Scleroderma following augmentation mammoplasty. Report of a case and review of the literature

A 46-year-old woman developed localized scleroderma after surgical manipulation of her silicone gel-filled breast prostheses. She developed firm, shiny plaques on her legs that progressed to involve the thighs. Histopathologic examination of a deep-skin biopsy specimen confirmed the diagnosis of scleroderma. On surgical removal of the silicone implants, and their replacement with saline-filled implants, the scleroderma gradually resolved. Histopathologic examination of the removed implant capsules revealed evidence of silicone leakage. All new female patients with scleroderma should be questioned and examined regarding augmentation mammoplasty. Until prospective studies are completed on the possible association between scleroderma and silicone breast implants, it would seem prudent to use the saline-filled, elastomeric envelope-type breast implant for augmentation mammoplasty rather than the silicone gel-filled implant.     

Pancreatic panniculitis and carcinoma of the pancreas

Pancreatic panniculitis is a rare complication of carcinoma of the pancreas, most often accompanying the rare acinar cystadenocarcinoma. It presents with painful erythematous subcutaneous nodules typically located on the leg. We present a case of a 79-year-old man with neuroendocrine carcinoma of the pancreas and liver metastasis, who developed painful subcutaneous nodules on his shins. Laboratory values included a raised lipase level with normal amylase level and peripheral eosinophilia. The patient was treated with nonsteroidal anti-inflammatory drugs, dexamethasone and antibiotics, with resolution of the dermatological symptoms.     

Polymorphous cutaneous and chronic multisystem sarcoidosis

Sarcoidosis is a systemic disorder in which cutaneous findings are often prominent. These may be polymorphous to the extent that sarcoidosis may mimic many other cutaneous diseases. We describe a 56-year-old woman with involvement of the skin, eyes, bones, heart, and lung. After an initial presentation 10 years earlier of erythema nodosum with bilateral hilar adenopathy, there were three types of cutaneous changes: subcutaneous, nut-sized palpable nodules localized along the upper and lower extremities, annular plaques on the shins, and erythema nodosum-like palpable and slightly tender nodules. It is very unusual to have all three types of skin lesions, especially the erythema nodosum-like histologically specific cutaneous ones in this setting, which is what prompted this report.     

Childhood erythema nodosum associated with kerion celsi: a case report and review of literature

Erythema nodosum (EN) in association with kerion celsi is a rare condition in children, with only 11 cases having been reported in the English literature. We describe a new case in a 7-year-old boy in whom the disorder had begun 2 months before. He had many inflamed, boggy, suppurative nodules over the left occipitoparietal area of the scalp and, 2 weeks later, developed multiple painful, erythematous subcutaneous nodules of the shins, thighs, and upper limbs. EN was confirmed by histologic examination. Our review of the literature of all cases of EN during kerion showed that it usually occurs at or slightly after the height of infection or after drug introduction. Trichophyton mentagrophytes was involved in the majority of cases, and improvement of EN usually occurs with griseofulvin.     

Differenzialdiagnostik der Pannikulitis

Panniculitides are diseases of the subcutaneous tissue with heterogeneous etiology. They may develop consequent to infections, as a reaction to drugs, after thermal injury, as part of autoimmune diseases, in metabolic disorders or due to infectious organisms. The clinical presentation with subcutaneous nodules is often nonspecific. Moreover, the differentiation from vasculitides of medium-sized vessels can be clinically challenging. Microscopic examination of biopsy specimens is of high importance in the differential diagnosis of panniculitides. Histopathologically, panniculitides can be classified according to the predominantly infiltrated area in septal and lobular panniculitides and they can be separated from vasculitides of medium-sized vessels. Diagnostic difficulties arise from inadequate biopsy specimens and from lack of clinicopathological correlation. This article summarizes diagnostic criteria of frequent and clinically important panniculitides.     

Unusual skin reaction to silicone content in breast implants

We present a patient who had a long history of unsuccessful bilateral mammary operations with insertion and extraction of various implants, some of which were filled with silicone gel, others with saline. In addition to complications in the tissue surrounding the prosthesis, she had distant widespread skin lesions which, we believe, were due to leakage from the implant. A cutaneous test with material from various implants, such as the gel content and the shells, caused an unusually prolonged inflammatory response, which was difficult to classify as being either irritative or allergic. Macromorphologically and histologically, the provoked lesions resembled the previous cutaneous lesions. We believe that the patient's complications are due to an unusual host response to silicone.     

Intralymphatic histiocytosis with granuloma formation associated with orthopaedic metal implants

A 75-year-old man presented with a 1-year history of asymptomatic reddish-brown nodules on his left knee, in which orthopaedic metal implants had been inserted for a transformation-related knee joint disorder. Histopathological examination revealed typical features of mixed cell granuloma with many dilated lymphatics that contained many histiocytes from the upper dermis to subcutaneous fat tissue. Results of qualitative analysis of biopsy specimens by energy-dispersive X-ray spectroscopy were positive for molybdenum, which was one of the constituents of the metal implant. We describe the first observation of intralymphatic histiocytosis with granuloma formation in the skin occurring in a patient bearing orthopaedic metal implants for a transformation-related knee joint disorder.     

A Case of Cutaneous Mycobacterium Chelonae Abscessus Infection in a Renal Transplant Patient

Abstract Background: Mycobacterium chelonae is an atypical "fast-growing Mycobacteria" that is a rare cause of human infection. There have been several reports of cutaneous infection among immunosuppressed patients, as well as in immunocompetent individuals following trauma. Most cases to date seem to have occurred among renal transplant recipients, raising the possibility that there is something inherent to the renal transplant patient that increases their susceptibility more than other immunocompromised patients. Objective: The differential diagnosis of subcutaneous nodules distributed in a sporotrichoid pattern is extensive, particularly in an immunocompromised host. Although several cases of cutaneous M. chelonae abscessus infection have been reported among both immunosuppressed and immunocompetent patients, the clinical presentation has varied, and few cases have reported the appearance of lesions in a sporotrichoid pattern. We present a case of a renal transplant patient with a reported history of trauma to the lower extremities, who presents with subcutaneous nodules distributed in a sporotrichoid pattern. The patient is found to have M. chelonae abscessus infection, fails several treatment regimens, and presents with a recurrence. The literature of M. chelonae infection is reviewed, and the various treatment options are discussed. Methods: An initial skin biopsy was stained with Hematoxylin and Eosin and revealed deep dermal abscesses with acid-fast bacilli in clusters. The culture became positive for Mycobacterium chelonae abscesses in four days and was found to be sensitive to multiple antibiotics. The patient underwent surgical excision of 14 nodules, which revealed findings consistent with the skin biopsy, and was subsequently treated with the appropriate antibiotics. Results: Despite treatment with a full course of an organism-sensitive antibiotic regimen, the patient returned with persistent and recurrent nodules six weeks later. The patient was then treated as an inpatient with a seven-week course of intravenous antibiotics and was discharged home on a combined intravenous and oral regimen. Conclusion: Although M. chelonae abscessus is an extremely rare cause of infection among humans, there seems to be a predominance of cases reported among renal transplant patients. The explanation for this is not entirely clear; however, the organism must be considered as a cause of infection in any renal transplant recipient who presents with subcutaneous nodules. Eradication of the organism presents a tremendous challenge to the clinician, and, as presented here, even with appropriate antibiotics, there is a high rate of recurrence.     

Metaplastic breast carcinoma histologically mimicking cutaneous spindle cell squamous cell carcinoma

Squamous cell carcinoma is one of the most common primary cutaneous carcinomas but on rare occasion, metastatic squamous cell carcinoma from a distant site or solid organ can present as a cutaneous lesion. Most metastases occur as dermal nodules or involve the dermal lymphatics, but when they are intimately associated with the epidermis, distinguishing the lesion as primary or metastatic may be extremely difficult and usually requires a clinical history or high index of suspicion. A 71-year-old woman presented with multiple eruptive nodules over her chest, flank, and back. Histologically the lesions appeared to be arising from the surface epithelium and consisted of atypical, predominantly spindle cells, some of which streamed off of the epidermis. Following the initial evaluation, a history of breast carcinoma with subsequent radiation therapy and ultimate mastectomy was obtained, and the original breast biopsy and mastectomy material was reviewed. After performing additional studies, it became clear that the origin of the carcinomas was metastatic from an underlying metaplastic breast carcinoma.     

肿瘤样钙质沉着症

报告1例肿瘤样钙质沉着症.患儿男,8岁.全身结节、肿块1年余.皮肤科检杳:颈部、躯干、四肢、臀部及手足可见约百个大小不一的结节和肿块,部分融合,边界清晰,少数包块顶端破溃,流出石灰状物质.皮损组织病理检查示真皮及皮下组织大量颗粒状灶性钙沉积.诊断:肿瘤样钙质沉着症.     

Primary localized cutaneous nodular amyloidosis and CREST syndrome: a case report and review of the literature

Primary localized cutaneous nodular amyloidosis (PLCNA) is a form of primary localized cutaneous amyloidosis (PLCA) that presents as yellowish waxy nodules on the extremities, face, trunk, or genitalia. We report the case of a patient with PLCNA and CREST (calcinosis, Raynaud phenomenon, esophageal motility disorders, sclerodactyly, and telangiectasia) syndrome. A diagnosis of her extensive PLCNA was made after biopsy specimens from the bilateral shins stained positive for amyloid extending from the superficial papillary dermis to the subcutis. Results of a workup were negative for paraproteinemia or signs of systemic amyloidosis and have remained so after 8 years of follow-up. We present a review of the literature describing the presentation and histopathology of the varying forms of amyloidosis.     

Skin involvement as the presenting sign of internal carcinoma. A retrospective study of 7316 cancer patients

From tumor registry data of 7316 cancer patients, we found 367 cases (5.0%) with skin involvement. Skin involvement was present at the time of presentation in 92 patients (1.3%), only 26 of whom had remote metastases. Skin involvement was the first sign of cancer in 59 patients (0.8%); 22 had direct extension of their tumor into the skin, 20 had local metastases, and 17 had distal metastases. Direct invasion was most common with breast cancer and second most common with oral cavity cancer. Local metastases were also most frequently caused by breast cancer but occurred in surgical scars in three women with pelvic cancer and in perianal abscesses in one patient with rectal carcinoma as well. Except for metastases from unknown primary sites, distant metastases were rare as presenting signs, and their origins were widely distributed. Our data show that internal cancer uncommonly presents with skin involvement. Nevertheless, an index of suspicion should be maintained and biopsy performed, particularly for nonhealing ulcers, persistent indurated erythema, and unexplained skin nodules.     

SILICONE GRANULOMA IN ACRAL SKIN IN A PATIENT WITH SILICONE-GEL BREAST IMPLANTS AND SYSTEMIC SCLEROSIS

A 68-year-old white woman was referred to us by her rheumatologist for possible participation in a clinical study of photopheresis for scleroderma. In February 1993, she noticed edema of her distal phalanges, Raynaud's phenomenon in both hands, flu-like symptoms, fatigue, intermittent diarrhea, abdominal pain, tearing in both eyes, dyspnea on exertion, dysphagia, and odynophagia. Bilateral silicone-gel breast implants had been placed 12 years before; 2 months before her present evaluation, they were removed and found to be ruptured.
Physical examination revealed edema, limited to the fingers and hands bilaterally, and slight induration of the skin on the dorsum of both hands and distal forearms. The remainder of the physical examination was normal.
According to our study protocol, a skin biopsy specimen from the dorsum of the right hand was taken, but all other laboratory investigations were refused. Histopathologic examination revealed multiple clear spaces of varying sizes in the dermis and multinucleated macrophages containing small refractile particles, characteristic of silicone granuloma (Figs. 1 and 2); however, the specimen showed no evidence of scleroderma. X-ray energy dispersive analysis by scanning electron-microscopy confirmed the presence of elemental silicon in the small refractile particles.
The patient did not receive any treatment after her diagnosis and shortly thereafter, she was lost to follow-up.     

A case of subcutaneous sarcoidosis in a patient with Cushing's syndrome

A 41-year-old female visited our department complaining of asymptomatic subcutaneous nodules on the right forearm. She had been diagnosed as having Cushing syndrome due to an adrenal tumor 5-months previously. After she underwent surgery for the adrenal tumor, the subcutaneous nodules gradually increased in number. Physical examination showed ill-defined plate-like subcutaneous indurations on the bilateral lower extremities, buttocks, and right forearm. A biopsy of one of the subcutaneous indurations showed non-caseating epithelioid cell granulomas involving the hypodermis and subcutaneous tissues. The patient was diagnosed as having sarcoidosis based on the Japan Society of Sarcoidosis and Other Granulomatous Disorders 2015 criteria. Skin lesions decreased in size and had completely disappeared. Although the mechanism is unknown, there may be a possibility that the activity of sarcoidosis is suppressed by high cortisol concentrations due to Cushing syndrome.     

Large plaque‐type blue naevus with subcutaneous cellular nodules

We report a new case of ‘large plaque‐type blue naevus (PTBN) with subcutaneous cellular nodules’ involving the breast. A 25‐year‐old‐woman presented with a large plaque, 140 × 100 mm in size, on the right chest wall involving the right breast, associated with recent subcutaneous nodules. Histopathological examination revealed features of cellular and common blue naevus. Dermatoscopy was performed, and the diagnosis of PTBN was made. PTBN is a rare condition with an imprecise prognosis. In cases of PBTN lesions on the head, clinicians must keep in mind the risk of malignant transformation of PTBN or an association with cutaneous neurocristic hamartoma. For this new variant of PTBN appearing on the trunk, we propose close monitoring of the patient if surgical excision is impossible.     

Signet ring cells in carcinomatous lymphangitis due to gastric adenocarcinoma

Cutaneous metastases are rare. They usually present as nodules or tumors. Diagnosis is based on histopathological examination and prognosis is unfavorable. This report describes the case of a female patient, 72 years old, with surgically treated gastric antrum adenocarcinoma. Pathology showed poorly differentiated adenocarcinoma with signet ring cells. It evolved with bone involvement, lymph node enlargement in the inguinal region, and skin infiltration in the lower limbs, abdomen, and root of the upper limbs. Skin biopsy demonstrated signet ring carcinoma embolizing the dermal and hypodermic vessels and invasion of adipose tissue, confirming carcinomatous lymphangitis. Carcinomatous lymphangitis is the cutaneous and subcutaneous lymphatic invasion by tumor cells. Cutaneous metastasis is relatively uncommon and presents mainly as cutaneous or subcutaneous nodules, and more rarely as inflammatory lesions. The present case reports carcinomatous lymphangitis associated with gastric cancer.     

Pretibial myxoedema presenting as a scar infiltrate

A 41-year-old man developed pretibial myxoedema localized to soars following treatment for hyperthyroidism. Pre-existing scars on both lower legs, present for more than 20 years, were infiltrated with firm and nonpitting nodules and plaques over his shins. The clinical presentation of this patient highlights pretibial myxoedema as a cause of scar infiltration. The pathogenesis or pretibial myxoedema is reviewed.     

结节性红斑的诊疗进展

结节性红斑是以皮下脂肪炎症反应为特征的炎症性疾病,临床表现为双下肢疼痛性红斑。病因主要包括特发性、感染、自身免疫性疾病、妊娠、药物、肿瘤等。相关检查包括皮损活检、血沉、抗“O”、结核试验、胸片、血常规等。应该对症对因治疗。如非甾体抗炎药、糖皮质激素、碘化钾、沙利度胺等免疫抑制剂可以用于严重难治性病例。中医中药治疗及物理治疗也有较好疗效。     

皮下血管内大B细胞淋巴瘤

报告1例皮下血管内大B细胞淋巴瘤.患者男,73岁.因双侧大腿皮下结节,于2007年2月初就诊.皮损组织病理检查见血管腔内有大量肿瘤细胞聚集,免疫组化染色结果示肿瘤细胞CD20阳性,诊断为皮下血管内大B细胞淋巴瘤(IVLBCL).予环磷酰胺、长春新碱、泼尼松(COP方案)化疗后皮损缩小.IVLBCL恶性程度较高,临床表现无特异性,预后较差,皮损组织病理检查有助于诊断.     

Multinodular Cutaneous Spread in Neuroendocrine Tumor of the Breast

Carcinoid tumors are the most common type of neuroendocrine tumors with an incidence of 1.5 per 100 000 of the population. Skin manifestations of carcinoid tumors include those associated with the carcinoid syndrome and sequelae from metastatic disease. Carcinoid tumors in the breast, which were first described in 1977, are rare and may present either as primary or metastatic lesions. The existence of primary breast carcinoid tumors is controversial, however, and, if they do exist, would account for <1% of primary breast cancers. We report the case of a 76-year-old woman who presented to the M.D. Anderson Cancer Center with a long-standing history of a breast lump. Core biopsy of the mass and left axillary lymph node aspiration revealed neuroendocrine tumor of the breast, which stained positive for synaptophysin and chromogranin. Subsequently, the patient developed a left-sided pleural effusion, and a further work-up revealed metastases to the lung parenchyma and pleural space. Three years after her diagnosis, she complained of a persistent, erythematous thickening of skin over the surface of her left inferior breast, which had been present for 1 year. On examination, multiple erythematous grouped nodules arranged in an oval pattern were present. A punch biopsy from one of the nodules revealed invasive low-grade carcinoma with neuroendocrine features similar to those in her prior breast core biopsy. The tumor was seen to be infiltrating the dermis. This is a unique case of a neuroendocrine tumor of the breast with cutaneous spread. The number of reported cases of neuroendocrine tumors with cutaneous involvement remains small.