Chondrodermatitis nodularis helicis in an adolescent boy: not just for old men

Chondrodermatitis nodularis helicis (CNH) is a solitary, chronic, painful, often ulcerated lesion on the upper portion of the ear, mostly in older men. We present an unusual case of CNH in a 17-year-old adolescent boy who was a lifeguard. Correlation between clinical and histopathologic characteristics of CNH is outlined in the context of the existing literature to increase awareness of this condition in younger patients as well as to guide appropriate management and surveillance.

Programmed cell death 1 protein and programmed death-ligand 1 inhibitors in the treatment of nonmelanoma skin cancer: A systematic review

BACKGROUND

Immunotherapy using programmed cell death 1 protein (PD-1) or programmed death-ligand 1 (PD-L1) inhibitors has been increasingly reported in a variety of nonmelanoma skin cancers (NMSCs).

OBJECTIVE

To analyze the evidence of PD-1 and PD-L1 inhibitors in the treatment of NMSC.

METHODS

A primary literature search was conducted with the PubMed, Cochrane Library, EMBASE, Web of Science, and CINAHL databases through October 28, 2018, to include studies on the use of PD-1 or PD-L1 inhibitors in patients for NMSC. Two reviewers independently performed study selection, data extraction, and critical appraisal.

RESULTS

This systematic review included 51 articles. The most robust evidence was in the treatment of Merkel cell carcinoma and cutaneous squamous cell carcinomas, as supported by phase 1 and 2 clinical trials. Treatment of basal cell carcinoma, cutaneous sarcoma, sebaceous carcinoma, and malignant peripheral nerve sheath tumor also showed benefit with PD-1/PD-L1 inhibitors, but data are limited. There does not appear to be efficacy for PD-1/PD-L1 inhibitors in cutaneous lymphomas.

LIMITATIONS

More investigation is needed to determine the efficacy, tumor responsiveness, and the safety profile of PD-1 and PD-L1 inhibitors in NMSC.

CONCLUSION

PD-1 and PD-L1 inhibitors exhibit treatment efficacy in a variety of NMSCs.

Cutaneous Balamuthia mandrillaris infection as a precursor to Balamuthia amoebic encephalitis (BAE) in a healthy 84-year-old Californian

Soil and freshwater-dwelling amoebae may opportunistically infect the skin and evoke a granulomatous dermatitis that camouflages their underlying morphology. Amoebic infestations are incredibly rare in the U.S., predominantly occurring in the young, elderly, and immunocompromised. Sadly, because diagnosis is difficult and unsuspected, most cases are diagnosed at autopsy. The following case is of a healthy 84-year-old man with a non-healing nodulo-ulcerative cutaneous lesion on his left forearm that appeared following a gardening injury. Lesional punch biopsies repeatedly showed non-specific granulomatous inflammation with no pathogens evident histologically or by culture. Histopathologic diagnosis was made five months after initial presentation via identification of amoebic trophozoite forms in tissue from a large excisional specimen. Anti-amoebic therapy was initiated immediately. The patient experienced mental status changes three days following lesion excision, with evidence of a cystic mass in the left medial parieto-occipital lobe by CT. Both intraoperative brain biopsies and cutaneous tissue samples tested positive for Balamuthia mandrillaris by indirect immunofluorescent antibody assay performed at the Centers for Disease Control. The patient achieved a full recovery on a triple antibiotic regimen. Clinical suspicion and thorough histopathologic analysis may determine the difference between survival and death for a patient presenting with a treatment-refractory localized granulomatous lesion.

Calcific periarthritis: more than a shoulder problem: a series of fifteen cases

BACKGROUND

Calcific periarthritis, referring to a circumscribed juxta-articular deposit of minute non-birefringent mineral grains, is rarely the clinical diagnosis accompanying a pathologic specimen. Familiarity with the clinical, pathologic, and radiologic manifestations of calcific periarthritis, particularly when encountered adjacent to joints other than the shoulder, facilitates diagnosis and may obviate biopsy, avoid confusion with other entities, and speed appropriate treatment.

METHODS

Pathologic specimens that fulfilled the criteria for a diagnosis of calcific periarthritis were prospectively collected. Clinical history and radiologic studies were acquired and analyzed. Well-controlled special stains were employed on two specimens with a neutrophilic infiltrate that excluded fungal and bacterial agents, as corroborated by microbiologic cultures showing no growth.

RESULTS

Over a five-year period, fifteen patients between the ages of thirty-one and eighty-eight years (mean age, fifty-nine years) presented to various local healthcare providers for treatment of juxta-articular swelling that was subsequently determined to be calcific periarthritis. In seven patients, deposits were alongside a toe joint; in five, alongside a finger joint; and in three, involving the shoulder. The majority of the patients were female (73%). No patient had a documented recurrence of calcific periarthritis in follow-up periods ranging from eighteen to eighty-seven months (average forty-five months).

CONCLUSIONS

Of twelve histologically verified cases of calcific periarthritis adjacent to joints other than the shoulder, in only one patient (toe) was the preoperative clinical diagnosis accurate, which signals the need for greater awareness of this entity as a differential diagnostic option.

Surfer's toe: trauma-induced idiopathic acro-osteolysis in the toes of a 46-year-old surfer: a case report

Acquired acro-osteolysis (AOL) is defined as the resorption of bone from the tufts or shafts of the terminal phalanges. Acquired acro-osteolysis can manifest as a primary osteolysis syndrome and also appears in a number of disease states including rheumatologic disorders, neuropathic diseases, the result of prolonged exposure to polyvinyl chloride, and in rare cases, as a response to repeated mechanical stress. In this report, a 46-year-old surfer was evaluated for AOL as a complication of sports-related repetitive trauma to the right second and third toes. Radiography showed the bony tips of his right second and third toes had been eroded away. Acquired acro-osteolysis in the surfer's toes resulted from increased blood flow initiated to repair microdamage caused by repeated trauma to the distal ends of his second and third right toes due to the habitual dragging of the affected toes across a surfboard. The always initial lytic phase of bone repair was magnified by the increased arterial input to warm the extremities after prolonged exposure to cold. At 6-years' follow-up, the use of a protective bandage while surfing has permitted full regeneration of the affected toes.

Frontal sinus osteoma with osteoblastoma-like histology and associated intracranial pneumatocele

Osteomas of the cranial sinuses are rare, benign bony tumors that can be complicated by the formation of an intracranial pneumatocele. If not treated promptly, a pneumatocele can lead to abscess formation, meningitis, or ventriculitis. In the present case, an intracerebral pneumatocele was formed when an 18 cm(3) osteoma breached the posterior wall of the frontal sinus creating a one-way valve through which air could enter the intracranial cavity. The patient presented after forceful sneezing with nonspecific symptoms of headache, nausea, and vomiting. CT demonstrated a frontal collection of loculated air with mass effect within the left cerebral hemisphere. A partly mineralized mass occupied the left superior nasal ethmoid sinus and left frontal sinus. Of interest pathologically in this case, the tumor had a substantial osteoblastoma-like component. Surgical repair involved frontal craniotomy to remove the osteoma and debride frontal sinus mucosa, plugging the frontal nasal ducts and sinus with fat and bone wax, and dural restoration using an underwater closed drainage system to vent intracranial air and stabilize the patient.

Plastic bag clip discovered in partial colectomy accompanying proposal for phylogenic plastic bag clip classification

A plastic bag clip was incidentally found anchored in the mucosa of a partial colectomy specimen 2.6 cm proximal to a ruptured diverticulum for which the patient, a mentally retarded, diabetic, 58-year-old man, underwent surgery. Over 20 cases of accidental ingestion of plastic bag clips have been published. Known complications include small bowel perforation, obstruction, dysphagia, gastrointestinal bleeding and colonic impaction. Preoperative diagnosis of plastic clips lodged in the gastrointestinal tract is frustrated due to radiographic translucency. This occult threat could likely be prevented by the design of gastrointestinally safe, plastic-bag-sealing devices. Presented here is a morphologically based classification of bag clips as a possible guide for determining the most hazardous varieties and to aid further discussions of their impact on health.

Digital dermatofibromas--common lesion, uncommon location: a series of 26 cases and review of the literature

Dermatofibroma (DF), also referred to as cutaneous fibrous histiocytoma (CFH), is a common tumor of the skin presenting as a firm nodule located predominantly on the limbs and shoulder and pelvic girdles that often extends into superficial subcutaneous tissue. This is a retrospective study of 26 DFs located on digits. All case slides were retrieved from saved files for diagnostic verification. One case was rejected after revision of the diagnosis to giant cell tumor of the tendon sheath. The 26 remaining cases constitute this reported series. Digital DFs affected 27 to 70 year-olds in a 2.25:1 male to female ratio. The most common clinical diagnosis submitted was "growth" or wart. In only 6 out of the 26 cases was the pre-biopsy diagnosis of DF ventured. Although lesional tissue went to dermal margins in 14 specimens, only one has been re-excised in follow up ranging from 2 months to 10 years. Because DFs can resemble several entities including leiomyosarcoma and dermatofibrosarcoma protuberans, a lack of familiarity with the occurrence of DF on the digits may result in more aggressive treatment than otherwise necessary. DF should be in the differential diagnosis of circumscribed, firm nodules presenting on the digits.