Kaposiform hemangioendothelioma in an adult with rheumatoid arthritis

This report describes a case of kaposiform hemangioendothelioma arising in an adult man during the course of rheumatoid arthritis treated with steroids and methotrexate. The vascular proliferation began in the terminal phase of the disease, which culminated in acute renal failure and death. We discuss the possible relationship between rheumatoid arthritis, its treatment, and the onset of vascular proliferation, as well as the role of kaposiform hemangioendothelioma in aggravating the autoimmune disease and leading to its fatal outcome.

Lane's type pseudosarcoma of glans penis

We herein present a rare case of polypoid "pseudosarcomatous lesion" of the glans penis, associated with in situ or mini-invasive squamous carcinoma. These lesions, described by Lane, in the upper aerodigestive tract, can rarely occur elsewhere. Immunohistochemistry is crucial for a correct diagnostic interpretation, confirming that the aytpical cells are components (fibroblasts, myofibroblasts, endothelial) of granulation tissue.

Infliximab Monotherapy for Refractory Psoriasis: Preliminary Results

Tumour necrosis factor (TNF)-alpha plays an important role in the pathogenesis of psoriasis. Infliximab is an anti-TNF-alpha chimeric monoclonal antibody, which is licensed for the treatment of rheumatoid arthritis and Crohn's disease. Some reports have shown the efficacy of infliximab, either in monotherapy or in combination with methotrexate, for the treatment of psoriatic arthropathy and psoriasis.

The efficacy and tolerability of infliximab monotherapy was evaluated in 29 patients with moderate to severe psoriasis, unresponsive to conventional treatments. Fourteen patients suffered from concomitant arthropathy. Patients received intravenous infliximab, 5mg/kg, at weeks 0, 2, and 6. After this 3-dose-induction regimen, patients were followed-up at monthly intervals and retreated with a single-dose infusion in case of relapse of signs and symptoms. Clinical assessment was performed using the psoriasis area and severity index (PASI) to monitor psoriasis activity; pruritus and joint pain were assessed on a scale of 0 to 3. A marked improvement of skin lesions and subjective symptoms was noted in the majority of patients; an excellent reduction of PASI score (⩾75%) was observed in 13.8% of cases at week 2, 71.4% at week 6 and 78.6% at week 10. During the follow-up period, some patients maintained satisfactory clinical results without requiring any additional infusions. In general, skin lesions showed a trend towards a more prolonged and sustained improvement as compared with subjective symptoms. Treatment was well tolerated and no serious adverse events occurred.

Sporadic melanoma in South-Eastern Italy: the impact of melanocortin 1 receptor (MC1R) polymorphism analysis in low-risk people and report of three novel variants

Environmental and genetic risk factors are involved in the development of melanoma. The role of the melanocortin 1 receptor (MC1R) gene has been investigated and differences according to geographic areas have been described. To evaluate the role of some clinical and genetic risk factors in melanoma development, we performed a case-control study involving 101 melanoma patients and 103 controls coming from South-Eastern Italy (Puglia), after achieving informed consent. We confirmed the role of known clinical risk factors for melanoma. Furthermore, 42 MC1R polymorphisms were observed. Three of these variants (L26V, H232L, D294Y) were not previously reported in the literature. Their predicted impact on receptor function was evaluated using bioinformatic tools. We report an overall frequency of MC1R variants in our population higher than in Northern or Central Italy. The most common polymorphism found was V60L, that has been recently reported to spread among South Mediterranean population. This variant influenced phenotypic characteristics of our population while it did not impinge on melanoma risk. An increased risk of melanoma was associated with two or more MC1R variants, when at least one was RHC, compared to people carrying the MC1R consensus sequence or a single MC1R polymorphism. Interestingly, we observed an increased risk of melanoma in subjects with darker skin and lower nevus count, usually considered at low risk, when carrying MC1R polymorphisms.

A peculiar fibroma-like lesion of superficial soft tissue: morphologic and immunophenotypic evaluation

Apeculiar lesion of superficial soft tissue characterised by fibroma-like morphology and an immunohistochemical profile consisting of CK+, VIM+, CD34+, CD31+/-, FLI1+ and INI-1 retained is described. The lesion entered into differential diagnosis with the so-called fibroma-like variant of epithelioid sarcoma, with the entities defined as ES-like/pseudomyogenic haemangioendothelioma and the recently identified entity defined as superficial CD34+ fibroblastic tumour. All of these entities share a common morphological structure, but differ in their immunophenotypic profile.

Cutaneous targets in drug-induced reactions

Skin is the main sufferer of the adverse drug reactions (ADRs), being involved in 30% of all ADRs cases. However, ADRs are generally underestimated because of the difficulty to correlate the event to a particular drug. A careful anamnestic history is crucial to establish the causal link between an ADR and the specific drug. Clinical, developmental and medical history is important to define an ADR but sometimes you need to make histological examination to get additional diagnostic indications. However, the histological findings observed during the ADRs are hardly or not easily distinguishable from other skin diseases. Furthermore, the patient is often administered multiple drugs, so that the evaluation of histological findings is a complex one. In the present work we have reviewed the most frequently reported histological pictures induced by drugs as associated with a specific ADR, following, as criterion, the localization of the damage within the skin. So ADRs are divided into reactions in which the damage is localized in the epidermis, at dermal-epidermal (junction) level, in the dermis, subcutaneous fat and adnexal structures. We then briefly describe the clinical and histological pictures most frequently observed in ADRs.

Three novel human sporadic melanoma cell lines: signaling pathways controlled by MC1R, BRAF and β-catenins

We studied the behaviour of three novel human sporadic melanoma cell lines (hmel1, hmel9, hmel11) extracted from tumors with different degrees of malignancy, concerning the cell signalling pathways controlled by MC1R, BRAF, NRAS and β-catenins. The novel cell lines were compared to metastatic cell lines (HBL, LND1), wild type (wt) for MC1R and BRAF genes, that have been extensively characterised and were used as control. All the novel cell lines have silent or no MC1R mutations even though MC1R signalling is severely impaired. Conversely, they harbour BRAF mutations at the V600 residue. These mutations determine a constitutive ERK phosphorylation in all the three cell lines. Our new melanoma cell lines were BRAF mutated in hetero- and homozygosis, even with a wild type MC1R, and unresponsive to NDP-MSH treatment. Quantity and subcellular localization of β-catenin were analyzed in both novel and control cell lines. In HBL and LND1 there were high levels of beta-catenin distributed in the cytoplasm/nucleus, while in the novel melanoma cell lines β-catenins were less abundant and seemed to be located at the plasma membrane/cytoplasm and absent in the nucleus. We sequenced beta-catenin cDNA for all the melanoma cell lines, and found mutations in HBL, LND1 and hmel1, while hmel9 and hmel11 were wt. We found that beta-catenin levels were not influenced by the RAS/RAF/MAPK pathway because inhibition with PD98059 (a MEK inhibitor) did not produce any effect on beta-catenin stability and/or localization.

Mycosis fungoides: disease evolution of the "lion queen" revisited

Mycosis fungoides (MF), which represents the most common subtype of primary cutaneous T-cell lymphoma (CTCL), is an epidermotropic lymphoma included as an indolent form in the recent WHO/EORTC classification. From a clinical point of view, the classic disease progression usually is slow and takes over years or even decades, and characterized by the evolution from patches to more infiltrated plaques and eventually to tumours or erythroderma. However, the analysis of the MF disease course has been greatly impaired by the rarity of the disease, thus data about the time course of disease progression and pattern of relapse during time are not well known. In this review, a summary of published data on MF large patients cohorts will be presented, together with the results obtained by a retrospective analysis of clinical features and follow-up data of 1,422 MF patients diagnosed and followed-up from 1975 to 2010 in 27 Italian Centres (Italian Study Group for Cutaneous Lymphoma). From a clinical perspective, the amount of data support the relevance of a stage-tailored, differentiated follow-up strategy, in as much as the TNMB staging appears not only to be associated with different progression rates, but also shows as a new finding a relationship with different patterns of disease progression. From a biological point of view, there is the need to understand the molecular basis of the different clinical pathways of disease progression, to be able to potentially identify at an earlier phase of disease evolution, the patients who are more likely to develop erythroderma or tumour-stage progression. In conclusion, if MF is indeed a true "lion queen", as dermatologists we need to be expert and wise tamers to keep it under control.

Molecular characterization of novel melanoma cell lines

We isolated two novel cell lines from different types of sporadic human malignant melanoma: the hmel1 line was obtained from a melanoma skin metastasis and the hmel9 cell line from a primary superficial spreading melanoma. The karyotype and pigmentation parameters were assessed in these cell lines. Cytogenetic analysis in early stages of culture revealed that both cell lines had chromosome instability and simultaneous growth of heteroploid subpopulations. The molecular analysis of some genes involved in melanoma showed that both cell lines harbor BRAF mutations. The unpigmented hmel1 and the pigmented hmel9 lines were found to express the tyrosinase gene. The tyrosine hydroxylase activity was detectable only in hmel9 cells and practically absent in the hmel1 cell line. This activity was found to be correlated with the relative tyrosinase protein amount in both melanoma cell lines. The biological behaviour in the two melanoma cell lines, derived from two different types of melanoma lesions displaying distinct clinical and histopathological features, confirms the heterogeneous characteristics of sporadic melanoma. Similarities and/or differences between cell lines extracted from different melanoma cases could be useful in the future for diagnostic, prognostic and therapeutic purposes.

Pemphigus vulgaris with circulating anti-desmoglein 3 and anti-BP180 antibodies: a case report and brief review of cases with coexistence of pemphigus vulgaris and bullous pemphigoid

Pemphigus vulgaris (PV) and bullous pemphigoid (BP) are two autoimmune blistering diseases involving the skin and the mucous membranes characterized by circulating autoantibodies directed against desmosomal cadherins or antigens expressed in the basement membrane zone, respectively. The simultaneous presence of clinical and/or immunopathological features of PV and BP in the same patient has been reported in very few cases in the literature to date. Most of these cases had exclusive cutaneous involvement, while a minority showed concomitant oral lesions. We describe the case of a 59-year-old female patient with a 10-year history of refractory PV lesions limited to mucous membranes (conjunctiva, oral cavity and genital mucosa), which were controlled by the addition of mycophenolate sodium to oral prednisone. Immunofluorescence studies revealed findings consistent with PV, whereas enzyme-linked immunosorbent assay revealed circulating anti-BP180 antibodies in association with anti-desmoglein 3 antibodies. The significance and relevance of this finding are briefly discussed, in light of the literature data.

Efalizumab in moderate-to-severe plaque psoriasis: a retrospective case series analysis from clinical practice

Efalizumab is an anti-CD11a humanized monoclonal antibody which is safe and effective for the treatment of plaque psoriasis. We performed a retrospective analysis on -high-need- patients with moderate-to-severe psoriasis treated with Efalizumab monotherapy for more than 2 years. Chart review of patient records also concerned information about rebound, relapse, and retreatment after temporary interruption, as well as transitioning from Efalizumab to alternative treatments. Of the 52 patients who completed the initial 12 weeks of treatment, 65% attained the PASI-50 response at week 12. A notable improvement of skin lesions on critical sites, such as palmoplantar surfaces or genitals, was also observed. Continuous treatment resulted in a sustained response in the majority of patients, with a PASI-75 response in nearly 88% of those Efalizumab-treated in the long term (week 72 onwards) and a PASI-90 in 77% of patients by weeks 120-132. In general, the treatment was well tolerated, with mild-to-moderate flu-like symptoms as the most frequent adverse events, particularly after the first two doses. Increase of leukocyte and/or lymphocyte counts was the most common laboratory test alteration during treatment, also in the long term. In our case series, Efalizumab was safe and well-tolerated even in patients with relevant comorbidities, including one patient with HBsAg carriage and five patients with latent TB.

Interobserver reproducibility of histological features in cutaneous malignant melanoma

AIMS

To assess the interobserver reproducibility of certain histological features proposed for the diagnosis of melanoma.

METHODS

In a series of melanomas, 13 histological parameters were analysed: dimension > 6 mm, asymmetry, poor circumscription, irregular confluent nests, single melanocytes predominating, absence of maturation, suprabasal melanocytes, asymmetrical melanin, melanin in deep cells, cytological atypia, mitoses, dermal lymphocytic infiltrate, and necrosis.

RESULTS

The agreement (reproducibility) between the nine observers was excellent (kappa > 0.75) for 10 of the 13 examined features (dimension > 6 mm, poor circumscription, irregular confluent nests, single melanocytes predominating, absence of maturation, suprabasal melanocytes, asymmetrical melanin, melanin in deep cells, mitoses, and necrosis). The agreement for asymmetry was very close to excellence (kappa = 0.74), and that for cytological atypia (kappa = 0.65) and dermal lymphocytic infiltrate (kappa = 0.47) was slightly lower, but in the fair to good agreement range. The kappa values obtained by comparison with the majority diagnosis were generally high (> or = 0.85); the mean value of kappa was lower (0.70) for only one parameter (dermal lymphocytic infiltrate).

CONCLUSIONS

The parameters investigated showed an overall good reproducibility.

Histological features used in the diagnosis of melanoma are frequently found in benign melanocytic naevi

AIMS

The histological features used in the diagnosis of melanoma may be present in benign naevi, but quantitative data are not available. The aim of this study was to establish the real prevalence of such features in naevi.

METHODS

Ten dermatopathologists, from nine Italian institutions, studied a series of naevi. Eleven histological parameters currently used in melanoma diagnosis were analysed: asymmetry, poor circumscription, predominance of single melanocytes, irregular confluent nests, suprabasal melanocytes, hair follicle involvement, absence of maturation, cytological atypia, dermal lymphocytic infiltrate, mitoses, and necrosis.

RESULTS

Ninety one naevi were examined: 22 junctional, 59 compound, and 10 intradermal. None of the studied parameters was seen in 22 of the benign naevi studied. One or more investigated features were found in 69 naevi. Poor circumscription was found in 49 cases, single melanocytic predominating in 42, asymmetry in 41, irregular confluent nests in 16, cytological atypia in 14, suprabasal melanocytes in seven, and hair follicle involvement in seven; absence of maturation, mitoses and necrosis were not found.

CONCLUSIONS

The histological features used for the histological diagnosis of melanoma are often present in benign melanocytic naevi. This suggests a critical, non-mechanical use of them in melanoma diagnosis.

Melanocytic nevi of the breast: a histologic case-control study

BACKGROUND

Melanocytic nevi in the genital, acral, and flexural sites often display clinical and histologic features that may simulate melanoma. We verified whether this is the case also for nevi of the breast.

METHODS

Eleven dermatopathologists, from nine Italian Institutions, collected the specimens of melanocytic lesions from the breast and other body sites, excluding the acral, genital, and flexural areas, as controls. Cases and controls were matched for sex and age. All nevi were observed 'blindly' and simultaneously by all participants. For each lesion, 10 histological parameters were analyzed: asymmetry, absence of lateral demarcation of melanocytes, lentiginous proliferation, nested and dyshesive pattern, intraepidermal melanocytes above the basal layer, involvement of the hair follicle, absence of maturation of dermal melanocytes, melanocytic atypia, fibroplasia of the papillary dermis, and lymphocytic dermal infiltrate. Each parameter was scored 2 when present and 1 when absent or not valuable. A total score was calculated for each lesion. Results were statistically analyzed by the chi-square test and the Mann-Whitney U-test.

RESULTS

One hundred and one nevi came from the breast area and 97 from elsewhere. Breast nevi exhibited significantly more atypical features than nevi from other sites. In particular, breast nevi with intraepidermal melanocytes, melanocytic atypia, and dermal fibroplasia were significantly more numerous. We did not find any sexual difference.

CONCLUSIONS

To avoid undue concerns, dermatopathologists should be aware that melanocytic nevi of the breast may show a high degree of atypical features.

Neovascularisation, expression of fibroblast growth factor-2, and mast cells with tryptase activity increase simultaneously with pathological progression in human malignant melanoma

Tissues from 92 proliferative lesions of the melanocytic lineage defining distinct steps in tumour progression were investigated immunohistochemically for changes in angiogenesis, expression of fibroblast growth factor-2 (FGF-2) and density of total mast cells (MCs) and MCs expressing tryptase, an angiogenic-inducing molecule. Although the microvessel number was low in common nevi, it increased significantly in nevi with architectural disorder with varying degrees of melanocytic atypia (termed 'nevi with ADMA'), and these changes persisted during tumour development. Progression of primary melanomas was accompanied by a high microvessel number, and the progression to metastases by another significant increase in the microvessel counts. Expression of FGF-2, evaluated as percentages of positive lesions and positive cells per lesion was upregulated in the course of progression. Changes in expression were associated with nevi with ADMA, tumour changeover, penetration of the tumour into the dermis and metastases. A high correlation was demonstrated in all groups of tissues between the microvessel counts, percentages of FGF-2-positive tumour cells, and both total metachromatic and tryptase-reactive MCs. These results suggest that angiogenesis in human melanoma increases with tumour progression and that FGF-2 secreted by tumour cells and tryptase secreted by host MCs cooperate in its induction.

Fexofenadine in chronic idiopathic urticaria: a clinical and immunohistochemical evaluation

Fexofenadine is a non-sedating selective third-generation antihistamine, which also exerts an anti-inflammatory action. The aim of this study was to evaluate the influence on the expression of inflammatory skin mediators, together with the efficacy and tolerability, of fexofenadine in chronic idiopathic urticaria (CIU). Fexofenadine 180mg was administered once daily for 4 weeks after a placebo run-in phase of 3 to 7 days. Efficacy paramaters were obtained from patients' assessment of urticaria symptoms. Non-lesional skin of patients with active CIU was studied immunohistochemically before and after treatment. The expression of the following mediators was evaluated: adhesion molecules (ICAM-1, ELAM-1, VCAM-1); mast cell proteases (chymase and tryptase) and proinflammatory cytokines (IL-1beta, IL-3, IL-6 and TNF-alpha). Of the 20 subjects enrolled, 3 dropped out of the study. Treatment proved successful in most cases (88.2%) (p <0.01) and a significant improvement of all symptoms was registered. Treatment was well-tolerated by all patients; adverse events, neither serious nor drug-related, occurred in any case. Immunochemistry revealed at the baseline a significant expression of ELAM-1, VCAM-1, tryptase, chymase, and TNF-alpha (p= 0.05) in non-lesional skin of patients compared to normal controls. After treatment with fexofenadine, there was a significant decrease in the expression of ELAM-1 (p= 0.02), VCAM-1 (p= 0.04) and tryptase (p= 0.04), whereas no relevant change was observed for the other parameters examined. This work confirms the efficacy and tolerability of fexofenadine HCl 180mg in CIU. These preliminary data show a trend towards a decrease in the expression of tryptase and some adhesion molecules after treatment, suggesting an anti-inflammatory activity of fexofenadine.

The effect of fixation type on DNA extracted from paraffin-embedded tissue for PCR studies in dermatopathology

BACKGROUND

Amplification of nucleic acids from paraffin-embedded material by the polymerase chain reaction (PCR) is widely used to detect viral genomes, clonal gene rearrangements and oncogene mutations in skin specimens. Fixation with embedding of skin tissue is a procedure that has a profound effect on its molecular arrangement.

OBJECTIVE

The aim of this study was to determine the effect of different fixatives on the PCR amplification of DNA.

METHODS

We fixed randomly chosen fresh pathologic skin specimens in formalin, ethanol and Histochoice for 24 and 72 h and then embedded the tissue in paraffin. DNA was extracted from the paraffin-embedded tissues and used as template for amplification, producing 530- and 760-bp fragments of the phosphoglycerokinase gene.

RESULTS

Our results indicate that PCR can be performed with excellent results on ethanol- and Histochoice-fixed, paraffin-embedded skin tissue with a rate of success comparable to that using fresh tissues; formalin-fixed tissue gave slightly less satisfactory results.

CONCLUSION

This investigation corroborates previous reports investigating the effect of ethanol and formalin fixation on DNA amplification by PCR. Moreover, this is the first study showing that DNA extracted from tissue fixed with Histochoice is suitable for PCR gene amplification.

A modified cell block technique for fine needle aspiration cytology

A modification of the cell block technique, useful in processing material obtained by fine needle aspiration (FNA), is described. Four hundred six aspirates, obtained from 333 consecutive patients, were studied after immediate fixation in 4% buffered paraformaldehyde. Conventional histochemical and immunohistochemical staining methods were used. Histologic verification of the cytologic diagnoses made by FNA was possible in 67 cases. The overall accuracy was 97%, with a sensitivity of 95% and specificity of 100%. A major disadvantage of the cell block technique is time. Therefore, even if this technique increases the accuracy of cytologic diagnosis, its routine use is impractical because the delay in diagnosis when compared with smears may be considerable. The cell block technique is a valuable method, particularly when immunohistochemical staining for a battery of markers is required.

[Human dirofilariasis in southern Italy. I. The Puglia Region]

Nine new cases of human Dirofilariasis by Dirofilaria repens, in subjects living in Apulia, aged 30 to 60 years, are reported. Six were subcutaneous and three subconjunctival. Many of them occurred a number of years ago and were identified thanks to a specific joint investigation carried out by a parasitologist, some histopathologists and ophthalmologists. Of special relevance is one subcutaneous case with contemporary presence of 2 nodules in different regions of the body (mamma and forearm) and another subconjuctival case with strong inflammatory reaction (episcleritis, chemosis, orbital cellulitis) associated with the passage of the nematode under the Tenon's capsule.

[Contact dermatitis of the hands in housewives: the results of a multicenter study]

The survey was carried out between January 1988 and June 1990. It consisted in a clinical and allergological study of 1489 housewives, 880 of which had contact dermatitis at their hands. (group of "cases"). The other 609 represented the control group. The anamnesis was gathered with a guided questionnaire: the questions concerned familiar and personnel pathology, use of detergents and cosmetics, use of means of prevention and therapies. Patch tests with haptens of GIRDCA series and with the most common detergent components were performed. In 98% of cases hands were the lace of beginning of symptoms; in the group of "cases" 46% were positive to at least one patch test. Nickel sulphate gave positivities in the 28% of cases. Results of the search of this metal (and of chrome and cobalt) in detergents are described. Other possible occasions of contact are described. Other causes of sensitization are represented by rubber additives, by perfumes and by preservatives. Cutipositivities for detergents are very really limited. Means of protection, in particular barrier creams, are described as scarcely used.

Cytosolic levels of estrogen-regulated pS2 protein in breast cancer: correlation with tumor proliferative activity

Using a new immunoradiometric assay, a total of 100 cytosols obtained from primary breast tumors were examined for content of pS2, an estrogen-regulated protein. In our series, the median pS2 value was 5 ng/mg protein cytosol which was used as the cut-off. pS2 content was not correlated with menopausal status, tumor size, nodal involvement or tumor proliferative activity expressed as labeling index (tritiated thymidine LI). A positive correlation was found between pS2 and estrogen (ER) and progesterone (PgR) hormone receptors. pS2 in association with ER and PgR seems to identify tumor subgroups with diverse hormone responsiveness. Moreover, in favorable and unfavorable prognostic subgroups, LI and pS2 further emphasize this prognostic diversity.

Morphologic and immunohistochemical observations on the mammary and extramammary Paget's disease: implications for the histogenesis

Using a panel of three anti-CK MoAbs, belonging to Gown's Classes II, III and IV, the Paget's cells shown a variable reactivity to such antibodies indicating a more frequent immunocytochemical similarity to the cells of the epidermal basal-ductal system than to the cells of the glandular secreting section of the epidermal derivatives. According these findings the P.C. not necessarily is the result of a cellular migration from ductal section toward the epidermis, but may arise from a epidermal basal-stem cell, from a ductal or more rarely from glandular secreting cell. This assumption is enforced also by the expression of the CEA from morphologically bonafide basal epidermal cells in proximity of the pagetic lesion.

Total Circulating b Lymphocyte Abnormalities in a Primary Cerebral Localization of Non-Hodgkin Lymphoma: A Case Report

The authors describe a case of primary central nervous system lymphoma In a 43-year-old male. Interest in this rare form of B-lymphocyte non-Hodgkin's lymphoma is due to its increasing incidence in the last decade, especially in immunodeficient patients. Extraneural involvement was excluded by staging examinations: bilateral bone marrow biopsy from the posterior iliac crest, bipedal lymphography, abdominal CT scan, skeletal, thoracic and gastrointestinal X-rays, spinal puncture, ORL and clinical examination. The peripheral immunologic state was particularly interesting: there was a substantial decrease in total circulating B-lymphocytes at diagnosis (4.4 % = 80/mmc; nv 13 ± 4 % = 287 ± 130/mmc) and a further decrease after 2 and 4 months of therapy (0.16% = 2/mmc). Three months after completion of therapy, the B-lymphocyte level returned to the base level at diagnosis (7 % = 88/mmc). At 10 months after diagnosis and 3 months after completion of chemotherapy, the patient is alive and in good health except for the after-effects of a left hemiparesis. The etiologic and possible pathogenic factors are considered.