Kikuchi—Fujimoto's Necrotizing Lymphadenitis in Association with Discoid Lupus Erthematosus: A Case Report

Background:

Kikuchi–Fujimoto's necrotizing lymphadenitis (KFNL) is a rare, benign, self-limited condition characterized by constitutional symptoms, lymphadenopathy, and skin lesions.

Objective:

We report a case of KFNL in a 43-year-old East Indian woman with a ten-year history of discoid lupus erythematosus (DLE) of the scalp and a three-month history of a erythematous plaque on the left nasal bridge, cervical lymphadenopathy, and fever. Skin biopsy samples were taken from the face and lymph node.

Results:

Histopathological examination of the skin revealed a mixed infiltrate of inflammatory cells, nuclear dust, and histiocytes phagocytosing nuclear debris in the reticular dermis. The lymph node showed interfollicular liquefactive necrosis, immunoblasts, and a similar cellular infiltrate as the skin. The non-necrotic areas demonstrated follicular hyperplasia. These pathological changes are associated with a diagnosis of KFNL.

Conclusions:

KFNL is reported in association with systemic lupus erythematosus, but only two other cases of systemic KFNL in association with DLE exist in the literature. This case is unique in that the patient presented with cutaneous and systemic KFNL in the setting of longstanding DLE.

Metastatic Basal Cell Carcinoma: Report of Two Cases and Literature Review

Background:

Metastatic basal cell carcinoma (MBCC) is defined as primary cutaneous basal cell carcinoma (BCC) that spreads to distant sites as histologically similar metastatic deposits of BCC. There are less than 300 reported cases of MBCC in the literature.

Methods:

This article examines two cases of MBCC and provides a literature review of risk factors inherent in epidemiology, patient demographics, and the clinicohistopathological characteristics of primary and metastatic BCC lesions.

Results:

MBCC is a rare complication of BCC with high morbidity and mortality rates. Patients with MBCC often begin with long-standing primary BCC lesions that are either large or recurrent after treatment. Cases of MBCC have a higher incidence of the more aggressive histologic patterns (morpheic, infiltrating, metatypical, and basosquamous). Perineural space invasion may be an indicator of aggressive disease. Metastases often involve regional lymph nodes, lungs, bone, and skin.

Conclusion:

These case reports and review provide important diagnostic and management considerations for primary BCC and MBCC. Early intervention with aggressive treatment measures may improve the prognosis and survival of MBCC patients.

Peripheral Neuropathy for Dermatologists: What If Not Diabetic Neuropathy?

Background:

Patients with cutaneous manifestations associated with peripheral neuropathy often present to the dermatologist's office.

Objective/Methods:

This article outlines a practical approach for obtaining the history, performing a screening physical examination, and ordering initial diagnostic testing to diagnose the cause of nondiabetic neuropathy. When to refer for neurologic consultation and principles of management of neuropathic pain and neuropathy-related ulcers are also discussed.

Results:

Cutaneous manifestations of peripheral neuropathy may be secondary to a medical condition predisposing the patient to neuropathy or a manifestation of neuropathy itself. In the latter category, skin affected by neuropathy may show characteristics of xerosis, anhidrosis, rubor, edema, callus, ulceration, muscle wasting, and foot deformity. Most often these findings occur in association with diabetic neuropathy; however, many other infectious, inflammatory, metabolic, paraneoplastic, hereditary, and medication- or toxin-related causes should be considered. The treatment of cutaneous manifestations of neuropathy includes pressure downloading, control of edema, and optimal ulcer and neuropathic pain management.

Conclusion:

It is important for dermatologists to have a basic approach to neuropathy in patients with related skin disease. Referral to Neurology is warranted when basic workup for reversible causes is negative or for any severe, rapidly progressive symptoms.

Vascular lesions

Advances in laser and light-based technology have increased their potential applications, safety and efficacy for the management of vascular lesions in dermatology. Light devices for vascular lesions include the variable-pulse 532 nm potassium titanyl phosphate laser, 577 to 595 nm pulsed dye laser, intense pulsed light devices, and 800 to 940 nm diode, long-pulse 755 nm alexandrite and 1,064 nm Nd:YAG lasers. This review will discuss the various different laser and light-based devices, and provide a focused treatment approach for the management of common congenital and acquired vascular lesions.

Gianotti-Crosti syndrome in two adult patients

BACKGROUND

Gianotti-Crosti syndrome was first described in Italy by Gianotti in 1955. It is considered a benign, self-limited exanthem that occurs in younger children. Adult cases are rare.

OBJECTIVE

We report two cases of Gianotti-Crosti syndrome in a previously healthy 37-year old Asian and 21-year old Caucasian female.

METHODS/RESULTS

Histopathological analysis of 4-mm punch biopsies from the upper extremity of both patients revealed an interstitial dermatitis with mild to moderate perivascular lymphocytic infiltrate and occasional scattered eosinophils in the superficial and mid-dermis. Clinicopathological correlation was consistent with Gianotti-Crosti syndrome.

CONCLUSION

Since both patients experienced significant pruritus, patient 1 was initially treated with a high potency topical corticosteroid followed by a two-week course of oral prednisone and patient 2 was treated with a potent topical corticosteroid. Both patients were asymptomatic at follow-up 3 to 4 weeks after their initial presentation.

Cutaneous Myiasis from Panama, South America: Case Report and Review

Background:

Myiasis is a cutaneous infestation with larvae of Diptera, the two-winged arthropod order. Eggs and/or larvae are transmitted directly from the environment or via arthropod vectors. Larvae are able to burrow into the dermis of intact skin or external body orifices. Three clinical variants of myiasis are furuncular, migratory (creeping), and infestation of wounds.

Methods:

A 35-year-old male presented with a 1-month history of worsening furuncles on the left knee and posterior thigh following his return from Panama, South America. Clinical examination revealed tender 6 cm and 2 cm erythematous to violaceous furuncles with surrounding desquamation and central puncta draining serosanguinous fluid. Five-millimeter punch biopsies and tissue swabs were performed.

Results:

All larvae were of the Dermatobia hominis species. The patient was empirically treated with cephalexin and ciprofloxacin for secondary bacterial cellulitis. Tissue swabs later cultured group B streptococcus. A tetanus booster was recommended.

Conclusion:

This case report describes a relatively rare cutaneous infestation with D. hominis, a Central and South American endemic larva of the human botfly. Increasing trends toward immigration and global travel to tropical and subtropic areas will likely increase the frequency of encounters with such parasitic cutaneous infestations in North American outpatient dermatology clinics.

Ophthalmologic manifestations of cutaneous conditions

Many cutaneous conditions have associated ophthalmologic findings, which are important to recognize for both dermatologists and ophthalmologists. This review highlights some important ophthalmologic manifestations associated with neurocutaneous syndromes and inherited connective tissue diseases.

Use of etanercept in human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) patients

BACKGROUND

Etanercept (Enbrel, Amgen, Thousand Oaks, CA), a soluble p75 tumor necrosis factor receptor:FC (TNFR:FC) fusion protein for plasma cytokines, specifically tumor necrosis factor-alpha (TNF-alpha), is used in the treatment of immune-mediated rheumatic diseases. To our knowledge, the use of etanercept in patients with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) is relatively uncommon.

OBJECTIVE

The main purpose of this short review is to examine the safety of etanercept in patients with HIV/AIDS.

METHODS

A Medline search was conducted using the keywords etanercept and HIV and/or AIDS for any published articles between 1966 to the present (September 2004).

RESULTS

A case report, one case series, and one clinical trial pertained to the use of etanercept in HIV patients. No reports were found on the use of etanercept in AIDS. In addition, two case reports were found documenting the use of infliximab in HIV patients.

DISCUSSION

Preliminary reports indicate that the administration of etanercept does not appear to increase the morbidity or mortality rates in HIV. The inhibition of TNF-alpha may actually improve the symptoms of HIV/AIDS-associated aphthous ulcers, cachexia, dementia, fatigue, and fever, as well as help manage concomitant rheumatic diseases and psoriasis.

CONCLUSION

The use of etanercept shows promise for applications in disease management in patients with HIV/AIDS. Continued research efforts are necessary to establish the long-term safety and efficacy of etanercept and other biologic agents in this patient population.

Clinical, microbiological, and epidemiological findings of an outbreak of Mycobacterium abscessus hand-and-foot disease

In 2003, we identified an outbreak of clinically distinct lesions involving the hands and feet associated with a public wading pool in Edmonton, Alberta, Canada. A total of 85 cases were identified. The management and follow-up of 41 children and 1 adult patients is presented. Skin lesions occurred within a median incubation period of 29 days and approximately 88 days for the adult patient. Lesions resolved within a median of 58 days and approximately 150 days for the adult patient. Patients were treated with clarithromycin, topical antibiotic dressings, and/or incision and drainage of pustules or followed without treatment. All resolved without complication. The pool was closed and cleaned. The M. abscessus hand-and-foot disease is characterized by the onset, mainly in children, of tender, erythematous papules, pustules, and abscesses with a self-limited course. This is the first documented M. abscessus outbreak associated with wading pool exposure.

Kikuchi-Fujimoto's necrotizing lymphadenitis in association with discoid lupus erthematosus: a case report

BACKGROUND

Kikuchi-Fujimoto's necrotizing lymphadenitis (KFNL) is a rare, benign, self-limited condition characterized by constitutional symptoms, lymphadenopathy, and skin lesions.

OBJECTIVE

We report a case of KFNL in a 43-year-old East Indian woman with a ten-year history of discoid lupus erythematosus (DLE) of the scalp and a three-month history of a erythematous plaque on the left nasal bridge, cervical lymphadenopathy, and fever. Skin biopsy samples were taken from the face and lymph node.

RESULTS

Histopathological examination of the skin revealed a mixed infiltrate of inflammatory cells, nuclear dust, and histiocytes phagocytosing nuclear debris in the reticular dermis. The lymph node showed interfollicular liquefactive necrosis, immunoblasts, and a similar cellular infiltrate as the skin. The non-necrotic areas demonstrated follicular hyperplasia. These pathological changes are associated with a diagnosis of KFNL.

CONCLUSIONS

KFNL is reported in association with systemic lupus erythematosus, but only two other cases of systemic KFNL in association with DLE exist in the literature. This case is unique in that the patient presented with cutaneous and systemic KFNL in the setting of longstanding DLE.

Metastatic Basal Cell Carcinoma: Report of Two Cases and Literature Review

BACKGROUND

Metastatic basal cell carcinoma (MBCC) is defined as primary cutaneous basal cell carcinoma (BCC) that spreads to distant sites as histologically similar metastatic deposits of BCC. There are less than 300 reported cases of MBCC in the literature.

METHODS

This article examines two cases of MBCC and provides a literature review of risk factors inherent in epidemiology, patient demographics, and the clinicohistopathological characteristics of primary and metastatic BCC lesions.

RESULTS

MBCC is a rare complication of BCC with high morbidity and mortality rates. Patients with MBCC often begin with long-standing primary BCC lesions that are either large or recurrent after treatment. Cases of MBCC have a higher incidence of the more aggressive histologic patterns (morpheic, infiltrating, metatypical, and basosquamous). Perineural space invasion may be an indicator of aggressive disease. Metastases often involve regional lymph nodes, lungs, bone, and skin.

CONCLUSION

These case reports and review provide important diagnostic and management considerations for primary BCC and MBCC. Early intervention with aggressive treatment measures may improve the prognosis and survival of MBCC patients.

Intravascular pulmonary metastases from sarcoma: appearance on computed tomography in 3 cases

INTRODUCTION

Various common malignant neoplasms (ie, liver, kidney, stomach, and breast) have been reported to embolize to the pulmonary arterial system. This uncommon occurrence can also result from metastatic sarcoma. We report 3 cases--2 chondrosarcomas and 1 osteosarcoma-associated with intravascular metastases to the pulmonary vasculature and discuss the clinical presentation and differentiating radiologic features on computed tomography (CT).

DISCUSSION

Intravascular pulmonary tumour emboli may present with nonspecific respiratory symptoms or remain completely asymptomatic, and therefore, many patients are often misdiagnosed with thromboembolic disease or undiagnosed until autopsy. Chest CTs in all our patients demonstrated a striking pattern of multifocal tubular branching beaded opacities along the pulmonary vasculature in a multilobular distribution.

CONCLUSION

Our observations and a review of the literature indicate that chest CT is the most useful diagnostic tool for detecting intravascular pulmonary tumour emboli. CT can distinguish this entity from mucous plugging by demonstrating the normal adjacent bronchus. The tubular nature of these metastases distinguishes them from the more common parenchymal metastases.

First case series on the use of imiquimod for morphoea

BACKGROUND

Morphoea is characterized by fibrosis, which is mediated by cytokines including transforming growth factor (TGF)-beta.

OBJECTIVE

Our objective was to use imiquimod 5% cream (Aldara), an inducer of interferon-gamma, known to inhibit TGF-beta, to treat morphoea.

METHODS

Patients with morphoea were treated with imiquimod and evaluated during their follow-up visits to 6 months.

RESULTS

The dyspigmentation, induration and erythema of 12 patients with morphoea lesions improved. The histology of the skin also showed a decrease in dermal thickness.

CONCLUSION

This is the first case series describing the successful application of imiquimod in the management of morphoea.

Psoriasis treatment: traditional therapy

Even before the recent development of biological agents, a long list of effective treatments has been available for patients with psoriasis. Topical therapies such as corticosteroids, vitamin D analogues, and retinoids are used for localised disease. Phototherapy including broadband ultraviolet B (UVB), narrowband UVB, PUVA, and climatotherapy are effective for more extensive disease. Systemic therapies such as methotrexate, retinoids, and ciclosporin are effective for patients with refractory or extensive cutaneous disease.

Allergic contact dermatitis to propolis

A 35-year-old Asian woman was referred to the dermatology clinic with a 2-week history of enlarging, fluid-filled, pruritic lesions on the right foot. The affected area had a recent history of minor trauma for which the patient applied an over-the-counter propolis ointment. At presentation, the patient was also noted to have been using the following, as prescribed by her primary care physician: valacyclovir, ciprofloxacin, terbinafine cream, mupirocin ointment, and 2% hydrocortisone cream. No clinical improvement was observed with these agents. Examination revealed grouped erythematous papules progressing into vesicles and bulla on the lateral side of the right foot. A KOH scraping was negative. We diagnosed the patient with allergic contact dermatitis to propolis.

The story of Clostridium botulinum: from food poisoning to Botox

In the last fifty years, Clostridium botulinum has become notorious for its ability to produce the deadly botulinum neurotoxins. While botulinum toxin A, better known as Botox, is universally recognised by the public as a cosmetic enhancement tool, the botulinum neurotoxins are commonly used off-label for many medical conditions in ophthalmology, neurology and dermatology. The versatility of these botulinum toxins has made Clostridium botulinum one of the most widely known bacterial pathogens in medical history. This article outlines the discovery of botulinum toxins through to their present day applications in medicine.

Bilateral facial apocrine chromhidrosis

A young woman presented to the office with a history of bluish discoloration involving the superior malar region bilaterally. When the bluish discoloration became darker, she would press on her cheeks resulting in excretion of "black sweat" that temporarily lightened her skin color. Examination revealed ill-defined slightly swollen soft plaques involving both superior cheeks. Upon pressure on the cheeks, a dark brown fluid was expressed. Histologic examination revealed collections of ectopic apocrine glands within mid-reticular dermis. The diagnosis of apocrine chromhidrosis was made, an uncommon cause of chromhidrosis and one in which bilateral facial presentation is rare.

Therapy of external anogenital warts and molluscum contagiosum: a literature review

Anogenital warts and mollusca contagiosum are virally induced, benign skin tumors for which there is no single preferable therapy. Treatments include physical and chemical destruction, surgical removal, and biological response modifiers to enhance the natural immune response. The choice of therapy is an art, and depends upon patient preference, finances, number of lesions, and lesional morphology. However, the therapy of these lesions can sometimes be very painful and expensive, and therapy should not be worse than the disease.

Extraprostatic biopsy improves the staging of localized prostate cancer

OBJECTIVE

To evaluate the role and safety of biopsy of the seminal vesicles and neurovascular bundles in determining the pathologic stage of prostatic carcinoma.

METHODS

Eighty-one consecutive patients were enrolled in a comprehensive cryosurgical biopsy protocol that included sextant intraprostatic plus extraprostatic biopsy. The pathologic stage, determined after biopsy, was compared with the clinical stage, determined by digital rectal examination (DRE) and transrectal ultrasonographic (TRUS) evaluation. As well, complication rates for these patients were compared with rates for a separate group that underwent sextant intraprostatic biopsy alone.

RESULTS

Of the 81 patients, 61 (75%) were confirmed to have cancer by biopsy. None of these patients was considered to have extraprostatic extension by clinical evaluation (DRE and TRUS), but 16 of 61 (26%) were identified to have extraprostatic cancer in the seminal vesicles (8 of 61, 13%) or in the neurovascular bundles (8 of 61, 13%) by extraprostatic biopsy. There was no significant difference in the complication rates between sextant intraprostatic biopsy and sextant intraprostatic plus extraprostatic biopsy (p>0.97).

CONCLUSIONS

Extraprostatic biopsy identifies extension of carcinoma in a large proportion of patients in whom clinical evaluation by DRE and TRUS indicates organ-confined disease. Extraprostatic biopsy is therefore warranted as routine evaluation before surgery in order to correctly stage prostatic carcinoma and select appropriate therapy.