A rare mimic of basal cell carcinoma

Lymphoepithelioma-like carcinoma of the skin is an extremely rare tumour whose aetiology is yet to be established. An 83-year-old female presented with a rapidly growing plaque on the chest wall diagnosed as lymphoepithelioma-like carcinoma histologically.

Patient characteristics in tardive COVID-19 pseudoperniosis: a case series of 16 patients

Background

Acute pseudoperniosis (PP) has a recognized association with COVID‐19 and tends to occur without cold precipitation in young, healthy patients, often without a clear history of COVID‐19. These lesions usually resolve within 2 weeks and without long‐term sequelae. In the early months of 2021, patients with delayed and protracted PP began to emerge. We have called this presentation ‘tardive COVID‐19 PP (TCPP)’.

Aim

To consolidate and expand knowledge on TCPP, we describe the clinical characteristics, treatments and outcomes of 16 patients with TCPP who were reviewed by our outpatient dermatology service.

Results

The initial clinical manifestations were erythema, swelling and PP of the fingers in 56.2%, and of the toes in 31.2%, desquamation in 56.2% and acrocyanosis in 12.5%. Ten patients had eventual involvement of all acral sites. The median duration of symptoms was 191 days. Six patients reported close contact with a confirmed or suspected case of COVID‐19, but only two had positive COVID‐19 tests. Four patients experienced complete or almost complete resolution of symptoms, while the rest remain under active treatment.

Conclusion

Unlike acute PP, TCPP has a protracted and delayed presentation that is typically associated with profound acrocyanosis. Patients with TCPP represent a new phenomenon that is part of the post‐COVID‐19 syndrome, with risk factors and pathophysiology that are not yet fully understood. Our data indicate that likely predisposing factors for developing TCPP include young age, a preceding history of cold intolerance and an arachnodactyloid phenotype. Anorexia, connective tissue disorders or sickle cell trait may also predispose to TCPP. In addition, low titre antinuclear antibody positivity, the presence of cryoglobulins, or low complement levels may represent further risk factors. Finally, prolonged low temperatures are also likely to be contributing to the symptoms.

Inherited pulmonary cylindromas: extending the phenotype of CYLD mutation carriers

Background

Germline mutations in the tumour suppressor gene CYLD are recognized to be associated with the development of multiple cutaneous cylindromas. We encountered such a patient who presented with breathlessness because of multiple pulmonary cylindromas.

Objectives

To search for clinical and radiological features of multiple pulmonary cylindromas in a cohort of 16 patients with CYLD mutations.

Methods

A retrospective case‐note review was carried out in a tertiary dermatogenetics clinic where CYLD mutation carriers are reviewed on an annual basis. In‐depth investigation was carried out for patients with pulmonary tumours.

Results

Four patients had radiological imaging of their lungs, of which two had multiple pulmonary cylindromas that were confirmed histologically. Serial computed tomography monitoring allowed for pre‐emptive endobronchial laser ablation, preventing major airway obstruction and pulmonary collapse.

Conclusions

Pulmonary cylindromas are an unrecognized, but infrequently symptomatic, aspect of the phenotype in these patients that can have implications for patient care. They should be considered in patients with a high tumour burden that present with respiratory symptoms, and where appropriate, monitored with serial imaging.

What's already known about this topic?

Germline mutations in the tumour suppressor gene CYLD are recognized to be associated with the development of multiple cutaneous cylindromas, spiradenomas and trichoepitheliomas.

Beyond the skin, salivary gland tumours are seen in less than approximately 5% of patients, but otherwise the tropism of this disease is recognized as exclusively cutaneous.

What does this study add?

We report multiple pulmonary cylindromas in two patients out of a series of 16 patients, a previously unreported aspect of this genetic disease.

Deep phenotyping with radiological, histological and genetic approaches provides evidence that supports that these tumours are similar to cutaneous cylindromas and share a cytokeratin signature seen in cutaneous cylindroma.

What is the translational message?

Patients with this rare disease should be investigated if they present with new symptoms of respiratory disease.

These data inform the clinical surveillance and management of patients with this rare condition and also inform the longstanding debate on benign metastases.

https://doi.org/10.1111/bjd.17046 available online

https://goo.gl/Uqv3dl

Morphoea with prominent plasma cell endoneuritis

Morphoea (localized scleroderma) is a cutaneous inflammatory condition characterized by the development of indurated and discoloured plaques. The histological features of morphoea typically include a superficial and deep perivascular and periadnexal chronic inflammatory infiltrate associated with variable degrees of dermal and/or subcutaneous sclerosis. The infiltrate is typically composed of lymphocytes, macrophages and conspicuous plasma cells. The early stages of morphoea may have a very prominent inflammatory infiltrate associated with subtle sclerosis. In addition, the inflammatory infiltrate may show a perineural and rarely intraneural distribution. We report two cases of morphoea that histologically showed plasma cell endoneuritis associated with subtle dermal sclerosis. These two cases highlight the potential for diagnostic confusion with infectious and inflammatory diseases, particularly leprosy and lupus.

Multiple cutaneous, oropharyngeal and pulmonary nodules

Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytosis defined by heterogeneous multiorgan involvement. Due to the rarity of this disease strong evidence-based therapies have yet to be established and prognosis has previously been considered to be poor, with more than half of patients dying within 3 years of initial presentation. We describe an 86-year-old woman with a 34-year history of extensive cutaneous and internal nodules with typical pathological and immunophenotypical (CD68(+) /CD1a(-) ) features of ECD without evidence of the BRAF V600E mutation. The cosmetic appearance of cutaneous nodules and hoarse voice caused by vocal cord nodules has been managed surgically. More aggressive therapies reported for ECD were trialled for this patient, such as radiotherapy and interferon-α, with no response. This case demonstrates a relatively good prognosis in ECD that has been managed conservatively.

When nonspecific histology can be a clue to the diagnosis: three cases of trigeminal trophic syndrome

Trigeminal trophic syndrome (TTS) is a rare cause of facial ulceration, which is usually associated with damage to the trigeminal nerve pathway, either centrally or peripherally, the most common causes being cerebrovascular accidents and trigeminal nerve ablation procedures. We present three cases of TTS, emphasizing the histopathological features. All three patients presented with facial ulceration. Two patients had a single lesion, and the third had several ulcers. However, in all cases, there was involvement of the nasal ala, and the lesions were strictly unilateral. Histology consistently showed ulceration with signs of severe chronic trauma: scarring, lichenification and/or pseudoepitheliomatous hyperplasia. Diagnosis of TTS can be difficult, and requires close clinicopathological correlation. Histology is important in excluding the majority of possible conditions included in the differential diagnosis, mainly malignancy and infectious processes. Several treatments have been described, but TTS is frequently refractory to treatment.