Dupilumab for the Treatment of Actinic Prurigo

A 42-year-old Latino man with a medical history of vitiligo presented to our outpatient clinic with a 25-year history of a recurrent, itchy eruption on his face and hands. Physical examination revealed pink, scaly, erythematous, lichenified papules and plaques with overlying crusts, photodistributed on the nose, chin, cheeks, hands, and ears (Figures 1a and 2a). The lips were edematous with hemorrhagic crusting, and conjunctival injection and partial corneal opacities were noted (Figures 1b-1c). Histologic evaluation demonstrated psoriasiform hyperplasia with hyper-granulosis and a superficial perivascular infiltrate composed of lymphocytes, histiocytes, and eosinophils. Human leukocyte antigen (HLA) class II typing was positive for HLA-DRB1*0407, thus confirming the diagnosis of actinic prurigo (AP).

Bullous Amyloidosis Masquerading as Pseudoporphyria

Amyloidosis is not a singular disease but describes a group of diseases that result from abnormalities in protein folding and metabolism, leading to β-sheet polymers and amyloid fibrils. Cutaneous involvement is common and may occur as a primary disorder or secondary to systemic disease. Bullous skin changes, however, are rare occurrences in cutaneous amyloidosis. Bullous amyloidosis presents with characteristic histopathologic, immunohistochemical, and immunofluorescence patterns, all of which allow for careful distinction from other similar diseases. Importantly, bullous amyloidosis should prompt consideration of an underlying diagnosis of a lymphoproliferative disorder. We present the case of a woman who was diagnosed with bullous amyloidosis due to multiple myeloma after an extensive workup initially suggested other bullous diseases. We highlight the importance of recognizing this rare entity to prevent delay in diagnosis and management of its underlying cause.

Reviewing the use of imiquimod for molluscum contagiosum

We discuss imiquimod associated with non-application site mucosal reactions and two of our own clinical cases. In one of our patients, erosive cheilitis developed in a young boy after using topical imiquimod 5% cream for 5 nights weekly on bilateral cheeks, chin, and near vermillion border for molluscum contagiosum. The case is discussed with concerns for imiquimod use in molluscum contagiosum when used near mucosal surfaces.

Gene delivery polymer structure-function relationships elucidated via principal component analysis

Principal component analysis was applied to a biomaterial library of poly(beta-amino ester)s, useful for non-viral gene delivery, to elucidate chemical parameters that drive biological function. Correlative relationships and principal components were analyzed between 24 physico-chemical polymer properties and 3 cell-based functional variables in human glioblastoma cells (transfection, uptake, and viability).

Amyopathic dermatomyositis complicated by pneumomediastinum

Dermatomyositis is an inflammatory disease of unclear etiology with characteristic cutaneous and musculoskeletal findings. Amyopathic dermatomyositis is a subtype without musculoskeletal involvement. Many cases of dermatomyositis are associated with underlying malignancy, but pulmonary manifestations can also be seen, the most common of which is interstitial lung disease. Pneumomediastinum is a rare complication that is important for clinicians to recognize, as it may be fatal if left untreated. The sudden onset of facial edema and shortness of breath in the setting of dermatomyositis should raise the suspicion of this condition.

Levamisole-induced Wegener's granulomatosis following contaminated cocaine abuse

A 44-year-old woman with a medical history of chronic pain syndrome presented with a 3-day history of a painful "rash" that started on her face and spread to her legs. Further history revealed that she recently started a new medication, varenicline, 7 weeks prior to admission and had a long-standing history of intranasal cocaine use. Review of systems was significant for rhinitis, nasal congestion, joint pain, and a febrile episode 2 days prior to admission. Physical examination revealed centrally violaceous, tender, stellate, and retiform purpuric patches and plaques on her extremities, nasal dorsum, and cheeks. Approximately 1.0-centimeter tender purpuric nodules were noted on her bilateral second proximal interphalangeal joints. She was afebrile. Initial laboratory data revealed a mild leukopenia, normal serum urea nitrogen and creatinine without hematuria, and an elevated erythrocyte sedimentation rate. Further analysis showed a normal complement level, negative antinuclear antibody, human immunodeficiency virus, rapid plasma reagin, and hepatitis panel. Trace cryoglobenemia and a positive anti-streptolysin O were noted, along with a positive antineutrophil cytoplasmic antibody (c-ANCA) (> 8.0 U) and perinuclear antineutrophil cytoplasmic antibodies, or p-ANCA (1.5 U). The hypercoagulable workup was negative. A skin biopsy taken from the left thigh was consistent with leukocytoclastic vasculitis. After several weeks of high-dose oral prednisone taper, the patient's symptoms improved, but flared upon discontinuation. On follow-up, she admitted to frequent relapses of cocaine abuse and had developed tender purpuric plaques on her nose, ears, and extremities, some with ulcerations (Figure 1 and Figure 2). She also had significant edema and joint pain that limited her ambulation. Further evaluation revealed normal chest x-ray results; however, computed tomography of her sinuses demonstrated thickened maxillary sinuses consistent with subacute/ chronic sinusitis. She also developed hematuria. Mass spectrometry analysis ofhair and urine samples tested positive for cocaine and levamisole. A presumptive diagnosis of levamisole-induced Wegener's vasculitis was made. She was restarted on high-dose prednisone and methotrexate with improvement and advised to discontinue cocaine use, so as to avoid exposure to both substances.

Primary carcinoid tumor of the skin

We describe the case of a 64-year-old man with a cutaneous carcinoid tumor. Clinical investigation and diagnostic studies failed to reveal an internal primary tumor. Five cases of primary cutaneous carcinoid tumor have been reported in the literature. Interestingly, our patient had coexisting lichen planus, which has been reported previously in association with carcinoid.

Inflammatory actinic keratoses secondary to systemic chemotherapy

Traditionally, systemic 5-fluorouracil has been associated with a reaction that produces inflammation of preexisting and subclinical actinic keratoses (AKs). We report a case of an inflammatory reaction occurring in AKs secondary to the use of doxorubicin. The cutaneous reaction was successfully managed with the application of high-potency topical steroids over the body and with pain management. When the doxorubicin was discontinued and another agent (paclitaxel) was instituted, the cutaneous reaction gradually diminished.

Development of a novel gene delivery scaffold utilizing colloidal gold–polyethylenimine conjugates for DNA condensation

We have developed a novel gene delivery scaffold based on DNA plasmid condensation with colloidal gold/polyethylenimine conjugates. This scaffold system was designed to enable systematic study of the relationships between DNA complex physical properties and transfection efficiency. Using an enhanced green fluorescent protein-coding reporter plasmid and a Chinese hamster ovary cell line, we have measured the transfection efficiencies of our complexes using flow cytometry and their cytotoxicities using the trypan blue assay. We have also assayed complex particle morphologies using atomic force microscopy, photon correlation spectroscopy, and a novel plasmon absorbance peak position analysis. We achieved comparable rates of transfection relative to the commonly used polycationic condensation agents calcium phosphate and LipofectAMINE, with comparably low cytotoxicities. In addition, by manipulating colloidal gold concentration, we could partially decouple complex physical properties including charge ratio, size, DNA loading, and polyethylenimine concentration. Our morphological analyses showed that complexes with a diameter of a few hundred nanometers and a charge ratio of approximately 8 perform best in our transfection efficiency assays. The use of colloidal gold as a component in our delivery system provides a versatile system for manipulating complex properties and morphology as well as a convenient scaffold for planned ligand conjugation studies.

Dermatofibrosarcoma protuberans occurring in a smallpox vaccination scar

Dermatofibrosarcoma protuberans (DFSP) is a locally aggressive, rarely metastatic, spindle cell tumor. Trauma has been associated with its development. Since the 1940s, malignant tumors have been described to occur in sites of smallpox vaccination scars. Five cases in the literature document DFSP arising in sites of prior immunizations. We report a case of DFSP occurring in a smallpox vaccination scar and review the available literature.

Does low phosphorus supply limit seedling establishment and tree growth in groves of ectomycorrhizal trees in a central African rainforest?

•  In a forest grove at Korup dominated by the ectomycorrhizal species Microberlinia bisulcata , an experiment tested whether phosphorus (P) was a limiting nutrient. •  P-fertilization of seven subplots 1995-97 was compared with seven controls. It led to large increases in soil P concentrations. Trees were measured in 1995 and 2000. M. bisulcata and four other species were transplanted into the treatments, and a wild cohort of M. bisulcata seedlings was followed in both. Leaf litter fall from trees and seedlings were analysed for nutrients. •  Growth of trees was not affected by added P. Transplanted seedlings survived better in the controls than added-P subplots: they did not grow better with added-P. M. bisulcata wildlings survived slightly better in the added-P subplots in yr 1 but not later. Litter fall and transplanted survivors had much higher concentrations of P (not N) in the added-P than control subplots. •  Under current conditions, it appears that P does not limit growth of trees or hinder seedling establishment, especially of M. bisculcata , in these low-P grove soils.

Xerosis in hypothyroidism: a potential role for the use of topical thyroid hormone in euthyroid patients

Xerosis is an extraordinarily common problem in dermatology. Despite the knowledge of well recognized aggravating factors, its etiology is an enigma, and the management of the condition is often suboptimal. Dry skin may be a manifestation of hypothyroidism. The nature of this association is reviewed, culminating in the speculation that topical thyroid hormone may represent a useful modality in euthyroid patients with xerosis or other disorders of keratinization.

Light and seed size affect establishment of grove-forming ectomycorrhizal rain forest tree species

•  Regeneration of the dominant ectomycorrhizal tree Microberlinia bisulcata in groves in Korup, Central Africa, is very poor. The hypothesis was tested that this species is more shade intolerant than other co-occurring species. •  In two 1-yr trials, each with M. bisulcata and four other species at a nursery close to Korup, growth was measured under five PAR levels, with ± added P and ± watering in the dry season. In parallel experiments the effects of PAR with two R : FR ratios were investigated. •  Increasing PAR had a consistent effect on the rates of increase in plant mass and on changes in the other variables. Doubling soil P, watering and halving the R : FR ratio had almost no effect. However, across species, mass at low PAR and relative growth rate related positively and negatively, respectively, to seed mass. •  One contributing factor for the poor recruitment of M. bisulcata is therefore its low survival and slow growth at low PAR, due to its small seed size. The two codominant ectomycorrhizal grove species of Tetraberlinia, with larger seeds, were less affected by low PAR.

Shade and leaf loss affect establishment of grove-forming ectomycorrhizal rain forest tree species

•  The poor regeneration of Microberlinia bisulcata in groves in Korup, Central Africa was investigated in the forest to highlight factors that interact with light. •  Survival and growth of nursery-grown seedlings of M. bisulcata with four other species in each of two 1-yr trials were recorded after transplantation into quadrats differing in PAR. Total mass was predicted for PAR treatments in nursery trials reported separately. •  Plant mass was strongly dependent on PAR for all species. At low PAR, across species, plant mass was positively related to seed mass. Forest : nursery mass ratios decreased with increasing PAR; M. bisulcata had the lowest ratios of all species at high PAR. Leaf weight ratio declined more steeply with increasing PAR in the forest than in the nursery and this was particularly marked for M. bisulcata. •  Herbivory was the most probable cause of leaf loss. Forest : nursery ratios were negatively correlated with species' abundances in the forest. Besides its small seed size and shade intolerance, M. bisulcata is highly susceptible to leaf loss when illuminated. Opportunities for seedling release are thus very low.

Pseudoporphyria

Pseudoporphyria is the term used to describe a photodistributed bullous disorder with clinical and histologic features of porphyria cutanea tarda, but without accompanying biochemical porphyrin abnormalities. Medications, chronic renal failure/dialysis, excessive sun exposure and UVA radiation have all been reported to cause pseudoporphyria. Recognition, diagnosis, and appropriate management of pseudoporphyria are discussed.

Localized whirlpool folliculitis in a football player

Pseudomonas aeruginosa folliculitis occurs in patients exposed to contaminated water. Most out-breaks are associated with whirlpools. The infection is characterized by follicular, erythematous papules and pustules located on immersed body surfaces. Most reported cases are the result of recreational water use, occur in a diffuse pattern, and are devoid of green pustular pigment changes. The case described occurred in a football player after whirlpool treatment for an ankle strain. Green pustules and a localized affected area are unusual aspects of this case.

Linear childhood discoid lupus erythematosus following the lines of Blaschko: a case report with review of the linear manifestations of lupus erythematosus

Seventeen cases of childhood discoid lupus erythematosus (DLE) have been previously reported in the literature. We describe the first reported case of childhood linear DLE following the lines of Blaschko. The clinical and histologic characteristics of childhood DLE are discussed and a review of the linear manifestations of childhood LE is presented.

Postmortem MR imaging of lobar cerebral infarction with pathologic and in vivo correlation

Postmortem magnetic resonance (MR) imaging features of different types of lobar cerebral infarction are correlated with the findings in gross and histologic specimens. The postmortem findings are also correlated with in vivo findings in similar cases selected from teaching files. In acute infarction, white matter vasogenic edema leads to high signal intensity on T2-weighted images and blurring of the gray-white matter junction. Petechial hemorrhage in the cortex results in inhomogeneous signal intensity on T2-weighted images. In laminar necrosis, the hyperintense cortex on T1-weighted images is due not to hemorrhage but possibly to necrosis and the presence of lipid-laden macrophages. In subacute infarction, cortical edema and necrosis may cause the gyral pattern of enhancement. Meningeal inflammation and early fibrosis are probably responsible for meningeal enhancement. In chronic infarction, gliosis and cystic malacia are responsible for the increased signal intensity of white matter on T2-weighted images. Knowledge of the pathologic features of cerebral infarction helps in understanding the MR imaging findings.

Ultrasonography in the detection of aneuploidy in the first trimester

Ultrasonography has been used increasingly in the first trimester to identify fetal anomalies as early as possible in gestation. First trimester sonographic screening may detect a greater proportion of aneuploid fetuses than sonography performed later in pregnancy, and it may allow determination of potential markers for prediction of chromosomal anomalies.

Fetal echocardiography in multiple gestations

We reviewed fetal echocardiograms from 36 multiple gestations from 20 weeks gestation to term. Seven sets of twins plus one set of triplets were referred because of a suspect cardiac anomaly in one fetus; heart disease was confirmed in one fetus of six sets of twins and in one triplet. Six sets were referred because of extracardiac malformations and heart disease was confirmed in two sets (including both twins in one set). The remaining case was detected in a patient sent for evaluation of karyotypic abnormality. Thus 11 fetal cardiac defects were detected in ten pregnancies. Chromosomes were abnormal in three of the anomalous fetuses. Two sets discordant for heart disease were monochorionic. Intervention, including a change in the planned location of delivery, or maternal digitalization for fetal congestive failure, occurred in six. We conclude that fetal echocardiography is feasible and useful in appropriate multiple gestations. Although often ethically complex, the information gained can be applied to patient management.

Diagnosis and significance of cystic hygroma in the first trimester

Thirty cases of cervical cystic hygroma were diagnosed in the first trimester of pregnancy. Karyotype analysis was available in 29 (97 per cent). Fifteen (52 per cent) had a chromosomal abnormality. The ultrasound appearance was described as posterior cervical, lateral cervical, or cervical hygroma with hydrops. Of the 14 euploid embryos, six were electively aborted, two are undelivered, and six have been delivered as phenotypically normal infants. In cases in which the chromosomes were normal and the pregnancy continued, all lesions resolved by 18 weeks.

Saphenous vein rupture pressure, rupture stress, and carotid endarterectomy vein patch reconstruction

Early postoperative patch rupture is a catastrophic complication of carotid endarterectomy reconstruction with greater saphenous vein. Mechanical determinants of saphenous vein rupture were identified by structural measurements and the results applied to carotid endarterectomy patch geometry. Diameter and rupture pressure was measured in fresh saphenous vein segments from the ankle, knee, or thigh in 157 patients undergoing bypass operations. Circumferential hoop rupture stress was calculated and the results were applied to 157 carotid endarterectomy reconstructions. All vein ruptures were in the cylindric axis. The mean vein diameter was 4.58 mm. The mean vein rupture pressure was 2873 mm Hg (3.78 atm). Vein diameter was larger in the thigh than in the ankle or knee (p less than 0.01), but there was no significant difference in rupture pressure between veins from the three locations. Women had a smaller vein diameter than had men at all locations (p less than 0.01). There was a positive linear correlation between vein diameter and rupture pressure. The mean maximum diameter of curvature of 157 carotid endarterectomy reconstructions with a vein patch was 13.3 mm. Multiple random applications of the 157 veins to 157 carotid diameters predicted a mean patch rupture pressure of 1087 mm Hg (1.43 atm), 1163 mm Hg (1.53 atm) for men, and 866 mm Hg (1.14 atm) for women. Predicted vein patch rupture pressures less than 300 mm Hg were found in 5.7% of cases (8.8% women and 1.2% men). Only 0.6% of patients (1.8% women and 0% men) had a predicted rupture pressure less than 200 mm Hg. No veins with a diameter greater than or equal to 4.0 mm had a predicted patch rupture pressure less than 300 mm Hg. These results suggest that small-diameter saphenous veins have a higher risk of rupture when used as a carotid patch.

Fetal cardiac output in the isoimmunized pregnancy: a pulsed Doppler-echocardiographic study of patients undergoing intravascular intrauterine transfusion

The mechanism of development of hydrops fetalis in severe isoimmunization has been subject to speculation. We performed pulsed Doppler assessment of cardiac output in 13 severely isoimmunized fetuses before and after intravascular transfusion and compared the results with 37 control fetuses between 20 and 34 weeks' gestation. The cardiac index of the anemic fetuses was significantly greater than that of the control group. A significant (right ventricle, p less than 0.01; left ventricle, p less than 0.02) increase in indexed output was noted from both ventricles and in the combined ventricular output (mean +/- SEM 644 +/- 35.3 ml/kg/min in control fetuses versus 879 +/- 86.0 ml/kg/min in anemic fetuses, p less than 0.006). An increase in cardiac output was also noted when anemic fetuses were compared with gestational age-specific norms. We conclude that severely anemic fetuses of isoimmunized pregnancies tend to have significantly higher cardiac output than do unaffected fetuses and that this high output state may play a part in the development of hydrops fetalis.

Pulsed Doppler flow-velocity waveforms in the prediction of fetal hematocrit of the severely isoimmunized pregnancy

We previously reported a significant relationship between the hematocrit levels of anemic fetuses and information derived from ultrasonographic and Doppler flow-velocity waveforms. In this study we prospectively tested two formulas for the prediction of hematocrit values, by use of gestational age, presence or absence of hydrops, and Doppler indices. Although one of the two formulas predicted hematocrit values significantly, the only component of the formula that made a significant contribution was fetal hydrops. We conclude that currently available fetal Doppler measurements are unable to be applied in the prospective prediction of hematocrit values in anemic fetuses of isoimmunized pregnancies.

Transdermal clonidine therapy and nicotine withdrawal

Images

In utero intravesicular pressure and the prune belly syndrome

The pathogenesis of the prune belly syndrome is unclear. The proposed etiologies include a distal obstructive uropathy or a mesodermal defect of the anterior abdominal wall and urinary tract. Detection of increased intravesicular pressure might identify those fetuses with an obstructive etiology who, therefore, would benefit from shunting.

Sportsmedicine forum

A Forum For Our Readers Sportsmedicine Forum is intended to provide a sounding board for our readers. Perhaps you have a special way to treat a common medical problem, or you may want to air your views on a controversial topic. You may object to an article that we have published, or you may want to support one. You may have a new trend to report, identified through an interesting case or a series of patients. Whatever your ideas, we invite you to send them to us. Illustrative figures are welcomed. Address correspondence to Sportsmedicine Forum, THE PHYSICIAN AND SPORTSMEDICINE, 4530 W 77th St, Minneapolis, MN 55435.

Abdominal ultrasound examination of the first-trimester fetus

The first-trimester fetus can now be comprehensively studied with ultrasound. Various biometric measurements correlate well with gestational age, such as crown-rump length (r2 = 0.938) and cranial apex to ear diameter (r2 = 0.983). On the other hand, yolk sac diameter (r2 = 0.129) and abdominal perimeter (r2 = 0.58) correlate poorly with gestational age. By 10 weeks' gestation, kidneys can be visualized in 60% of cases; 98% will be seen at 11 weeks; and 100% of cases will be visible by 12 weeks. The bladder appears later, and by 12 weeks' gestation this organ can be identified in 50% of cases. It is likely that renal agenesis can be diagnosed (or excluded) reliably in the first trimester. With improving technology, prenatal diagnosis of some fetal anomalies is now possible in the first trimester.

The frequency of aneuploidy in prenatally diagnosed congenital heart disease: an indication for fetal karyotyping

The frequency of chromosomal abnormalities in infants with congenital heart disease has been estimated from postnatal clinic data to be 5% to 10%. Over an 18-month period we performed fetal echocardiograms on 502 fetuses and found cardiac anomalies in 34. Eleven of these fetuses (32%) had abnormal chromosomes. This marked discrepancy from the data found in the pediatric literature may relate to nonviable fetuses identified in utero, who escape pediatric case identification. We conclude that in cases of fetal heart disease the workup should include either amniocentesis or fetal blood sampling for chromosome analysis. The information can be used for complete parental counseling and for managing delivery and neonatal care.