Bilateral accessory axillary breast tissue in a premenarchal female

A 9-year-old premenarchal female presented to pediatric dermatology with a 6-month history of periodically tender, bilateral and symmetric axillary masses. Magnetic resonance imaging and subsequent surgical excision confirmed the diagnosis of bilateral accessory axillary breast tissue. Accessory axillary breast tissue is a rare condition seen most in pubertal, pregnant and breastfeeding women. However, it can arise in pre-adolescent patients and should be added to the differential diagnosis of an axillary mass.

Whole-Exome Sequencing of a Case of Squamoid Eccrine Ductal Carcinoma Reveal Similarities With Cutaneous Squamous Cell Carcinoma

ABSTRACT

Squamoid eccrine ductal carcinoma (SEDC) is a poorly documented but likely underrecognized sweat gland malignancy with significant risk for local recurrence and potential for metastasis and rare disease-related mortality. Histopathologically, the tumor demonstrates a biphasic differentiation pattern: superficially, the tumor has squamous differentiation [indistinguishable from well-differentiated cutaneous squamous cell carcinoma (cSCC)], while the deeper aspect has a more infiltrative pattern with prominent ductal differentiation. Diagnosis of SEDC relies upon histopathologic examination alone. Its pathogenesis is poorly understood, and its genomic features have yet to be described. In this article, we characterize the genomic features in a case of SEDC through whole-exome sequencing, then compare its features with cSCC and other eccrine ductal carcinomas. Whole-exome sequencing revealed 30 mutations/Mb with 21 pathogenic or likely pathogenic mutations in total, identified across 14 different genes. The genomic abnormalities identified in this case of SEDC overlap considerably with those found in cSCC but not those of other sweat gland malignancies. The clinical and histopathologic features of SEDC previously reported and the genetic features determined from this case suggest that this tumor may arise initially as a well-differentiated cSCC that subsequently undergoes divergent differentiation focally to resemble a sweat gland malignancy. Genetic analyses of additional cases are warranted to clarify this consideration.

Comparing Follicular Extension Between Low-Grade and High-Grade Dysplastic Nevi

ABSTRACT

Dysplastic nevi are an important subset of melanocytic nevi with atypical clinical, histopathologic, as well as genomic features compared with common acquired nevi. Dysplastic nevi are characterized histologically by both cytologic atypia and architectural disorder. The established criteria for cytologic atypia used to distinguish between low-grade and high-grade dysplastic nevi are often subjective, although there is a dearth of more objective, reproducible features of architectural disorder (eg, pagetoid scatter) that have been validated to differentiate between low-grade and high-grade dysplastic nevi. In this study, we sought to determine whether the presence and degree of follicular extension differ between low-grade and high-grade dysplastic nevi. We retrospectively examined the histopathologic features of 90 dysplastic nevi: 60 cases of low-grade dysplastic nevi (average age of 47.2 ± 18.1 years; 62.7% female) and 30 cases of high-grade dysplastic nevi (average age of 47.4 ± 19.8 years; 60.0% female). After examination, 50% of the cases of dysplastic nevi (n = 45) had hair follicles within the lesion, for which the presence and degree of follicular extension was then determined. Low-grade and high-grade dysplastic nevi do not differ significantly regarding the presence of follicular extension, average depth of follicular extension, and confluence of nevus cells along the follicular epithelium. Both low-grade and high-grade dysplastic nevi in our study demonstrated follicular extension that was superficial, that is, above the level of isthmus of hair follicles (insertion of sebaceous gland into hair follicle). Future studies are warranted to confirm these preliminary findings.

Intralesional corticosteroid injections to treat lip swelling associated with oral Crohn's disease in a child

This procedural report details the case of a 10-year-old boy with oral Crohn's disease successfully treated with intralesional corticosteroid injections. The intervention used topical anesthesia with a eutectic mixture of lidocaine 2.5%/prilocaine 2.5% cream followed by intralesional triamcinolone acetonide. This approach safely and effectively reduced patient discomfort while allowing for an acceptable and durable clinical outcome.

Letter to Editor: Characterizing the Lack of Specificity of the Histopathological Findings Seen in Multicentric Reticulohistiocytosis and Reticulohistiocytoma

Both reticulohistiocytoma and multicentric reticulohistiocytosis are defined by their shared histopathologic appearance of dermal proliferations of mononuclear histiocytes and multinucleated giant cells with eosinophilic "ground-glass" or "two-toned" cytoplasm. To assess the specificity of the histopathologic findings seen in reticulohistiocytoma and reticulohistiocytosis, this study retrospectively examined 109 random, unscreened excision specimens of ruptured cysts to determine at what frequency "ground-glass" or "two-toned" histiocytes and multinucleated giant cells are seen in reactive cutaneous infiltrates. Slightly more than half (56.9%) of the ruptured cyst cases had "ground-glass" histiocytes. The majority (84%) of the ruptured cyst cases had multinucleated giant cells. The shared histologic findings associated with reticulohistiocytoma and reticulohistiocytosis are much more pervasive than previously documented and are relatively non-specific. Identification of immunohistochemical and/or molecular biomarkers that distinguish reticulohistiocytoma and reticulohistiocytosis from histologic mimickers would likely prove indispensable.

Sporadic superficial angiomyxomas demonstrate loss of PRKAR1A expression

Superficial angiomyxomas are cutaneous mesenchymal tumors that typically present clinically as slow-growing, solitary, asymptomatic nodules that can occur at any age. Histopathologically, these dermal and subcutaneous tumors are characterized by abundant myxoid stroma, numerous thin-walled and often arborizing blood vessels, and spindled to stellate fibroblast-like cells. While usually sporadic, superficial angiomyxomas can occasionally be associated with Carney complex (CNC), an autosomal dominant disorder characterized by inactivating germline mutations in the 1-alpha regulatory subunit of protein kinase A (PRKAR1A) and various clinical manifestations, including: cardiac myxomas, facial lentigines, epithelioid blue nevi, endocrinopathies, and psammomatous melanotic schwannomas. In this study, we sought to characterize the presence or absence of PRKAR1A expression by immunohistochemistry (IHC) in sporadic superficial angiomyxomas based on our observations in an index case. In total, PRKAR1A immunohistochemical expression was determined in 15 sporadic superficial angiomyxoma cases retrieved from the surgical pathology archives. IHC demonstrated that the lesional cells in 12 cases (80%) were non-reactive to antibodies against PRKAR1A. This study provides evidence in support of a role for PRKAR1A in the development of clinically non-syndromic superficial angiomyxomas. Along with previous studies, this report demonstrates that PRKAR1A may play an important role in the development of a variety of myxomatous mesenchymal tumors.

Pityriasis lichenoides-like drug reaction with numerous eosinophils

Pityriasis lichenoides-like drug reactions simulate pityriasis lichenoides clinically and histopathologically, though important differences exist. As a rule, pityriasis lichenoides has minimal to no eosinophils. However, this case illustrates that pityriasis lichenoides-like drug reaction can present with numerous eosinophils. This, in our experience is not rare, but contrasts with clinical reports in the literature that describe pityriasis lichenoides-like drug reactions with minimal to no eosinophils in the infiltrate. While similar, distinguishing these diseases is important given that pityriasis lichenoides is a lymphoproliferative disorder with a more protracted clinical course that is difficult to treat. We provide histopathological clues to aid in this important distinction.

Leukemia Cutis With Histopathologic and Immunophenotypic Features Resembling S100-Negative CD1a-Positive Cutaneous Histiocytosis

ABSTRACT

S100-negative CD1a-positive cutaneous histiocytosis is an exceedingly rare histiocytosis that is defined histopathologically by a dense dermal infiltrate of ovoid mononuclear cells with grooved nuclei and ample cytoplasm with variable nuclear atypia and mitoses that are immunohistochemically positive for CD1a and negative for S100 and CD207 (langerin). The histogenesis of S100-negative CD1a-positive histiocytosis is unclear, and its precursor cell has yet to be characterized. Although all cases thus far have been described as benign and occasionally self-resolving, the clinical course and outcome of this disease are not fully understood. This case expands the spectrum of disease associated with S100-negative CD1a-positive histiocytosis given its malignant course.

Genetic barcoding and phylogenetic analysis of dusky cotton bug (Oxycarenus hyalinipennis) using mitochondrial cytochrome c oxidase I gene

Cotton dusky bug (Oxycarenus spp.) mostly attack on cash crops such as Gossypium, Cola and Hibiscus which affect the national economy therefore sustainable pest management is needed. Cytochrome c oxidase I (COI) gene is utilized as marker gene for DNA barcoding, genetic and ecological study of insects. In present study insect (cotton dusky bug) samples were collected from cotton fields in Faisalabad. COI gene was amplified from genomic DNA of bug and cloned into pTZ57R/T vector (Fermentas). The clone was sent to Macrogen (South Korea) for Sanger sequencing. The phylogenetic analysis and pairwise multiple sequence alignment showed that our cotton dusky bug grouped with two species of Oxycarenus genus and highest sequence identity was 91.1% with Oxycarenus hylinipennis. This is the first report of genetic barcode of Oxycarenus hylinipennis from cotton from Pakistan.

Imported fire ant envenomation: A clinicopathologic study of a recognizable form of arthropod assault reaction

BACKGROUND

Skin reactions to the sting of the imported fire ant have characteristic clinicopathological features.

METHODS

One case of experimental envenomation was prospectively followed during 48 hours, with biopsies. In addition, 6 cases from our laboratory were retrospectively evaluated histopathologically for the following features: spongiosis, exocytosis (and type of cells), pustule formation, erosion/ulceration, epidermal necrosis, scale/crust, papillary dermal edema, inflammatory dermal infiltrate (cell type, density, depth, distribution, shape), red blood cell extravasation, vasculopathy and vasculitis.

RESULTS

The typical lesion follows a very distinctive clinical and histopathologic evolution over 48 hours, with the formation of a subepidermal pustule overlying a wedge-shaped area of dermal collagen basophilic degeneration with scattered neutrophils. In the 6 cases retrieved from our files, the main features were a superficial and deep dermal, perivascular, periadnexal and interstitial infiltrate consisting of neutrophils, with basophilic degeneration of the collagen. A subepidermal pustule was noted in half of the cases.

CONCLUSIONS

In biopsies taken in a clinical setting, even in the absence of the characteristic subepidermal pustule, the diagnosis of imported fire ant sting can be suspected if there is a superficial and deep perivascular, periadnexal and interstitial infiltrate composed of neutrophils, with some basophilic denaturation of collagen.

Blue-White Veil as Novel Dermatoscopic Feature in Discoid Lupus Erythematosus in 2 African-American Patients

Dermoscopic features of discoid lupus erythematosus (DLE) depend on the stage of the lesions: active lesions include yellow-brown dots and red dots, whereas longstanding inactive lesions show absence of follicular openings, cicatricial milky red or white patches, structureless white and brown areas, and thick arborizing vessels. Loss of pinpoint white dots, blue-gray dots in a speckled pattern, and a peripheral pigmented network have been described on dermoscopy of DLE in dark skin. We report a blue-white veil as a novel dermoscopic feature in 2 cases of biopsy-proven DLE in African-American patients. Dry trichoscopy revealed a central white area surrounded by irregular patchy areas of confluent blue and brown pigment and an overlying white "ground-glass" hue. This corresponds on pathology to the hyperkeratosis overlying interface changes at the dermal-epidermal junction, with pigment incontinence and melanophages in the papillary dermis.

Voriconazole Exposure and Risk of Cutaneous Squamous Cell Carcinoma, Aspergillus Colonization, Invasive Aspergillosis and Death in Lung Transplant Recipients

Voriconazole is a triazole antifungal used to prevent and treat invasive fungal infections after lung transplantation, but it has been associated with an increased risk of developing cutaneous squamous cell carcinoma (SCC). Despite widespread use, there are no clear guidelines for optimal prophylactic regimens that balance the competing risks and benefits. We conducted a retrospective cohort study of all lung transplant recipients at the University of California, San Francisco, who were transplanted between October 1991 and December 2012 (n = 455) to investigate whether voriconazole exposure affected development of SCC, Aspergillus colonization, invasive aspergillosis and all-cause mortality. Voriconazole exposure was associated with a 73% increased risk of developing SCC (hazard ratio [HR] 1.73; 95% confidence interval [CI]: 1.04-2.88; p = 0.03), with each additional 30-day exposure at the standard dose increasing the risk by 3.0% (HR 1.03; 95% CI: 1.02-1.04; p < 0.001). Voriconazole exposure reduced risk of Aspergillus colonization by 50% (HR 0.50; 95% CI: 0.34-0.72; p < 0.001), but we were underpowered to detect risk reduction for invasive aspergillosis. Voriconazole exposure significantly reduced all-cause mortality among subjects who developed Aspergillus colonization (HR 0.34; 95% CI: 0.13-0.91; p = 0.03) but had no significant impact on those without colonization. Physicians should consider patient-specific factors that modify the potential risks and benefits of voriconazole for the care of lung transplant recipients.

An overview of parabens and allergic contact dermatitis

Esters of p-hydroxybenzoic acid (parabens) are the most widely used preservatives in cosmetic, pharmaceutical, and industrial products. However, since the 1960s, controversy has surrounded its use and safety as a potential cause of allergic contact dermatitis. Despite the cloud of suspicion that has hovered over parabens ever since, these ubiquitous compounds have withstood four decades of extensive skin testing conducted by a variety of organizations, both North American and European, and now, it seems parabens have shown to be one of the least sensitizing preservatives in commercial use. Of the very limited reports of paraben-induced allergic contact dermatitis, these cases are often attributable to the application of parabens on damaged skin.

Ciclopirox delivery into the human nail plate using novel lipid diffusion enhancers

CONTEXT

Onychomycosis is a common fungal infection of the nail plate and bed that affects up to 14% of the population and can have a substantial impact on the quality of life of those affected.

OBJECTIVE

This study compared the onychopharmacokinetics, nail absorption, nail distribution, and nail penetration of [(14)C]-ciclopirox dissolved in novel lipid diffusion enhancers with that of a commercial ciclopirox nail lacquer using the in vitro finite dose model.

MATERIALS AND METHODS

The penetration rate of ciclopirox was determined by applying doses of topical formulation twice daily to human nail plates for 11 d. Drug absorption was then measured by monitoring its rate of appearance in each nail layer and in the cotton pad/nail supporting bed.

RESULTS

After a multiple day treatment, cumulative concentrations of ciclopirox formulated with lipid enhancers in the deep nail layer and the nail bed were significantly greater than cumulative concentrations of the commercial ciclopirox lacquer (p < 0.001) as well as several orders of magnitude greater than the minimal inhibitory concentration (MIC) deemed necessary to inhibit the growth of the causative dermatophyte species.

CONCLUSION

When formulated with lipid enhancers, the amount of ciclopirox in the ventral/intermediate layer and supporting bed dramatically exceed the inhibitory concentration of ciclopirox for the most common onychomycosis organisms. These results suggest that topical ciclopirox with lipid enhancers has the potential to be an effective topical treatment for onychomycosis, and the lipidic pathway of the nail can be utilized as a means of effective transungual delivery.

Pulsatile tinnitus in cerebrovascular arterial diseases

In a prospective study of 100 patients evaluated at the University of Wisconsin Stroke Program, we sought to document cases of incidental pulsatile tinnitus that could be ascribed to stenotic, occluded, ectatic, tortuous, or dissected craniocerebral arteries. Angiographic detail, magnetic resonance angiography, catheter-generated x-ray angiography, or both were necessary for inclusion into either Group 1 (n=29), those with pulsatile tinnitus, or Group 2 (n=71), those without pulsatile tinnitus. Patients did not appear to have head/neck tumors, aneurysms, arteriovenous malformations, transmitted cardiac murmurs, or venous etiologies for their tinnitus. Age, sex, and stroke risk factor profiles did not separate the two groups. Factors that were significantly more common in Group 1 included (1) severe, > or =70% stenosis through complete occlusion, internal carotid artery disease (59% for Group 1 v 21% for Group 2, P<.05); (2) severe, > or =50% stenosis through occlusion, vertebral or basilar disease (38% v 18%, P<.05); (3) tortuosity of at least one carotid, vertebral, or basilar artery (31% v 18%, P<.05); and (4) basilar artery dolichoectasia (14% v 0%, P=.006). We also noted when pulsatile tinnitus was either "objective" (11 of 100, 11%) or "subjective" (18 of 100, 18%), duration of tinnitus, transient versus permanent nature of tinnitus, and reasons seen in consultation by one of us.

History of childhood maltreatment is associated with comorbid depression in women with migraine

BACKGROUND

A bidirectional relationship between migraine and depression suggests a neurobiological link. Adverse experiences, particularly childhood maltreatment, may alter neurobiological systems, and predispose to a multiplicity of adult chronic disorders. Our objective is to determine, within a headache clinic population of women, if depression moderates the abuse-migraine relationship.

METHODS

At six headache specialty clinics, women with migraine were diagnosed using ICHD-II criteria, and frequency was recorded. A questionnaire regarding maltreatment history, headache characteristics, current depression, and somatic symptoms was completed.

RESULTS

A total of 949 women with migraine completed the survey: 40% had chronic headache (> or =15 headache days/month) and 72% had "very severe" headache-related disability. Major depression was recorded in 18%. Physical or sexual abuse was reported in 38%, and 12% reported both physical and sexual abuse in the past. Migraineurs with current major depression reported physical (p < 0.001) and sexual (p < 0.001) abuse in higher frequencies compared to those without depression. Women with major depression were more likely to report sexual abuse occurring before age 12 years (OR = 2.30, 95% CI: 1.14 to 4.77), and the relationship was stronger when abuse occurred both before and after age 12 years (OR = 5.08, 95% CI: 2.15 to 11.99). Women with major depression were also twice as likely to report multiple types of maltreatment (OR = 2.07, 95% CI: 1.27 to 3.35) compared to those without depression.

CONCLUSIONS

Childhood maltreatment was more common in women with migraine and concomitant major depression than in those with migraine alone. The association of childhood sexual abuse with migraine and depression is amplified if abuse also occurs at a later age.

High prevalence of somatic symptoms and depression in women with disabling chronic headache

OBJECTIVE

To better define, in women with headache, the relationship of depression and somatic symptoms to headache, characterized by diagnoses, frequency, and disability.

METHODS

At six headache specialty clinics, women with headache were classified using ICHD-II criteria, and frequency was recorded. A questionnaire addressing demographics, age at onset of headache, headache-related disability, somatic symptom, and depression severity was completed. Logistic regression was performed to measure the associations of headache frequency and headache-related disability with somatic symptom and depression severity.

RESULTS

A total of 1,032 women with headache completed the survey, 593 with episodic (96% with migraine) and 439 with chronic headache (87% with migraine). Low education and household income was more common in chronic headache sufferers and in persons with severe headache disability. Somatic symptom prevalence and severity was greater in persons with chronic headache and with severe headache-related disability. Significant correlation was observed between PHQ-9 and PHQ-15 scores (r = 0.62). Chronic headache, severe disability, and high somatic symptom severity were associated with major depressive disorder (OR = 25.1, 95% CI: 10.9 to 57.9), and this relationship was stronger in the subgroup with a diagnosis of migraine (OR = 31.8, 95% CI: 12.9 to 78.5).

CONCLUSIONS

High somatic symptom severity is prevalent in women with chronic and severely disabling headaches. Synergistic relationship to major depression exists for high somatic symptom severity, chronic headache, and disabling headache, suggesting a psychobiological underpinning of these associations.

Isolated petrous carotid stenosis and transient ischemic attack

Although anterior circulation transient ischemic attacks (TIAs) tend to be more common in patients with extra- cranial carotid arterial disease than in those with intracranial carotid or middle cerebral arterial disease, the authors recently encountered 4 patients with both recurrent, stereotypical TIAs as well as isolated stenosis of their petrous internal carotid artery (ICA). While the gold standard for establishing the diagnosis of intracranial large-artery disease has always been conventional angiography, magnetic resonance angiography changes, confirmed with intra-arterial digital subtraction angiography in 2 of these patients, were quite sufficient to define the occlusive disease in each of the cases. Petrous ICA stenosis is not uncommon, but it has often been overshadowed by the search for extracranial ICA disease that might be amenable to surgical reconstruction.

Tortuosity of carotid and vertebral arteries: a magnetic resonance angiographic study

Nine patients (group A) were found on magnetic resonance angiography (MRA) to have excessive carotid artery, vertebral artery, and vertebrobasilar junction tortuosity. A control group (group B) were age- and sex-matched to group A patients, were selected randomly from our MRA or stroke data banks, and had not undergone MRA for evaluation of migraine, "carotidynia," or pulsatile tinnitus. Factors more prevalent in group A patients included migraine, chronic daily headache, carotidynia, pulsatile tinnitus, and a positive family history of headache. Factors more prevalent in group B patients included a positive family history of stroke, large-vessel atherosclerosis, and scan evidence of ischemic infarctions; many group B patients had undergone MRA for stroke or transient ischemic attack evaluation. Men were slightly underrepresented at 44%, and were younger than women (34 +/- 6 years vs. 43 +/- 3 years; p = 0.01). Relationships in this preliminary study between arterial tortuosity and migraine seem evident.

Differing mechanisms between posterior and middle cerebral artery infarctions

Cardiac embolism has been thought to be one of the principal causes of posterior cerebral artery territory infarction. To determine stroke mechanisms and stroke risk factors in patients with posterior cerebral artery infarction, we studied 23 consecutive patients with recent infarcts in the posterior cerebral artery distribution (PCA infarcts) and compared these with a case-control group of 46 patients with recent infarcts in the middle cerebral artery distribution (MCA infarcts). All patients were similarly studied, including angiography and echocardiography. Case controls were age- and sex-matched and were randomly chosen from the most recent MCA infarcts seen at our institutions. All subjects were white. PCA infarcts had significantly more cardiac-source emboli (P=.01), less evident atherothrombosis (P=.003), multiplicity of infarctions (P=.05), and documented branch occlusions in the vessel involved (P=.05). MCA infarcts had more preinfarction transient ischemic attacks (P=.03) and evident occlusion of the appropriate extracranial vessel (P=.03). Different stroke mechanisms should lead to different diagnostic and therapeutic decisions.

Recurrent ischemic strokes in a patient with Medtronic-Hall prosthetic aortic valve and valve strands

Fine strands associated with prosthetic heart valves have been demonstrated with transesophageal echocardiography, but the pathologic identity of these strands is unclear. A case of a man with a prosthetic aortic Medtronic-Hall valve with prominent valve strands and recurrent strokes is discussed. The patient underwent valve replacement surgery, and histopathologic examination of the strands identified them as Lambl's excrescences.

Kanerocin: A New Triterpene from the Leaves of Nerium oleander

From the fresh, undried, and uncrushed leaves of NERIUM OLEANDER a new triterpenoid, kanerocin, has been isolated along with known ursolic and oleanolic acids and its structure established through chemical and spectroscopic methods as 3alpha-hydroxy-urs-18,20-dien-28-oic acid.

Oleanderoic Acid and Oleanderen from the Leaves of Nerium oleander

A new labdane diterpene, oleanderoic acid and a new triterpene, oleanderen have been isolated from the fresh, undried and uncrushed leaves of NERIUM OLEANDER. Their structures have been established as 8alpha-methoxylabdan-18-oic acid, and 12-ursene, respectively, through chemical and spectral studies, including 2D-NMR (COSY-45, NOESY and 2D- J resolved) and (13)C-NMR data.

Isolation and Structure of Neriucoumaric and Isoneriucoumaric Acids from the Leaves of Nerium oleander

Two new coumaryloxy triterpenoids, neriucoumaric and isoneriucoumaric acids, have been isolated from fresh, undried and uncrushed leaves of NERIUM OLEANDER and their structures established as 3beta-hydroxy-2alpha-cis- P-coumaryloxy-urs-12-en-28-oic acid and 3beta-hydroxy-2alpha- TRANS- P-coumaryloxy-urs-12-en-28-oic acid respectively, through chemical and spectroscopic methods.

Isolation and Structure of Neriumol and Nerifol from the Leaves of Nerium odorum

From the fresh, undried, uncrushed leaves of NERIUM ODORUM, two hydroxy acid methyl esters, neriumol and nerifol, have been isolated and their structures established as methyl (7 S,16)-dihydroxyhexadeca-8 Z-enoate and methyl (8,16)-dihydroxyhexadecanoate, through chemical and spectroscopic methods.