[Malignant transformation of an eccrine spiradenoma]

INTRODUCTION

Malignant eccrine spiradenoma is a rare and aggressive tumor, developed on the epithelium of eccrine sweat glands. Typically, it occurs after malignant transformation of benign eccrine spiradenoma, but sometimes it happens de novo.

OBSERVATION

We report a case of malignant eccrine spiradenoma in a 62-year-old woman. The patient presented a rapid increase in size of a long-standing tumoral lesion of her forearm. There was no secondary lesion on the chest, abdomen or pelvis at the CT-scanner. Cutaneous biopsy of the lesion was performed and showed a carcinoma with no contact with epidermis. On this biopsy, we could not affirm if the tumor was a metastatic process or a primary tumor of the skin. Histologic examination of the surgical removal of the tumor showed an undifferentiated carcinoma with adjacent nodules of eccrine spiradenoma. Immunohistochemical assessment of Ki67 expression showed a weak expression (5%) in the benign spiradenoma nodules and a high rate expression (80%) in the malignant neoplasm. The final diagnosis was an undifferentiated carcinoma arising from preexisting benign spiradenoma.

DISCUSSION

Malignant eccrine spiradenoma is not frequent and is rarely described in the international literature that may lead to diagnostic difficulties.

[Auto-inflammatory disease with hyperimmunoglobulinemia D of late onset]

BACKGROUND

The term "auto-inflammatory diseases" encompasses a group of disorders characterised by febrile episodes of sudden onset associated with joint, abdominal, lymph node and cutaneous signs, each presenting a genetic and/or laboratory specificity allowing their identification. Polyclonal elevation of serum IgD is highly suggestive of hyper-IgD syndrome, a disease with autosomal recessive transmission that usually begins before the age of one year.

CASE REPORT

We report the case of a 46-year-old woman presenting a disease since the age of 30 years clinically very similar to hyper-IgD syndrome except for ocular and pulmonary involvement. However, tests revealed neither mevalonate kinase gene mutation nor elevation of urinary mevalonic acid. The near-monthly attacks were controlled with mycophenolate mofetil.

DISCUSSION

Three cases with identical clinical and laboratory profiles have been reported in the literature and diagnosed as late-onset hyper-IgD syndrome. Our case is the only one involving indirect screening for mutation of the mevalonate kinase gene, which proved negative. This finding rules out the diagnosis of classic hyper-IgD syndrome in our case and raises the possibility of auto-inflammatory disease with reactional hyper-IgD of a different cause, either acquired or secondary to an as yet unidentified mutation.

Milia-like idiopathic calcinosis cutis

Milia-like idiopathic calcinosis cutis is a rare entity. Only 17 cases have been reported so far. Two-thirds of these have been associated with Down syndrome. We report the fifth case occurring in a child without Down syndrome. Milia-like idiopathic calcinosis cutis has long been regarded as a peculiar subtype of idiopathic calcinosis cutis. The pathogenesis of the disorder remains unclear.

Oral calcitriol: a new therapeutic agent in cutaneous lichen sclerosis

BACKGROUND

Lichen sclerosus remains an elusive disease with an uncertain relationship to morphea and scleroderma. The disorder has been difficult to treat, with no consistent and reproducible efficacious therapy. Recently, a beneficial effect of treatment with oral calcitriol (1-25 dihydroxyvitamin D3) in patients with scleroderma or morphea was described. This fact could be ascribed to the immunomodulatory effects of calcitriol observed in vitro and to inhibition of fibroblastic growth. Because of the success of calcitriol in localized scleroderma, we attempted this therapy in a patient with LS.

OBSERVATION

One patient with cutaneous generalized LS resistant to different therapeutics was treated with calcitriol in an oral daily dose of 0.5 mcg. After 6 months of treatment, the skin extensibility increased, and the lesions improved. The improvement persisted after discontinuation of therapy during a follow-up period of one year. The only side effect was hypercalciuria, which resolved with dose reduction.

CONCLUSION

Calcitriol has shown a beneficial effect in scleroderma and morphea during open studies. A case is reported of a patient with LS who had a dramatic response to calcitriol. Double blind, placebo-controlled trials are needed to assess the therapeutic value of calcitriol in patients with LS.

Primary cutaneous marginal zone B-cell lymphoma: a report of 9 cases

BACKGROUND

Primary cutaneous B-cell lymphoma is a heterogeneous group among which marginal zone B-cell lymphoma (MZL) appears to be the most common subtype.

OBJECTIVE

We analyze clinical presentation, histologic aspects, and outcome of patients with primary cutaneous MZL.

METHODS

All samples classified as primary cutaneous lymphoma over the past 10 years were reviewed, and cases of primary MZL were identified.

RESULTS

Nine cases of MZL were analyzed, all from the upper body region, with a predominance in elderly women. Histologic aspects included a dense, nodular, deep-seated infiltrate containing various proportions of small cells displaying a centrocyte-like, plasmacytoid or monocytoid appearance. Surface expression of CD5, CD10, and CD23 was negative. Long survival was noted but relapses in the skin, nodes, orbit, salivary glands, and breast were observed.

CONCLUSION

MZL is the predominant primary cutaneous lymphoma of our study. It has distinctive histologic and clinical features as well as outcome.

The atrophic variant of dermatofibrosarcoma protuberans in childhood: a report of six cases

Dermatofibrosarcoma protuberans (DFSP) is typically diagnosed during early adult life at a tumoral stage. It occurs only rarely in children. We report six childhood cases of DFSP which presented initially with the misleading clinical appearance of atrophic plaques, and we review over 140 cases of DFSP in childhood. As compared with adult forms, DFSP in children does not show distinctive features except for a tendency for acral localization. The diagnosis is difficult because of the slow course of the lesions, which present initially as apparently benign atrophic morphoeaor keloid-like plaques. We believe that DFSP in childhood is probably under-estimated, as a significant proportion of patients diagnosed as young adults had an onset several years earlier. Better knowledge of the initial appearance is important for making an early diagnosis and for an easier surgical treatment.

[Unilateral acro-keratoelastoidosis]

INTRODUCTION

Acrokeratoelastoidosis was first described by O. Costa in 1953. We report a new case with a unilateral localization.

CASE REPORT

A 27-year-old woman had atypical acrokeratoelastoidosis lesions of the right hand and foot since adolescence. Diagnosis was confirmed by histology.

DISCUSSION

Several cases of acrokeratoelastoidosis have been reported in the literature, but this case is novel because of the unilateral localization. We recall the characteristic features of this disease and emphasize the heterogeneous nature of the manifestations. Differential diagnosis is discussed for this disease which is one of the group of acral lenticular keratoses.

[Acquired tufted angioma in an adult]

INTRODUCTION

Acquired vascular tumors have been raising new interest since Kaposi's illness was discovered in human immunodeficiency virus infection. We herein report a case of a rare different entity of acquired vascular tumor, described by E. Wilson-Jones for the first time in 1976.

CASE REPORT

A 69-year-old woman had had for several months an asymptomatic erythematous lesion on the face gradually increasing in size. Histopathologic findings were pathognomonic of "tufted" angioma. The patient did not receive any treatment because of uncertain efficiency and because her lesion was well tolerated.

DISCUSSION

"Acquired tufted angioma" is a benign angioma of the skin mainly occurring in children and young adults of both sexes. Histopathologic findings are pathognomonic. Typically, tufted angioma enlarges for a few years and then ceases growing and remains stable. Spontaneous regression may occur. The principal differential diagnoses are Kaposi's illness and low grade malignant angiosarcoma. Pulsed dye laser in the most efficient treatment.

Disseminated superficial porokeratosis in a patient with AIDS

We report the case of a 50-year-old male homosexual suffering from AIDS, who developed diffuse annular hyperkeratotic lesions on the arms and legs. Histopathological examination revealed typical features of porokeratosis, which clinically was of the disseminated superficial type. Ultrastructural examination showed a paucity of keratohyalin granules and lamellar bodies. Immunohistochemical studies showed an almost complete absence of Langerhans cells in lesional epidermis. Involucrin and filaggrin expression were altered in areas of cornoid lamella formation, whereas basal keratinocytes in these areas expressed PCNA/cyclin and, to a lesser degree, p53 protein. Porokeratosis may affect immunocompetent patients, but has also been reported in the setting of immunosuppression following organ transplantation. As far as we are aware, the development of porokeratosis during the course of HIV infection has not been reported previously.

Keratinocyte proliferation in epidermal keratinocyte disorders evaluated through PCNA/cyclin immunolabelling and AgNOR counting

The assessment of cell proliferation is important to our understanding of hyperproliferative disorders. In this work we evaluated the proliferation characteristics of epidermal keratinocytes in diseases with abnormal keratinization by two different methods (immunostaining for the proliferating cell nuclear antigen--PCNA and histochemical staining for nucleolar organizer region--associated argyrophilic proteins--AgNORs). Twenty-seven specimens from diseases with an abnormal keratinization were studied and compared with specimens of normal human skin. As compared with the latter, the numbers of PCNA-positive epidermal keratinocytes were increased in psoriasis, congenital non-bullous ichthyosiform erythroderma, epidermolytic hyperkeratosis and chronic dermatitis and decreased in ichthyosis vulgaris, X-linked ichthyosis and pityriasis rubra pilaris. In most cases a parallel modification of AgNORs was found. We conclude that although PCNA immunolabelling and AgNOR staining do not provide strictly correlated values, both appear as useful markers for the assessment of keratinocyte proliferation in epidermal disorders.

Epidermolysis bullosa acquisita in a 3 1/2-year-old girl

A 3 1/2-year-old girl had a subepidermal bullous eruption with immunopathologic features that were consistent with epidermolysis bullosa acquisita or bullous systemic lupus erythematosus. This report highlights the difficulty encountered in distinguishing between epidermolysis bullosa acquisita and other bullous disorders that involve the dermoepidermal junction and the need for modern immunologic investigations in the diagnosis of bullous diseases in children.

Nucleolar organizer region enumeration in keratoacanthomas and squamous cell carcinomas of the skin

Keratoacanthomas (KA) and squamous cell carcinomas (SSC) are epithelial skin tumors exhibiting distinctive clinical and histologic features. However, the differential diagnosis between them in individual cases may be difficult or even impossible. In this article the authors examine the possibility that enumeration of associated proteins of nucleolar organizer regions (AgNOR) could be of help in differentiating KA from SCC. AgNOR counting, performed on unequivocal cases of SCC (n = 20) and KA (n = 16) showed statistically significant higher AgNOR counts in SCC (6.29 +/- 0.91) compared with KA (3.80 +/- 1.62). This result speaks in favor of the different biologic nature of SCC and KA; however, due to significant overlap between the two groups, AgNOR enumeration alone is not sufficiently discriminating so as to be used diagnostically in cases with borderline histologic features.

Human papillomavirus infection and filaggrin expression in paraffin-embedded biopsy specimens of extragenital Bowen's disease and genital bowenoid papulosis

Cutaneous Bowen's disease (BD) and genital bowenoid papulosis (BP) are considered as precancerous or cancerous lesions that are sometimes infected with human papillomavirus (HPV). We studied retrospectively paraffin-embedded sections of 11 samples of cutaneous BD and 6 samples of genital BP from the general population for HPV infection and filaggrin expression. Using in situ hybridization with biotinylated probes of HPV types 1, 2, 5, 6, 11, 16, and 18, under stringent and/or non-stringent conditions and a streptavidin-alkaline-phosphatase complex for hybrid detection, HPV DNA was detected in 6/17 cases (5 BD and 1 BP). Positive nuclei were located in intermediate or upper epithelial cell layers. HPV 16 was found in 2 cases of BD but associated either with HPV 2 or 18. Three additional lesions reacted only under non-stringent conditions; HPV could not be typed with the probes used. The positive case of BP reacted with the four probe types 1, 2, 16, 18 and was negative with HPV 6 or 11. Viral antigen was not detected by indirect immunofluorescence with a rabbit antiserum directed to group-specific viral capsid antigen. Differentiation disorders were observed in the intermediate and upper cell layers of these specimens, as shown by a reduced expression of filaggrin/profilaggrin, a marker of terminal differentiation, in extragenital BD (7/11 cases), and an increased expression in genital BP (4/5 cases) although viral DNA was not always detectable. This study shows that in situ hybridization is a valuable technique for HPV DNA detection and its typing in BD and BP lesions on deparaffinized sections. The positive nuclei were located in the cell layers that exhibited abnormal expression of differentiation. There is no relation between the HPV infecting type and the filaggrin expression.

Recombinant interferon alpha 2a is effective in the treatment of discoid and subacute cutaneous lupus erythematosus

Ten patients suffering from either discoid lupus erythematosus (DLE) or subacute cutaneous lupus erythematosus (SCLE) were treated with interferon alpha 2a. Eight received low or intermediate doses (18-45 x 10(6) U/week) for a short period of time (4-8 weeks), with marked improvement of skin lesions in six, an exacerbation in one patient and no change in the other. Two patients with SCLE received high doses (100-120 x 10(6) U/week) over 12 weeks, with complete clearing of the lesions in one and a marked improvement in the other. The responses were of short duration and within a few weeks of stopping treatment all who had improved or cleared relapsed. The side-effects in all the patients were fever and a flu-like syndrome which necessitated a reduction of the dose in one case. In two patients there were increases in the liver enzyme levels, but no haematological toxicity was noted.

Treatment of cutaneous T cell lymphoma with intermediate doses of interferon alpha 2a

In this study we treated 6 patients with epidermotropic cutaneous T cell lymphoma (CTCL) with intermediate doses of recombinant alpha 2a interferon (18-100 x 10(6) IU/week) for 2-6 months. One patient experienced complete clinical remission in spite of a persistent dense lymphocytic skin infiltrate. One patient was markedly improved and 2 patients were moderately improved. The clinical condition of the 2 remaining patients was unchanged by interferon treatment. In all cases lesions relapsed a few weeks after treatment was discontinued. This study shows that interferon can be used to treat epidermotropic CTCL. However, a 2- to 6-month treatment using moderate doses did not lead to the high percentage of remission previously reported by others with high doses of recombinant alpha 2a interferon, for longer periods. This result suggests that interferon should be used at high doses and/or for long time periods for clinical improvement of CTCL patients.

Cutaneous angiomas in POEMS syndrome. An ultrastructural and immunohistochemical study

Cutaneous manifestations of POEMS (polyneuropathy, organomegaly, endocrinopathies, M-protein, and skin changes) syndrome in a 51-year-old white man included two types of hemangiomas, ie, cherry-type and subcutaneous hemangiomas. By light microscopy and immunohistochemistry, both types of tumors showed features of capillary hemangiomas. By electron microscopy, a peculiar finding of subcutaneous hemangiomas was the presence of slender abluminal processes of endothelial cells that were frequently anastomosing to form electron-lucent blebs. Although the precise etiopathogenesis of the vascular proliferations remains speculative, these lesions merit study since they constitute an easily recognizable marker of POEMS syndrome.

Skin and mucosal manifestations in vitamin deficiency

The skin and mucosal changes in vitamin deficiency are described. Pellagra, which is the oldest known cutaneous manifestation among vitamin deficiencies, is reviewed. Cutaneous alterations caused by deficiency of the water-soluble vitamins B6, C, B1 and biotin, B12, folic acid, and riboflavin result in more mucosal alterations and are discussed. Alterations caused by fat-soluble vitamin deficiencies (vitamins A and K) are also considered.

A sequential study of histological and immunological changes in the skin after allogenic bone marrow transplantation

Histological and immunopathological studies were performed on serial skin biopsies from thirteen recipients of allogenic and two recipients of autologous bone marrow transplants. Marked dermoepidermal infiltration with Leu 2a+ (OKT8+) phenotype cells was found in two patients with severe graft-versus-host disease, but the infiltration did not precede clinical onset of the graft-versus-host disease. Absence of Langerhans cells was noted during the early posttransplant period in recipients of both allogenic and autologous transplantation. Intercellular epidermal staining with anti-DR was observed in three cases, without relation to graft-versus-host disease.

[Treatment of systemic scleroderma with factor XIII in 86 patients, with long-term follow-up]

Eighty-six patients with progressive systemic sclerosis were given coagulation factor XIII intravenously in different dosage regimens. The mean duration of treatment was 19 +/- 18 months and patients were followed up for 22.9 +/- 18.8 months. Improvement or stabilization of the lesions was obtained in 44/86 patients and exclusively concerned skin lesions; there was no improvement in visceral lesions. The drug was well tolerated in short-and long-term treatment. It is concluded that factor XIII demonstrated lasting effectiveness in one-half of the patients treated.

Basement membrane in Kaposi's sarcoma: an immunohistochemical and ultrastructural study

Basement membranes were investigated in early angiomatous and late sarcomatoid stages of Kaposi's sarcoma (KS). Seven frozen skin biopsies of KS from five elderly Mediterranean people and one renal allograft recipient were labelled, using an immunoperoxidase technique, for basement membrane-specific macromolecules, laminin and type IV-collagen. Twenty-seven other frozen cutaneous lesions including haemangio and lymphangiosarcomas, benign vascular tumours, and various epithelial, melanocytic, fibrohistiocytic, fibrosarcomatous and muscular tumours were processed in the same way. In addition an ultrastructural study was performed in two cases of KS, one haemangiosarcoma and one lymphangiosarcoma. Intense labelling was observed for both type IV-collagen and laminin, which appeared closely co-distributed, in all areas of KS. Staining pattern was often regular and continuous around neoplastic vessels in early lesions of KS, as in benign vascular lesions, whereas in late nodular lesions large amounts of basement membrane components were present in intercellular spaces between densely aggregated spindle cells. In contrast, ultrastructural examination disclosed early disruption of basement membranes around neoplastic vessels, and occasional fragments of external lamina were seen at the interface between KS spindle cells and collagen. Similar results were obtained in angiosarcomas both by immunohistological and ultrastructural study. In the comparative group, laminin and type IV-collagen were present, in significantly fewer quantities and in various distinctive patterns, in epithelial, melanocytic, fibrohistiocytic and muscular tumors. This study deals with basement membrane modifications in early and late lesions of KS and provides further evidence in favour of the endothelial nature of the spindle cells of KS.

[Bullous cutaneomucous herpes with torpid ulcers in chronic myeloid leukemia]

In malignant hemopathies the immunological deficiency may modify the clinical features of herpes. In a case of chronic myeloid leukemia, a herpetic infection was responsible for cutaneomucous blisters which developed into chronic ulcers mimicking a dermatological blistering disease.

[Norwegian scabies: etiological grounds (author's transl)]

Norwegian scabies is a rare clinical variant of human infestation with Sarcoptes scabiei var. hominis. It is characterized by hyperkeratotic lesions of the palmar and plantar surfaces, scalp and ears which contain myriad mites. The authors have observed three cases: the first occurred in a old delibited woman with a Recklinghausen's disease, the second in a boy with Down's syndrome, the last in a child treated with immunosuppressors. Review of the literature and study of etiological grounds. The pathogenesis is yet unclear but the altered host factors appear to be the principal determinant: primary or secondary specific immunologic deficit and inability to eliminate the mites because of the absence of scratching, hereditary predisposition to keratotic reaction of the skin.

[Pyoderma gangrenosum, ovarian carcinoma treated with Melphalan and acute myelomonocytic leukaemia: report of one case and literature review (author's transl)]

A 67-year-old woman suffered from an ovarian carcinoma with lymph nodes metastasis. During 3 years, she was treated with alkylating agents (Melphalan). At the end of therapy, no recurrence was observed. Two years later, she developed concomitantly pyoderma gangrenosum and acute myelomonocytic leukaemia. Death occurred rapidly. The association between pyoderma gangrenosum and acute leukaemia is discussed in the light of 16 cases previously reported in the literature. In this case, an induction of leukaemia by cytostatic drugs seems likely. The authors conclude that pyoderma gangrenosum may be considered as a cutaneous signs of acute leukaemia.