Extracorporeal photochemotherapy in the treatment of cutaneous T cell lymphoma and autoimmune disorders affecting the skin

Extracorporeal photochemotherapy (ECPCT) is a new form of chemoimmunotherapy which involves the ex vivo exposure of malignant peripheral blood cells to 8-methoxypsoralen (8-MOP) and ultraviolet A (UVA) radiation followed by reinfusion of the treated cells. This treatment has resulted in an unprecedented number of prolonged remissions in patients with therapeutically resistant forms of cutaneous T cell lymphoma (CTCL) characterized by the systemic dissemination of a clonal population of malignant helper T lymphocytes. Although the mechanism of the beneficial effect is uncertain, an immune reaction to the reinfused modified T cells probably results in tumour regression. Because the T cell antigen receptor (TCR) is an immunogenic structure and because an identical TCR is present on the entire clonal population of malignant T cells in each individual with CTCL, modification of this structure represents the most likely target for the effects of 8-MOP and UVA. Understanding of the precise events leading to tumour regression in CTCL during treatment with ECPCT may lead to the expanded use of this therapy for other lethal haemopoietic malignancies.

Oxalate kinetics and reversal of the complications after orthotopic liver transplantation in a patient with primary hyperoxalosis type 1 awaiting renal transplantation

We present the case of a young woman with end-stage renal disease secondary to primary hyperoxaluria type 1, who after 3 years and 6 months of maintenance hemodialysis, and despite intensification of the dialytic treatment, developed severe livedo reticularis in her extremities leading to ischemic cutaneous ulcerations, necessitating continuous intravenous infusion of narcotics for pain control. She received a liver transplant after native hepatectomy. However, due to positive crossmatch, she could not receive a kidney from that donor. After transplantation, following serial serum oxalate levels, the hemodialysis regimen was safely reduced from 4 h daily to 3 h three times weekly. Over the course of 6 weeks after liver transplantation, her livedo reticularis resolved, the ischemic ulcers markedly improved, she was weaned off all pain medications, and her erythropoietin-resistant anemia resolved. Our results suggest that in patients with primary hyperoxaluria type 1, who have received a liver transplant and are on maintenance hemodialysis, after serial serum oxalate determinations, some may safely be changed to a thrice-weekly maintenance hemodialysis regimen. Moreover, with this regimen the complications of systemic oxalosis can reverse.

Inpatient dermatology consultation

Common dermatologic conditions and skin signs of systemic disease are routinely present in hospitalized patients. Rapid detection and identification of these changes can have a significant impact on the patient's hospital course. Inpatient dermatology consultation can improve diagnostic accuracy, efficiency, and treatment of hospitalized patients with cutaneous findings. This article discusses the clinical aspects of inpatient dermatology consultation and the features of effective consultation.

Antiphospholipid antibodies and the antiphospholipid antibody syndrome

The antiphospholipid antibody syndrome is a multisystem disorder characterized by persistently elevated antiphospholipid antibodies and/or arterial or venous thrombosis, thrombocytopenia and recurrent spontaneous abortion. Anticardiolipin antibodies and the lupus anticoagulant are different classes of antiphospholipid antibodies associated with this disorder. Various hematologic, neurologic, obstetric and cutaneous abnormalities are manifest in this syndrome. This article reviews the characteristic features of the antiphospholipid antibody syndrome.

Primary cutaneous T-cell-rich B-cell lymphomas with flow cytometric immunophenotypic findings. Report of 3 cases and review of the literature

BACKGROUND

Primary cutaneous T-cell-rich B-cell lymphoma is a relatively rare entity that has been diagnosed most commonly using immunohistochemical and molecular techniques. Flow cytometric immunophenotyping (FCI) has not been described in this entity. We report the demonstration of B-cell monoclonality by FCI in 3 cases of primary cutaneous T-cell-rich B-cell lymphoma.

METHODS

Clinical and pathologic data were recorded for 3 cases of primary cutaneous T-cell-rich B-cell lymphoma. Immunohistochemical and FCI data were available in all cases; DNA analysis was performed in 1 case.

RESULTS

Flow cytometric immunophenotyping revealed a monoclonal B-cell population exclusively in the monocyte (large cell) region in all 3 cases. Immunohistochemistry confirmed the T-cell richness of the infiltrates within the cutaneous lymphomas; T cells accounted for 65% to greater than 90% of the cells within the infiltrates. DNA analysis by polymerase chain reaction in 1 case did not demonstrate a monoclonal rearrangement of the immunoglobulin heavy-chain gene.

CONCLUSIONS

Flow cytometric immunophenotyping in primary cutaneous T-cell-rich B-cell lymphoma may be useful in demonstrating monoclonality in these cases, especially if there is selective gating on the relatively small population of cells in the large cell region. The FCI data should be correlated with histology and immunohistochemistry.

Clinical reactogenicity of intradermal bacille Calmette-Guérin vaccination

Clinical, microbiological, and immunologic responses were evaluated in volunteers vaccinated intradermally with bacille Calmette-Guérin (BCG). Most volunteers (98%) developed ulcerative lesions that drained for a mean +/- SE of 4.3 +/- 0.29 weeks. Mycobacterial DNA was detected by a polymerase chain reaction-based amplification technique in biopsy specimens from BCG ulcers 2 weeks after vaccination and in blood specimens 3 days after vaccination. Mycobacteria were cultured from ulcer drainage 2 months after vaccination, demonstrating a prolonged potential risk of contact spread of the vaccine strain. The duration of ulcer drainage was inversely correlated with prevaccination lymphoproliferative (r = -0.515; P < .002) and interferon gamma (r = -0.841; P < .002) responses specific to mycobacteria and directly correlated with postvaccination increases in lymphoproliferative (r = 0.498; P < .002) and interferon gamma (r = 0.688; P < .02) responses specific to mycobacteria. These results demonstrate the clinical reactogenicity of BCG and the potential risk of contact spread of the vaccine strain and suggest that clinical reactogenicity is a trade-off for the induction of protective mycobacterial immunity.

Fluoroscopy-induced radiodermatitis after transjugular intrahepatic portosystemic shunt

Transjugular intrahepatic portosystemic shunt is a nonsurgical procedure used to manage the complications of portal hypertension. This report describes three cases of fluoroscopy-induced radiodermatitis after transjugular intrahepatic portosystemic shunt and reviews the characteristics and treatment of radiation-induced skin reactions.

Acute radiodermatitis after radiofrequency catheter ablation

Radiofrequency (RF) catheter ablation is used in the treatment of a variety of arrhythmias. This report describes the development of acute radiodermatitis after two prolonged RF catheter ablation procedures for supraventricular tachycardia. It also reviews the characteristics and treatment of radiation-induced skin reactions.

Antiphospholipid antibodies and the antiphospholipid antibody syndrome

The antiphospholipid antibody syndrome is a multiple-system disorder characterized by persistently elevated antiphospholipid antibodies and/or arterial or venous thrombosis, thrombocytopenia, or recurrent spontaneous abortion. Anticardiolipin antibodies and the lupus anticoagulant are different classes of antiphospholipid antibodies associated with this disorder. Cutaneous manifestations are common and may be the presenting sign of the underlying disease. This article reviews the clinical manifestations, laboratory assays, histopathologic features, and treatment of the antiphospholipid antibody syndrome.

Cutaneous reactions following herpes zoster infections: report of three cases and a review of the literature

Three patients, one healthy and two immunocompromised, developed cutaneous reactions that histologically mimicked granuloma annulare at sites of resolved varicella-zoster virus (VZV) reactivation infections. Variable latency periods between the infection and the granulomatous reaction were noted. As in other case reports, the presence of VZV DNA in these lesions was inconsistently demonstrated by the polymerase chain reaction (PCR) and appears more common in early, as opposed to late, post-zoster granulomas. In addition to various granulomatous reactions, vasculitic and neoplastic eruptions following resolved VZV infections have been described and are reviewed here. Therapeutically, topical, intralesional and systemic corticosteroids, as well as acyclovir, have been tried with inconsistent results. Although the pathogenesis remains unclear, the presence of VZV DNA in early lesions that histologically do not display viral cytopathic changes, suggests the virus induces an atypical delayed hypersensitivity reaction not affected by antiviral therapy.

Prevalence of cutaneous findings in hospitalized medical patients

BACKGROUND

Cutaneous signs may represent a systemic process or a primary cutaneous disorder. Prompt observation and identification of cutaneous abnormalities should improve care of hospitalized medical patients.

OBJECTIVE

Our purpose was to determine the prevalence of cutaneous abnormalities in newly hospitalized medical patients and the frequency with which these findings were noted by the admitting team.

METHODS

All new medical patients were offered a complete skin examination within 48 hours after admission to the hospital, and 231 participated. Cutaneous diagnoses were based on characteristic clinical features or skin biopsy in patients in whom a diagnosis could not be made clinically.

RESULTS

Ninety-three cutaneous findings were present in 83 (35.9%) of 231 patients. In 31 (13.4%) we found cutaneous signs related to the reason for hospitalization or associated with a systemic disorder. These were not noted by the admitting medical service in 14 patients. In two patients, one with metastatic adenocarcinoma and one with sclerosis, the cutaneous findings were manifestations of the new diagnosis. In 52 patients (22.5%) we found 62 primary cutaneous disorders. Fifty-eight disorders (93.5%), including 10 nonmelanoma skin cancers, were unrecognized at the time of admission.

CONCLUSION

Cutaneous findings representative of systemic disease or primary cutaneous disorders are commonly present and frequently overlooked in medical patients newly admitted to the hospital. These data suggest that a complete skin examination is necessary in all newly hospitalized medical patients.

Analysis of the polymerase chain reaction in the detection of herpesvirus DNA from fixed and stained tissue sections

BACKGROUND AND DESIGN

The polymerase chain reaction (PCR) is a molecular diagnostic technique that has been applied to many infectious processes. Stained and unstained Tzanck smears, vesicle fluid swabs, and crusts have all been used as the source for template DNA for the PCR to document evidence of herpes simplex virus and varicella-zoster virus infection. Thirty-five cases with histologic evidence of acute herpesvirus infection were retrieved from archival tissue blocks that were up to 5 years old. Paraffin and hematoxylin-eosin-stained tissue sections obtained from routinely prepared glass slides from these cases were then examined for herpesvirus DNA using the PCR.

RESULTS

The PCR-detected herpesvirus DNA from 34 (97.1%) of 35 paraffin tissue samples. Herpes simplex virus and varicella-zoster virus DNA were detected in eight and 26 of these cases, respectively. For hematoxylin-eosin-stained tissue samples, PCR detected herpesvirus DNA sequences in 16 (45.7%) of 35 cases. Herpesvirus DNA was isolated from paraffin tissue sections and recently prepared hematoxylin-eosin-stained tissue samples obtained from archival tissue blocks that were up to 5 and 2 years old, respectively.

CONCLUSIONS

The PCR can detect herpesvirus DNA in extremely high yield from unstained paraffin-embedded tissue samples with histologic evidence of acute herpesvirus infection that are up to 5 years old. Herpesvirus DNA can also be identified in approximately 50% of these cases from hematoxylin-eosin-stained tissue sections obtained from routinely prepared glass slides.

Detection of herpes simplex and varicella-zoster infection from cutaneous lesions in different clinical stages with the polymerase chain reaction

BACKGROUND

The polymerase chain reaction (PCR) can be used to diagnose a variety of infectious processes.

OBJECTIVE

We sought to determine whether Tzanck smear debris, vesicle fluid swabs, crusts, or fixed tissue specimens are the best source for template herpes simplex virus (HSV) or varicella-zoster virus (VZV) DNA for the PCR.

METHODS

Patients with both clinical and histologic evidence of HSV (n = 6) or VZV (n = 16) infection were examined. Stained Tzanck smears, vesicle fluid swabs, dried crusts, and skin biopsy specimens were obtained at the same time from each patient. DNA was extracted from the different clinical specimens and then examined for HSV or VZV DNA with PCR. Fifteen control subjects did not have clinical or histologic evidence of herpesvirus infection.

RESULTS

In cases of suspected VZV infection, PCR detected VZV DNA sequences from all 15 Tzanck smears, all 15 vesicle swabs, one of one crust, and 14 of 16 fixed tissue specimens. HSV DNA sequences were detected from all six Tzanck smears, all four vesicle fluid swabs, two of two crusts, and five of six fixed tissue specimens.

CONCLUSION

PCR can detect VZV and HSV DNA sequences from a variety of sources including formalin-fixed tissue specimens. Although viral DNA was detected slightly more frequently from Tzanck smear debris, crusts, and vesicle fluid swabs compared with fixed tissue specimens, each was an excellent source of target DNA for the PCR to confirm the diagnosis of herpesvirus infection.

Merkel cells in neurofibromas and neurilemomas

Merkel cells are an integral component of the cutaneous nervous system. They are commonly associated with dermal nerves under normal physiological conditions. We postulated that Merkel cells may be present in increased numbers within the epidermis overlying benign peripheral nerve sheath tumours such as neurilemomas and neurofibromas. Paraffin-embedded skin biopsy specimens from 21 patients with neurilemomas and 26 with neurofibromas, were analysed for the presence of Merkel cells using a standard immunohistochemical assay (avidin-biotin-peroxidase complex system) with an antibody to cytokeratin 8 (CAM 5.2). Ten cases of leiomyomas were examined as controls. Merkel cells were identified in the interfollicular area of the basal cell layer overlying 14 of 21 (67%) neurilemomas and nine of 26 (35%) neurofibromas. Merkel cells were more frequently observed in increased numbers in a linear array within the basal cell layer in neurilemomas than in neurofibromas, where they were found as individual cells. No Merkel cells were found in the epidermis overlying leiomyomas. The results of this study suggest that Merkel cells are quantitatively increased in the basal cell layer of the epidermis overlying benign peripheral nerve sheath tumours, particularly neurilemomas.

Merkel cells and prurigo nodularis

BACKGROUND

Increased numbers of dermal nerves have been demonstrated in prurigo nodularis and have been theoretically linked to the intense pruritus. We hypothesized that the neuronal proliferation in prurigo nodularis might be associated with an increased density of Merkel cells because they are also a component of the neurocutaneous system.

METHODS

We examined skin biopsy specimens from 20 cases of prurigo nodularis for Merkel cells with the use of a standard immunohistochemical assay (avidin-biotin-peroxidase complex system) with an antibody to cytokeratin 8 (CAM 5.2). Six cases of lichen simplex chronicus were examined as controls.

RESULTS

Merkel cells were present in the interfollicular area of the basal cell layer in 15 (75%) of 20 prurigo nodularis cases and in one (17%) of six cases of lichen simplex chronicus.

CONCLUSION

Merkel cells are increased in number in prurigo nodularis and may be a component of the neurocutaneous abnormality associated with this disorder.

Mucinous breast carcinoma. Single cutaneous metastasis

BACKGROUND

Mucinous or colloid carcinoma is an uncommon breast neoplasm which is generally associated with a good prognosis. Metastases tend to occur late in the disease and are found principally in lymph nodes, lungs, and bones. The longest latency period reported for development of a distant metastasis is 30 years after primary resection of the tumor.

OBJECTIVE

To describe a case of cutaneous metastasis from a mucinous breast carcinoma occurring 22 years after initial resection and review the literature.

RESULTS

Comparison of the primary tumor with the metastatic lesion showed identical histology. Review of the literature revealed this case represents the second longest latency for a distant metastasis from mucinous breast carcinoma and the unusual involvement of the skin.

CONCLUSION

This represents the second longest reported latency period for the development of a distant metastasis from mucinous breast carcinoma and its rare occurrence in the skin.

Disseminated infection with Trichosporon beigelii. Report of a case and review of the cutaneous and histologic manifestations

BACKGROUND

Trichosporonosis is a potentially life-threatening disseminated infection with Trichosporon beigelii, the causative agent of the white piedra. Systemic infection by this fungus has been most frequently described in immunocompromised hosts with neutropenia, but one case has been reported in the acquired immunodeficiency syndrome setting. We report a second case of trichosporonosis in a patient with acquired immunodeficiency syndrome and review the clinical and histologic characteristics of cutaneous involvement with this opportunistic fungal pathogen.

OBSERVATIONS

Trichosporonosis occurs most commonly in neutropenic patients receiving chemotherapy. We describe the second case developing in the acquired immunodeficiency syndrome setting. Cutaneous involvement occurred in approximately 30% of patients and most frequently presented as purpuric papules and nodules with central necrosis or ulceration. Biopsy specimens of these lesions revealed dermal invasion by fungal elements, and culture was positive in greater than 90% of the cases.

CONCLUSIONS

Disseminated infection with T beigelii can occur in immunosuppressed patients, including those with acquired immunodeficiency syndrome particularly if associated with neutropenia. Cutaneous involvement is common, presenting as purpuric papules and nodules. Biopsy and culture of cutaneous findings can help establish an accurate diagnosis resulting in rapid and appropriate treatment.

Onychomycosis: successful treatment with once-weekly fluconazole

We report a case of fingernail onychomycosis in an immunosuppressed renal transplant patient who was successfully treated with once-weekly fluconazole therapy. Relapse did not develop over the 2-month follow-up period. There were no adverse effects from therapy and the cyclosporin dose did not require adjustment. This case suggests that fluconazole may play a role in the treatment of onychomycosis with once-weekly dosing schedules. Future large-scale clinical trials are indicated to fully evaluate its safety and efficacy in onychomycosis.

Comparison of Tzanck smear, viral culture, and DNA diagnostic methods in detection of herpes simplex and varicella-zoster infection

OBJECTIVE

To compare Tzanck smears, viral cultures, and DNA diagnostic methods using the polymerase chain reaction (PCR) in detection of herpes simplex virus (HSV) or varicella-zoster virus (VZV) infection in clinically suspected cases.

DESIGN

A 12-month trial comparing PCR with viral cultures and Tzanck smears in patients with clinically suspected HSV or VZV infection.

SETTING

Both ambulatory and hospitalized patients were recruited from a tertiary referral center and the Miami (Fla) Veterans Affairs Medical Center.

PATIENTS

Convenience samples of patients clinically suspected to have HSV (n = 48) or VZV (n = 35). To be included in the final analysis patients needed to have a positive Tzanck smear, viral culture, or PCR result. Patients who were clinically suspected to have HSV but had VZV by viral culture or PCR were analyzed in the VZV group. Similarly, patients who were clinically suspected to have VZV, but had HSV by viral culture or PCR were analyzed in the HSV group. Seventy-seven patients were available for final analysis: HSV (n = 30), VZV (n = 32), and 15 control cases who did not have evidence of viral infection.

RESULTS

For HSV, PCR detected HSV DNA sequences in 73% of stained smears and 83% of unstained smears. For VZV infection, VZV DNA sequences were detected in 88% of stained smears and 97% of unstained smears. Viral DNA sequences were not detected in the 15 control cases. Viral cultures were positive in 83% and 44% of HSV and VZV cases, respectively. The Tzanck smear was positive in 60% and 75% of HSV and VZV cases, respectively.

CONCLUSIONS

PCR is a reliable method for detecting HSV and VZV DNA sequences from single stained and unstained Tzanck smears. It is clearly superior to viral culture in identifying VZV infection and is equivalent to conventional culture techniques in identifying cases of HSV.

Basal cell carcinoma of the scrotum. Report of three cases and review of the literature

BACKGROUND

Although basal cell carcinoma (BCC) is the most common human malignancy, only 21 cases involving the scrotum have been previously reported.

OBJECTIVE

Our purpose is to describe three additional cases of scrotal BCC and review the literature summarizing the clinical features and identifying any predisposing factors.

METHODS

We retrospectively reviewed 21 cases of scrotal BCC and described three new cases. Polymerase chain reaction (PCR) was used to detect human papillomavirus (HPV) DNA in our biopsy specimens.

RESULTS

Scrotal BCCs present as persistent ulcerations or plaques without identifiable predisposing factors. Lymphatic, pulmonary, or skin metastases were present in 3 of 24 cases (13%) resulting in death in one case. PCR did not detect HPV DNA in our three cases.

CONCLUSION

Scrotal BCC rarely occurs and should be considered in the diagnosis of a persistent scrotal ulcer or plaque. Metastatic disease may be more common than with other BCCs and wide local excision or Mohs micrographic surgery may be the most appropriate initial therapeutic approach.

Herpes simplex virus DNA in occult lesions: demonstration by the polymerase chain reaction

Herpes simplex virus DNA was identified by the polymerase chain reaction with primers specific for the herpes DNA polymerase gene. A herpes-specific amplimer was detected in two of three cases in which the clinical and histologic features were inconclusive.

Pityriasis rubra pilaris and HIV infection

Many cutaneous diseases have been reported in patients with human immunodeficiency virus infection. We report two patients with pityriasis rubra pilaris and human immunodeficiency virus infection. In one patient, the onset of pityriasis rubra pilaris preceded the discovery of human immunodeficiency virus infection. In the second patient, the onset of pityriasis rubra pilaris occurred shortly after the patient tested positive for human immunodeficiency virus infection. Both patients had a severe form of pityriasis rubra pilaris, and both had a minimal therapeutic response to etretinate.

Treatment of autoimmune disease with extracorporeal photochemotherapy: progressive systemic sclerosis

In this report, we describe the use of extracorporeal photochemotherapy in n the treatment of two patients with rapidly advancing progressive systemic sclerosis. Both patients experienced improvement in the cutaneous as well as the systemic manifestations of their disease while undergoing therapy. The potential therapeutic mechanisms are discussed.

Treatment of autoimmune disease with extracorporeal photochemotherapy: pemphigus vulgaris--preliminary report

Extracorporeal photochemotherapy is a new form of immunotherapy which involves the extracorporeal photoinactivation of peripheral blood cells by 8-methoxypsoralen in the presence of ultraviolet A irradiation, followed by readministration of the cells. To explore the efficacy of this therapy in the treatment of autoimmune disease, four patients with a lengthy history of corticosteroid and immunosuppressive drug-resistant pemphigus vulgaris were initiated on extracorporeal photochemotherapy. Three patients experienced a complete remission in cutaneous disease expression, permitting discontinuation of medications in two and a substantial decrease in the third. Significant reductions in serum antiepidermal cell antibody titers occurred in all four patients. The treatments were well tolerated without the occurrence of adverse events. These results in a small number of patients suggest that extracorporeal photochemotherapy may prove to be a useful tool in the treatment of aggressive autoimmune disease.

Bacteremic pneumococcal pneumonia and myoglobinuric renal failure

A case of bacteremic pneumococcal pneumonia associated with rhabdomyolysis and myoglobinuric renal failure is presented. This may be the first report of the association of these two disorders, and may influence the choice of antibiotic selection in patients with rhabdomyolysis and a pulmonary infiltrate.