[Embryonal malformation following etretinate therapy of Darier's disease in the mother]

A 22-year-old woman suffering from dyskeratosis follicularis Darier became pregnant 4 months after the last dose of etretinate (Tigason). The pregnancy was terminated in the 10th week because of teratogenic risk. The pathological examination of the fetus revealed severe malformation of the left leg with aplasia of tibia and fibula, as well as hypoplasia of the left femur. This observation emphasises the necessity of effective contraception even after discontinuation of etretinate therapy.

Panton-Valentine leukocidin-positive Staphylococcus aureus in skin and soft tissue infections from primary care patients

OBJECTIVES

To characterize deep skin and soft tissue infections (dSSTI) caused by Panton-Valentine leukocidin (PVL)-positive versus PVL-negative Staphylococcus aureus isolates.

METHODS

We performed a retrospective analysis of patients' records including S. aureus isolates from outpatients with dSSTI. Samples had been submitted by primary care physicians, i.e. general practitioners, surgeons, dermatologists and paediatricians, located in Berlin, Germany, in 2007-2017. Bacterial isolates were identified and tested for antimicrobial susceptibility by VITEK 2; PVL was detected by PCR.

RESULTS

In total, 1199 S. aureus isolates from 1074 patients with dSSTI were identified, and 613 (51.1%) of 1199 samples were PVL⁺. The median age of patients with PVL⁺S. aureus was lower than in patients with PVL- S. aureus (34 years, range 0-88 years, vs. 44 years, range 0-98 years; p < 0.0001). PVL was associated with repeated/multiple samples compared to single sample submission (69/92, 75% vs. 448/982, 45.6%, p < 0.0001; odds ratio (OR), 3.6; 95% confidence interval (CI), 2.2-5.8). Interestingly, the highest PVL positivity rate was found in isolates from gluteal (82/108, 75.9%; OR, 3.6; 95% CI, 2-5) or axillary (76/123, 61.8%; OR, 2; 95% CI, 1.1-3.3) localizations compared to isolates from the arm. The PVL positivity rate did not increase over time. Yet we noticed an increase in the trimethoprim/sulfamethoxazole (SXT) resistance rate in PVL⁺ isolates, mainly methicillin-sensitive S. aureus, when considering SXT resistance rates of 2007-2012 versus 2013-2017 (35/226, 15.5% vs. 74/289, 25.6%; p 0.01).

CONCLUSIONS

In outpatients, gluteal and axillary dSSTI are indicative of PVL⁺S. aureus. Providing SXT as a complementary treatment for dSSTI should be based on susceptibility testing.

[Progressive lymphangiokeratoma and angiosarcoma (Stewart-Treves syndrome) in congenital lymphedema]

Three unusual clinical and histopathological changes were found in a 59-year-old male patient with congenital lymphedema of the lower left leg. Firstly, a keratotic lymphangioma had developed in the course of only a few years and in the end involved the entire left leg up to the buttocks--far beyond the edematous area. Secondly, concealed beneath the lymphangiokeratoma, a solitary tumor almost the size of a table-tennis ball was found on the outer side of the lower left leg. Histopathologically, the tumor proved to be a malignant angiosarcoma, which had grown over a period of some months. It was characterized histopathologically by solid and angiomatous differentiation. Thirdly, the superficial and deep lymph vessels revealed remarkable atypia and papillary proliferations of endothelial cells. After amputation of the left leg at the thigh, with complete removal of the angiosarcoma, but leaving the pathologically altered vessels in the upper part of the left leg and the buttocks, no clinical signs of metastases of progression have been noted during the first year after operation.

[Therapy of alopecia areata with diphenylcyclopropenone]

Induction and maintenance of contact dermatitis of the scalp has proved effective in producing regrowth of hair in patients with alopecia areata. We observed regrowth of hair in 17 out of 20 patients after local application of the contact allergen, diphenylcyclopropenone. Only 3 patients were treated without success. In 3 patients regrowth of hair was also seen in areas that were not treated with diphenylcyclopropenone, suggesting that this treatment has an additional systemic effect. Patient acceptance of the induced dermatitis was excellent.

[Colliquation necrosis of the skin caused by a cardiac pacemaker]

In two patients with cardiac infarction of a medical intensive care unit blisters developing into deep necroses were observed on the upper extremities and adjoining regions of the trunk within the first days of treatment. Clinical findings and histology indicated extensive caustic artefacts. The cause for the initially mysterious event was found to be a defect in the extracorporeal cardiac pacemaker. Defective isolation had lead to a continuous current potential between pacemaker cover and electrode. The resulting electrolysis caused a dramatic increase of pH on the moist body surface underneath the pacemaker. As a result of the pH shift caustic damage with extensive dermal necroses was observed.