicopathologic data on five cases of sebaceous carcinoma arising in cutaneous locations outside of the ocular adnexae. Four of five patients were men, and the average age at diagnosis was 63 years. Three tumors occurred on the face, one arose in the skin of the neck, and another occurred on the penis, an anatomic site that is extremely rare for sebaceous carcinoma. Three tumors metastasized, and two patients died of tumor or with residual tumor growth. In light of this behavior, the premise that extraocular sebaceous carcinomas rarely spread to distant sites may need reexamination.