Digital ulcers and necroses: novel manifestations of angiocentric lymphoma

Systemic sclerosis: bilateral improvement of Raynaud's phenomenon with unilateral digital sympathectomy

OBJECTIVES

To demonstrate that unilateral digital sympathectomy, in patients with Raynaud's phenomenon (RP) and systemic sclerosis (SSc), may result in bilateral resolution of RP and digital ulcerations.

METHODS

We report a case of SSc and RP that had bilateral benefits from unilateral digital sympathectomy. A computer-assisted Medline/PubMed search of the medical literature was performed for 1960 through June 2009 using the keywords sympathectomy, Raynaud's phenomenon, systemic sclerosis, CREST, and digital ulcers. These searches were also combined with text words unilateral, ipsilateral, bilateral, digital sympathectomy, selective sympathectomy, autonomic nervous system, hyperhidrosis, etiology, pathogenesis, hypothesis, and treatment. Only pertinent literature, primarily in the English language, was included.

RESULTS

The majority of patients with SSc have RP and many suffer from digital ulcerations. Medical and behavioral management may have limited benefit and surgical intervention can be considered in recalcitrant cases, although efficacy data are sparse. We describe a man with limited SSc who underwent unilateral digital sympathectomy but manifested bilateral benefit. To our knowledge, this is the first published report of contralateral response with this procedure. The patient ultimately demonstrated these digital benefits when stressed with extreme cold and hypoxia while mountaineering. Despite the onset of high-altitude sickness and cerebral edema, his fingers remained unaffected while other mountaineers sustained severe frostbite or died of hypothermia.

CONCLUSIONS

Selective unilateral sympathectomy in SSc, for RP with digital ulcerations, can result in bilateral benefits despite intense challenge with cold and hypoxia.

[Digital arteritis preceding the diagnosis of a malignant B cell lymphoma]

We report the case of a young smoker woman who developed a severe acrosyndrome of rapid onset, involving both hands except the thumbs. The angiography showed digital arteritis. Antinuclear antibodies were present at high level. Three months later, a large B cell lymphoma was diagnosed. Complete remission was achieved, but the acrosyndrome persisted with only partial improvement. The antinuclear antibodies disappeared. The paraneoplastic nature of the acrosyndrome is discussed.

[A Case of Cutaneous Tuberculosis is Simulating Paraneoplastic Vasculitis]

We present the case of a patient with type T non-Hodgkin lymphoma, in clinical remission after treatment with chemo and radiotherapy, who was hospitalized due to hemorrhagic and necrotic skin lesions on his right hand and a clinical suspicion of paraneoplasic vasculitis. Nonetheless, study of the patient and complementary testing led to the diagnosis of disseminated tuberculosis with skin and lung involvement (cutaneous milliary tuberculosis). Anti-tuberculosis treatment was initiated with a satisfactory resolution of symptoms and signs.

Lymphome angiocentrique de la face : à propos de 2 cas

Angiocentric lymphoma of the face is a rare malignancy. During 11 years, only two patients were treated for a lymphoma of the face. The first patient, 31-year-old, had an angiocentric lymphoma of the nasal cavity, the second patient, 40-year-old, had an angiocentric lymphoma of the nasopharynx and the maxillary sinuses, with an extension the hard palate. According to the Ann Arbor classification, the disease was stage IEab and stage IIEbb, respectively. The first patient was treated by chemotherapy alone (COP regimen) and the second patient underwent combined chemotherapy (CHOP) and radiotherapy. The follow-up was marked by progression of the disease 7 and 9 months after the end of the treatment in the two cases. For the angiocentric lymphoma, treatment based on radiotherapy or chemotherapy alone or combined does not often provide local control and the overall survival rate does not exceed 40% at 5 years.

Rheumatic syndromes associated with malignancy

The relation between rheumatic syndromes and an underlying malignancy is a complex one. As a result of autoimmunity, an aberrant immune response, or the use of immunomodulatory drugs, many of the rheumatic diseases appear to pose an increased risk for the development of malignancy. Unfortunately, for many of the same reasons, the presence of an underlying malignancy can result in the development of features of rheumatic disease. Awareness of the associations between rheumatic syndromes and malignancy will aid the clinician in the accurate diagnosis of underlying pathology, more effective treatment of both the symptoms and underlying disease, and appropriate surveillance for the development of later complications.

Digital necrosis associated with squamous cell carcinoma of the tonsil

BACKGROUND

Digital necrosis is an uncommon paraneoplastic syndrome. Fewer than 50 cases have been sporadically reported through the literature over the last 30 years.

CASE REPORT

We describe the unfortunate case of a 62-year-old woman with a locally advanced squamous cell carcinoma of the tonsil. She was admitted to the hospital for symptomatic hypercalcemia and was found to have metastatic disease. She subsequently had digital necrosis develop. Despite numerous attempts to control the rapidly progressive ischemia, little objective evidence of response was noted. Her primary disease did not respond to palliative radiation, and her general condition rapidly deteriorated.

CONCLUSIONS

A review of the literature provided some insight into the possible etiology of this unique complication of malignancy. Unfortunately, the treatment options suggested were of limited value, because there was no discernible benefit with any directed treatment. A brief summary and discussion of the literature follows.

Raynaud's phenomenon

Raynaud's phenomenon is characterised by episodic vasospasm of the fingers and toes typically precipitated by exposure to cold. Mild Raynaud's is common and is not usually a harbinger of clinically important disability; its onset, however, can be startling and uncomfortable for patients, and the well recognised association in some cases with systemic rheumatic conditions often precipitates aggressive assessments for underlying diseases. Advances in vascular physiology have shed light on the role of the endothelium as well as endothelium-independent mechanisms in the altered vasoregulation of Raynaud's. We review clinical aspects of the disorder and new insights with respect to pathophysiology, and we discuss potential new therapeutics based on the disease mechanism, such as prostacyclin analogues, serotonin antagonists, and calcitonin gene-related peptides.