NECROLYTIC ACRAL ERYTHEMA: A CUTANEOUS MARKER OE VIRAL HEPATITIS C

Background. Necrolytic acral erythema (NAE) is a distinctive skin lesion that was found to affect the dorsa of the feet of seven patients having active viral hepatitis C. Necrolytic acral erythema occurs in the form of well circumscribed dusky erythematous areas that develop flaccid blisters in their early stages and a hyperkeratotic surface in their chronic form. Microscopically, lesions of NAE are similar to those of other necrolytic erythemas such as necrolytic migratory erythema, pellagra, and zinc deficiency. Method. Seven patients with NAE were included in this study. These patients underwent microscopic examination of punch biopsy specimens of the affected skin, abdominal sonography, ct scan of pancreas, and a liver biopsy. Blood samples were obtained for complete blood picture, serum glucose, zinc, amino acids, liver function tests, and markers of hepatitis. Results. All patients with nae were found to have hepatitis C by elisa and pcr . Conclusions. Necrolytic acral erythema is a distinctive type of necrolytic erythemas that was observed to occur almost exclusively with viral hepatitis C. Therefore, it should be considered an important cutaneous marker of hepatitis C, particularly in areas showing a high incidence of this form of hepatitis.     

ERYTHEMA PERSTANS

SUMMARY.— A review of the clinical features of 113 and the histological features of 42 patients with erythema perstans is presented. In none of the patients was a cause definitely established. Seven patients had an internal malignancy. In only 3 of the 7 was there a temporal relationship between the malignancy and the erythema perstans such that an aetioiogical relationship could be seriously considered. Six patients in a control group of 113 patients with psoriasis had an internal malignancy. Erythema perstans may sometimes be a sign of internal malignancy, but the present study indicates that this is true less often than previously suspected.     

ERYTHEMA DYSCHROMICUM PERSTANS

Erythema dyschromicum perstans (EDP) is a peculiar pigmented condition of unknown etiology, resistant to any treatment (1–3). We report a typical case of EDP and discuss its differential diagnosis.     

ERYTHEMA GYRATUM REPENS

Summary— The case histories of 2 patients with erythema gyratum repens (E.G.R.) are presented. In common with all previous reports, both were found to have a hitherto unsuspected underlying neoplasm, one having an adenocarcinoma of the bladder and the other a prostatic carcinoma. It is suggested that a simple and useful diagnostic aid in the differentiation of E.G.R. from other figurate erythemas, is to outline the lesions and observe them daily.     

ERYTHEMA ELEVATUM DIUTINUM

A 57-year-old woman presented with symmetrical reddish-brown plaques on the entire skin, especially the extremities. The lesions differed in size and shape, and their consistency ranged from soft to tight-elastic, to hard in the older lesions (Fig. 1). The forearms and the dorsae of the hands and feet were covered with confluent plaques; some of these had an isolated nodular lesion on top. The lesions on the arms were papular-nodular, arranged in rows to form “cords” with “pseudokeloid” appearance (Fig. 2). On the face, around the cheeks, the wings of the nose, and the ears, there were purplish nodular lesions and plaques. The lesions first appeared 14 years ago in the winter as lentile-sized, slightly reddish papules on both legs. These lesions disappeared spontaneously during the summer and returned the following winter. For 4 years the lesions followed this pattern of appearing and disappearing, leaving residual pigmentation. The patient reported that at each recurrence the lesions were larger and darker. Subsequently, the lesions had become permanent without any improvement during the summer and had also spread to the upper limbs and trunk. For the past 4 years the patient has had arthralgia of the large joints, swelling of the lower extremities, burning and pain in the lesions themselves. These symptoms became more evident in the evening and after exposure to cold. A biopsy specimen of a recent lesion showed a dermal perivascular infiltrate comprised mainly of neutrophilic granulocytes and histiocytes and a few eosinophils. The vessels appeared dilated with swelling of the endothelial cells (Fig. 3). In and around the vessel walls an eosinophilic deposit of fibrinoid material was noted. Electronmicroscopic examination revealed macrophages with secondary lysosomes containing electrondense, osmiophilic, probably lipid material, in the perivascular infiltrate. lnterdigitate cells, juxtaposed with the lymphocytes among the infiltrate cells were also seen (Fig. 4). Direct immunofluorescence (DIF) revealed linear IgA deposits at the dermoepidermal junction. Direct immunofluorescence on healthy perilesional skin after histamine injection¹ showed IgA, C3, and fibrinogen at the perivascular level in the superficial dermis and at the dermoepidermal junction with granular appearance. Cutaneous fibrinolytic activity (CFA) evaluated with Todd's autohistographic method¹, modified by Lotti et al.², was reduced by 80% compared to that of healthy subjects. Findings of other laboratory tests are listed in Table 1. Relevant investigations showed a decrease in fibrinogen, positive protein C and RA tests, the presence of cryoglobulin, and an increase in serum |gA.| Circulating immune complexes were detected and glucose-6-phosphate-dehydrogenase (GG-PD) was slightly low. The tests of clotting function showed some changes due to increased platelet aggregability from exogenous adenosine diphosphate (ADP), a slight reduc-tion in fibrinogenemia due to the presence of D-dimers and other products of fibrinogen degradation, suggesting a state of chronic intravascular coagulation. Treatment was begun with diaminodiphenylsulfone (50 mg/day), which was suspended because of adverse reac-tions (headache and nausea) and was replaced by clofa-zimine (starting dose 200 mg/day). Improvement in the sub-jective symptoms and healing of many lesions with residual pigmentation was noted.     

THE ROLE OE MAST CELLS IN TREATMENT OE SCABIES

Objective. The purpose of this study was to recognize the role of mast cells in the pathogenesis of scabies. Methods. One hundred and fifty patients and 10 controls were included in the study. Group 1 included 20 patients without previous treatment. In group 2, 80 patients were treated with antiscabietic drugs. Group 3 had 50 patients who received an antiscabietic drug followed by 3 days of crotamiton. Diurnal and nocturnal skin biopsies were taken from group 1. In groups 2 and 3, the biopsies were taken after 2 weeks of treatment. Sections were cut and stained by hematoxylin and eosin and Giemsa stains. Results. Mast cells were increased in diurnal and nocturnal biopsies. Evident degranulation of mast cells was detected in nocturnal biopsies. The mast cell number decreased to half its pretreatment number in patients treated with antiscabietic drugs and to its normal number in patients treated with antiscabietic drugs followed by 3 days with crotamiton. Conclusion. The number of mast cells are increased in scabietic lesions. This plays a role in the pathogenesis of the clinical and histologic picture of scabies. We recommend that an antiscabietic drug should be followed by 3 days of crotamiton in the treatment of scabies.     

ERYTHEMA MULTIFORME INFANTUM ATROPHICANS

ABSTRACT: A new case of erythema multiforme is described, characterized by multiforme eruption of erythematous papules, plaques and occasional bullous lesions. The acute stage lasts several weeks, then atrophy is noted. The face appears senile. Histo-pathologically, the lesions show erythema multiforme in the acute phase; in the atrophic stage, a disappearance of the elastic fibers was observed.     

ERYTHEMA NODOSUM VERSUS NODULAR VASCULITIS

Background. Erythema nodosum (en ) is usually considered to be a septal panniculitis, and nodular vasculitis (nv ) a lobular panniculitis. We tested the usefulness of this histologic classification in clarifying a frequent clinical dilemma: en versus nv . Methods. Over 3 years 109 patients with panniculitis were included in this study. After a history and a physical examination, a clinical diagnosis was made according to well-established criteria. Results. From the study of 88 patients, we concluded that in the clinically typical cases, the clinico-pathologic agreement was 93% and 94% for en and nv respectively, whereas it diminished to 79%, 72%, and 67% in the cases clinically diagnosed as en migrans, atypical en , and atypical nv , respectively. Moreover, septal and lobular panniculitis were always two clear-cut, different, opposite patterns of hypodermal inflammation to these conditions. Conclusions. In the absence of a known pathogenetic mechanism, the histopathology remains the most objective discriminating marker between en and nv , mainly in the clinically atypical and doubtful cases.     

ERYTHEMA NODOSUM LEPROSUM IN NIGERIA

The occurrence of erythema nodosum leprosum among leprosy patients treated with diamino diphenyl sulfone in an endemic area is not rare, unlike in the leprosy patients treated at Lagos University Teaching Hospital. Two Nigerian patients with this disease are described, in whom this rarity was seen. Recurrent monthly fever with painful skin swellings in lepromatous patients from an edemic area is highly suggestive of erythema nodosum leprosum. The occurrence of this reaction in lepromatous leprosy gives a relatively poor prognosis.