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Sakai Y, Ikawa Y, Takenaka M, Noguchi K, Fujiki T, Ikeda H, Wada T. Histopathological maturation in juvenile xanthogranuloma: a blueberry muffin infant mimicking aleukemic leukemia cutis. Int J Hematol 2024; 119:93-98. [PMID: 37989992 DOI: 10.1007/s12185-023-03675-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/27/2023] [Indexed: 11/23/2023]
Abstract
Juvenile xanthogranuloma (JXG) is usually identified by Touton giant cells, so their absence can complicate diagnosis. We encountered a case of non-typical neonatal JXG lacking Touton giant cells, which was difficult to differentiate from aleukemic leukemia cutis because of overlapping histopathological characteristics. A 1 month-old girl presented with a blueberry muffin rash and multiple 1-2 cm nodules within the subcutaneous and deeper soft tissues. Blood tests revealed pancytopenia. The initial nodule biopsy showed mononuclear cell infiltration, suggestive of mature monocytes or histiocytes, but no Touton giant cells. Bone marrow examination showed no evidence of leukemia. Despite worsening of the rash, pancytopenia, and weight gain over the following month, the results of the second biopsy remained consistent with the initial findings. Consequently, we provisionally diagnosed aleukemic leukemia cutis and initiated chemotherapy. After two courses of chemotherapy, the pancytopenia improved, but the nodules only partially regressed. A third biopsy of the nodule was performed to evaluate the histological response, and revealed Touton giant cells, confirming the diagnosis of JXG. In conclusion, distinguishing non-typical JXG from aleukemic leukemia cutis is challenging. This case highlights the importance of multiple biopsies and the potential for histopathological maturation.
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Affiliation(s)
- Yuta Sakai
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, 13-1 Takara-Machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Yasuhiro Ikawa
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, 13-1 Takara-Machi, Kanazawa, Ishikawa, 920-8641, Japan.
| | - Mika Takenaka
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, 13-1 Takara-Machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Kazuhiro Noguchi
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, 13-1 Takara-Machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Toshihiro Fujiki
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, 13-1 Takara-Machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Hiroko Ikeda
- Department of Diagnostic Pathology, Kanazawa University Hospital, Kanazawa, Japan
| | - Taizo Wada
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, 13-1 Takara-Machi, Kanazawa, Ishikawa, 920-8641, Japan
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Prieto-Torres L, Requena L, Rodríguez-Pinilla SM. Clinical, Histopathological and Molecular Spectrum of Cutaneous Lesions in Myelodysplastic Syndrome and Myeloproliferative Neoplasms (MDS/MPN): An Integrative Review. Cancers (Basel) 2023; 15:5888. [PMID: 38136431 PMCID: PMC10742063 DOI: 10.3390/cancers15245888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/07/2023] [Accepted: 12/16/2023] [Indexed: 12/24/2023] Open
Abstract
Myeloid neoplasms and acute leukemias include different entities that have been recently re-classified taking into account molecular and clinicopathological features. The myelodysplastic syndrome/myeloproliferative neoplasm (MDS/MPN) category comprises a heterogeneous group of hybrid neoplastic myeloid diseases characterized by the co-occurrence of clinical and pathological features of both myelodysplastic and myeloproliferative neoplasms. The most frequent entity in this category is chronic myelomonocytic leukemia (CMML) which is, after acute myeloid leukemia (AML), the main myeloid disorder prone to develop cutaneous manifestations. Skin lesions associated with myelodysplastic and myeloproliferative neoplasms include a broad clinical, histopathological and molecular spectrum of lesions, poorly understood and without a clear-cut classification in the current medical literature. The aim of this review is to describe and classify the main clinical, histopathological and molecular patterns of cutaneous lesions in the setting of MDS/MPN in order to improve the diagnostic skills of the dermatologists, hematologists and pathologists who deal with these patients.
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Affiliation(s)
- Lucía Prieto-Torres
- Department of Dermatology, Hospital Clínico Universitario Lozano Blesa, Universidad de Zaragoza, 50009 Zaragoza, Spain
| | - Luis Requena
- Department of Dermatology, Fundación Jiménez Díaz, Universidad Autónoma, 28040 Madrid, Spain;
| | - Socorro Maria Rodríguez-Pinilla
- Department of Pathology, Fundación Jiménez Díaz, Universidad Autónoma, 50019 Zaragoza, Spain;
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), 28040 Madrid, Spain
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3
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Zelman B, Bode-Omoleye O, Muhlbauer A, Agidi A, Mafee M, Velankar M, Mirza K, Speiser J, Mudaliar K. Chronic myeloid leukemia-leukemia cutis mimicking a neutrophilic panniculitis-like leukemia cutis: Report of a rare case. J Cutan Pathol 2021; 48:1277-1281. [PMID: 33891722 DOI: 10.1111/cup.14030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/15/2021] [Accepted: 04/06/2021] [Indexed: 11/29/2022]
Abstract
While drug-induced panniculitis is not uncommon in chronic myeloid leukemia (CML) patients on tyrosine kinase inhibitor therapy, it is rare for CML to initially present as a leukemic panniculitis. We present the case of a 45-year-old male with no relevant prior medical history presenting with 6 months of migratory nodules, 2 months of drenching night sweats, and a 20 pound weight loss. Physical examination showed firm subcutaneous nodules with overlying ecchymoses present on the right lateral thigh and left lower back. Biopsy of a nodule from the right thigh showed a subcutaneous lobular panniculitis involved by a dense infiltrate of neutrophils and granulocyte precursors. Fluorescent in-situ hybridization (FISH) was positive for t(9;22)(q34;q11.2)BCR-ABL1 fusion. A concurrent hemogram revealed a white blood cell count elevation of 600,000 K/μL. Bone marrow biopsy examination showed marked myeloid expansion with an increase in granulocyte precursors and Philadelphia chromosome positivity by FISH, consistent with bone marrow involvement by CML. Herein, we describe this unusual and rare case of CML initially presenting as a neutrophilic panniculitis-like leukemia cutis. Arriving at this challenging diagnosis may be easily missed without clinical and laboratory correlation, which would certainly lead to the patient's not receiving life-saving treatment.
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Affiliation(s)
- Brandon Zelman
- Department of Pathology, Loyola University Medical Center, Maywood, Illinois, USA
| | | | - Aaron Muhlbauer
- Department of Pathology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Ada Agidi
- Department of Dermatology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Mariam Mafee
- Department of Dermatology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Milind Velankar
- Department of Pathology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Kamran Mirza
- Department of Pathology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Jodi Speiser
- Department of Pathology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Kumaran Mudaliar
- Department of Pathology, Loyola University Medical Center, Maywood, Illinois, USA
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Hussain AN, Guo EL, Cardis MA. Plum-colored plaques on the scalp and extremities. JAAD Case Rep 2021; 9:21-23. [PMID: 33598520 PMCID: PMC7868935 DOI: 10.1016/j.jdcr.2020.12.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Aamir N. Hussain
- Medstar Washington Hospital Center/Georgetown University Hospital, Washington, DC
| | - Emily L. Guo
- Medstar Washington Hospital Center/Georgetown University Hospital, Washington, DC
| | - Michael A. Cardis
- Medstar Washington Hospital Center/Georgetown University Hospital, Washington, DC
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5
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Affiliation(s)
- Shuku Sato
- Division of Hematology, Shonan Kamakura General Hospital, Japan
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Khoshnaw N, Yassin AK, Alwan AF, Hassan HA, Mula‐Hussain L. Challenges associated with limited-resources cancer care facility: Bilateral breast myeloid sarcoma as an example. Clin Case Rep 2019; 7:2022-2026. [PMID: 31788245 PMCID: PMC6878049 DOI: 10.1002/ccr3.2407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 07/22/2019] [Accepted: 08/11/2019] [Indexed: 11/25/2022] Open
Abstract
Myeloid sarcoma (MS) is a rare myeloid malignancy. It can arise before, concurrent with, or following different malignant hematological diseases, most commonly acute myeloid leukemia (AML), myelodysplastic syndrome, or myeloproliferative neoplasms. Here we describe a 30-year-old female with AML-M1 who presented to the hematology department with bilateral breast pain and tenderness. Available diagnostic measures including ultrasound of breast and magnetic resonance imaging were used to determine the nature of these breast lumps. MS was definitively diagnosed via biopsy and the patient was treated with systemic chemotherapy. Despite her AML treatment she unfortunately died secondary to disease progression. The authors consider this case of particular educational value due to the bilateral and aggressive nature of this patient's disease in the setting of a cancer-care facility with limited resources. KEY CLINICAL MESSAGE In retrospect, if breast MS had been considered earlier in this patient's presentation, a referral to an outside center with matched stem cell transplantation capability may have been warranted after complete remission following first bone marrow relapse, rather than continuing chemotherapy alone.
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Affiliation(s)
- Najmaddin Khoshnaw
- Department of HematologyHiwa Cancer HospitalSulaymaniyahKurdistanIraq
- Program of HematologyKurdistan Board of Medical SpecialtiesErbilKurdistanIraq
| | - Ahmed K. Yassin
- Program of HematologyKurdistan Board of Medical SpecialtiesErbilKurdistanIraq
- Department of MedicineCollege of MedicineHawler Medical UniversityErbilKurdistanIraq
| | - Alaa F. Alwan
- Department of Clinical HematologyNational Center of HematologyMustansiriyah UniversityBaghdadBaghdadIraq
| | - Hemin A. Hassan
- Department of HematopathologyShorash HospitalSulaymaniyahKurdistanIraq
| | - Layth Mula‐Hussain
- Division of Radiation OncologyZhianawa Cancer CenterSulaymaniyahKurdistanIraq
- Program of Radiation OncologyKurdistan Board of Medical SpecialtiesErbilKurdistanIraq
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Araujo KM, Galardino BR, Carvalho TF, Capelluppi-Tófano VA, Denadai R. Cutaneous Myeloid Sarcoma Mimicking Skin Cancer in Aleukemic Patients: a Diagnostic Challenge in Surgery. Indian J Surg 2019. [DOI: 10.1007/s12262-019-01984-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
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Abstract
This article focuses on cutaneous hematopoietic neoplasms that are more likely to be encountered in the pediatric age-group and includes both lymphoproliferative and histiocytic disorders. The cutaneous hematologic disorders in children have a different epidemiologic profile to what is seen during adulthood. Although mycosis fungoides is the most frequent form of cutaneous lymphoma in adults, it is very rare in children. Because lymphoblastic leukemias and lymphomas are more frequent in the pediatric setting, cutaneous leukemic infiltrates are relatively common in this age-group. Similarly, histiocytic disorders are more common in children, particularly Langerhans cell histiocytosis and juvenile xanthogranuloma. Notably, the histiocytic disorders have undergone significant modifications on their nomenclature in the basis of the molecular characteristics that are present in them. A summary of the most frequent cutaneous hematopoietic disorders in children will be discussed further in this review.
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Affiliation(s)
- Alejandro A Gru
- 1 Department of Pathology, University of Virginia, Charlottesville, Virginia
| | - Louis P Dehner
- 2 Lauren V. Ackerman Laboratory of Surgical Pathology, St. Louis Children's Hospital and Dermatopathology, Washington University Medical Center, St. Louis, Missouri
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Besner Morin C, Côté B, Belisle A. An interesting case of pyoderma gangrenosum with immature hystiocytoid neutrophils. J Cutan Pathol 2017; 45:63-66. [DOI: 10.1111/cup.13053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 09/23/2017] [Accepted: 09/30/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Catherine Besner Morin
- Department of Dermatology, St-Luc Hospital; University of Montreal; Montreal Quebec Canada
| | - Benoit Côté
- Department of Dermatology, St-Luc Hospital; University of Montreal; Montreal Quebec Canada
| | - Annie Belisle
- Department of Pathology, Notre-Dame Hospital; University of Montreal; Montreal Quebec Canada
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Extensive ulcerated lesions in a patient with cutaneous myeloid sarcoma responded to twice-daily fludarabine and cytarabine regimen. Blood Cells Mol Dis 2017. [PMID: 28624256 DOI: 10.1016/j.bcmd.2017.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Almond LM, Charalampakis M, Ford SJ, Gourevitch D, Desai A. Myeloid Sarcoma: Presentation, Diagnosis, and Treatment. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2017; 17:263-267. [PMID: 28342811 DOI: 10.1016/j.clml.2017.02.027] [Citation(s) in RCA: 132] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 02/13/2017] [Accepted: 02/28/2017] [Indexed: 12/22/2022]
Abstract
Myeloid sarcoma is an extramedullary tumor of immature granulocytic cells. It is a rare condition, most often associated with acute myeloid leukemia (AML), although in some rare cases it may present in nonleukemic patients. It should therefore be considered as a differential diagnosis of any atypical cellular infiltrate. It may occur at any site, leading to very varied clinical presentations. Diagnosis is challenging and relies on a high index of suspicion as well as radiology, histology, immunophenotyping, and molecular analyses, which also are essential for risk stratification and treatment planning. Systemic chemotherapy using AML-like regimens should be commenced early, even in nonleukemic disease. Surgery and/or radiotherapy may be indicated for symptomatic lesions or tumors causing local organ dysfunction or obstruction. Allogeneic hematopoietic stem cell transplantation has demonstrated promising results, particularly in patients who achieved complete remission with AML-induction protocols, and recent advances in genetic profiling may enable the development of novel targeted therapies. Prospective multicenter controlled trials are required to further refine management decisions and investigate the role of novel targeted therapies.
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Affiliation(s)
- L Max Almond
- Midlands Abdominal and Retroperitoneal Sarcoma Unit (MARSU), University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.
| | - Maria Charalampakis
- Department of Haematology and Stem Cell Transplantation, Heart of England NHS Foundation Trust, Birmingham, United Kingdom
| | - Samuel J Ford
- Midlands Abdominal and Retroperitoneal Sarcoma Unit (MARSU), University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - David Gourevitch
- Midlands Abdominal and Retroperitoneal Sarcoma Unit (MARSU), University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Anant Desai
- Midlands Abdominal and Retroperitoneal Sarcoma Unit (MARSU), University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
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Johnstone K, Tsikleas G, Pool L, Barksdale S. S100/CD1a positive dermal infiltrate as an initial presentation of chronic myelomonocytic leukaemia. Pathology 2016; 48:628-31. [PMID: 27569552 DOI: 10.1016/j.pathol.2016.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 06/12/2016] [Accepted: 06/22/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Kate Johnstone
- Sullivan Nicolaides Pathology, Brisbane, Qld, Australia; Pathology Queensland, Brisbane, Qld, Australia; School of Medicine, The University of Queensland, Brisbane, Qld, Australia.
| | | | - Louis Pool
- Sullivan Nicolaides Pathology, Brisbane, Qld, Australia
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Wang X, Li WS, Zheng Y, Ying ZX, Wang YX, Wang YM, Zheng JF, Xiao SX. The progression of CD56 + myeloid sarcoma: A case report and literature review. Oncol Lett 2016; 11:3091-3096. [PMID: 27123069 DOI: 10.3892/ol.2016.4352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 12/23/2015] [Indexed: 11/05/2022] Open
Abstract
The current study presents a case of cluster of differentiation (CD)56+ myeloid sarcoma in a patient that initially presented with skin lesions, and provides evidence for the clinical and differential diagnosis of myeloid sarcoma. The patient of the present case report was a 65-year-old man who was admitted to hospital with a six-month history of bilateral purple-red papules and nodules, which were present on the upper limbs of the patient and had spread over his whole body one month prior to admission to the hospital. Pathological examination demonstrated a diffuse infusion of primitive round cells at the papillary dermis and subcutaneous tissues. The infiltrated cells were 40-60 µm in diameter and morphologically identical. Immunohistochemical examination revealed that the cells expressed myeloperoxidase, CD56, CD43 and T-cell intracytoplasmic antigen. In addition, several cells expressed CD34, and 90% of the cells expressed Ki67. While the majority of cells in myeloid sarcoma do not express CD56, the present case was a myeloid sarcoma that expressed CD56, which is extremely rare. The sarcoma in the present patient progressed rapidly, and the patient died eight months following the onset of disease. Clinicians should be aware of CD56+ myeloid sarcoma, which is easily misdiagnosed and inappropriately treated. Consequently, myeloid sarcoma may have a high malignancy and poor outcome for patients.
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Affiliation(s)
- Xin Wang
- Department of Dermatology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China
| | - Wen-Sheng Li
- Department of Pathology, The Third Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710068, P.R. China
| | - Yan Zheng
- Department of Dermatology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China
| | - Zhao-Xia Ying
- Department of Dermatology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China
| | - Yong-Xian Wang
- Department of Dermatology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China
| | - Ying-Mei Wang
- Department of Pathology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Jun-Feng Zheng
- Department of Pathology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Sheng-Xiang Xiao
- Department of Dermatology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China
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Abstract
OBJECTIVES This session of the 2013 Society of Hematopathology/European Association for Haematopathology workshop focused on extramedullary manifestations of myeloid neoplasms. METHODS We divided the submitted cases into four subgroups: (1) isolated myeloid sarcoma (MS); (2) MS with concurrent acute myeloid leukemia (AML), with a focus on karyotypic and molecular findings; (3) extramedullary relapse of AML, including relapse in the posttransplant setting; and (4) blast phase/transformation of a myeloproliferative neoplasm or chronic myelomonocytic leukemia. RESULTS Establishing a diagnosis of isolated MS requires a high index of suspicion and use of immunophenotypic methods. Recurrent cytogenetic abnormalities or gene mutations that occur in MS mirror those known to occur in AML. CONCLUSIONS In the era of targeted therapy and sophisticated risk stratification, every attempt must be made to perform a complete workup on MS cases (or concurrent AML) since the diagnosis of MS, in itself, is no longer adequate for patient management. Cases of blastic plasmacytoid dendritic cell neoplasm were also included and discussed in this session.
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Affiliation(s)
- Carla S. Wilson
- Department of Pathology, University of New Mexico Health Sciences Center, Albuquerque
| | - L. Jeffrey Medeiros
- The Department of Hematopathology, University of Texas MD Anderson Cancer Center, Houston
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Handler MZ, Schwartz RA. Neonatal leukaemia cutis. J Eur Acad Dermatol Venereol 2015; 29:1884-9. [PMID: 25851143 DOI: 10.1111/jdv.13049] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 01/19/2015] [Indexed: 11/29/2022]
Abstract
Neonatal leukaemia cutis is a significant neoplasm that may represent a cutaneous manifestation of systemic leukaemia, usually of myeloblastic type. Rarely, it may be or appear to be limited to skin, in which case it is called neonatal aleukaemic leukaemia cutis. By definition, it presents within the first 4 weeks of life and often has a 'blueberry muffin baby' appearance of magenta coloured nodules affecting almost any area of the skin, usually sparing mucous membranes, palms and soles. This clinical pattern is more commonly associated with neonatal infections such rubella and toxoplasmosis, and may be evident with other neonatal neoplasms such as neuroblastoma. Due to the morbidity associated with chemotherapy and reported cases of spontaneous remission without systemic progression in those with neonatal aleukaemic leukaemia cutis without 11q23 translocation, the authors not treating the child with chemotherapy, but to simply monitor for fading of the violaceous nodules, and watch for possible signs of systemic leukaemia.
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Affiliation(s)
- M Z Handler
- Dermatology, Pediatrics, Preventive Medicine, Community Health, and School of Public Affairs and Administration, Rutgers University New Jersey Medical School, Newark, NJ, USA
| | - R A Schwartz
- Dermatology, Pediatrics, Preventive Medicine, Community Health, and School of Public Affairs and Administration, Rutgers University New Jersey Medical School, Newark, NJ, USA
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