Indurated reticulate palmar erythema as a sign of paraneoplastic palmar fasciitis and polyarthritis syndrome

A 62-year-old woman presented with a 6-month history of polyarthritis. She had also noted a 2-month history of indurated palmar erythema and increasing bilateral hand swelling and stiffness. A biopsy from the area of palmar erythema showed interstitial fibroplasia within the dermis and subcutis representing a palmar fibromatosis. This presentation appears to belong to the spectrum of palmar fasciitis and polyarthritis syndrome. Rheumatologists have recognised this syndrome as a paraneoplastic disorder and subsequent investigations in our patient revealed an elevated cancer antigen 125 and an inoperable ovarian carcinoma. Indurated palmar erythema is a sign that is not widely recognised by dermatologists as a clue for this paraneoplastic syndrome, and skin biopsy demonstrating dermal and subcutaneous fibroplasia may help in diagnosis in the absence of advanced signs of palmar fasciitis.     

Leucemia cutánea en un paciente con leucemia mieloide aguda M2

—The leukemia cutis is the cutaneous infiltration by leukemics cells. Patients with acute myelogenous leukemia (AML) present specific cutaneous involvement in approximately 10% of the cases.We report the case of a leukemia cutis in a 73-year-old male with AML-M2. The patient presented with a one-week history of general malaise, asthenia, cough, dysnea and fever. Physical examination revealed and indurated red-brown plaque on his back of two moths duration, which was pruritic. Concomitance blood and bone marrow findings were diagnostic of AML-M2. A cutaneous biopsy was consistent with leukemia cutis. A CT and a bronchial biopsy showed pulmonary involvement. Since starting chemotherapy the patient had complete remission and the cutaneous lesion cleared, but 15 days later the skin lesion reappeared. A new bone marrow examination revealed recurrent leukemia. He died one month later.     

Multiple nodular cutaneous metastases as the first clinical sign of signet ring cell gastric carcinoma: case report

Cutaneous metastases from signet ring cell gastric carcinoma are uncommon. A 35-year-old male presented with a three-month history of multiple asymptomatic, indurated, pinky colored nodules of 2.5 to 4 cm in diameter, without any local and general symptoms. Nodule biopsy revealed an infiltrating signet ring cell carcinoma. Gastroscopy and biopsy confirmed the diagnosis of gastric carcinoma with signet ring cells. The present report describes an unusual clinical case of a young patient diagnosed with cutaneous metastasis before detection of his gastric carcinoma.     

Lingual traumatic ulceration (Riga-Fede disease)

An 11-month-old male infant was referred to our clinic because of a painful ulcer of approximately 5 months' duration on the ventral surface of the tongue (Fig. 1). On physical examination, the lesion was circular (3 cm x 2 cm) with erythematous, raised, and indurated borders. No pathologic findings emerged from the laboratory data, neurologic examination, or clinical history. The family history was also negative for developmental disorders and congenital syndromes. No biopsy was performed in view of the age of the infant, the particular site of the lesion, and the clinical evidence of diagnosis. The treatment included odontologic cream (methylvinylether/maleic acid) as a protective shield, a collutorium (chlorhexidine 0.2%), and the use of a teething ring. Complete healing of the lesion (Fig. 2) occurred within 3 weeks.     

Disseminated granuloma faciale

A 40-year-old man presented in January 2001 with multiple purple plaques and nodules, which had been present on the back for approximately 3 years. The lesions had gradually extended over the face, trunk and proximal extremities. He had no symptoms except occasional mild pruritus. The patient was in good health and was on no medications. Physical examination revealed multiple violaceous to brown, indurated, 5-50-mm, round to oval plaques on the face, arms, shoulders, and back (Fig. 1), as well as a solitary lesion on the right thigh. Surface telangiectases were noted, especially on the shoulder lesions. There was no scaling or ulceration. Routine laboratory tests were unremarkable. In April 1999, another medical center performed a biopsy of what they thought was sarcoidosis. The results were reported as "possible angiolymphoid hyperplasia with eosinophilia." With the possibility of granuoma faciale (GF) in mind, another skin biopsy was obtained from a facial lesion. This revealed a diffuse, relatively dense infiltrate of neutrophils, eosinophils and mononuclear inflammatory cells in dermis with an obvious Grenz zone (Fig. 2). Pilar units were intact, and endothelial cell swelling was present (Fig. 3). Retrospective evaluation of the initial biopsy, taken from the back, revealed the same changes, and helped confirm the diagnosis of GF. The patient was treated with liquid nitrogen for 20 s followed immediately by intralesional triamcinolone acetonide (5 mg/ml). This treatment was repeated every 4 weeks for three courses, resulting in partial resolution of the lesions.     

Superficial basal cell carcinoma on face treated with 5% imiquimod cream

Imiquimod, an immune response modifier, is known to possess both anti-viral and anti-tumor effect. We report our experience of treating a large superficial spreading basal cell carcinoma with 5% imiquimod cream. A 65-year-old male had an asymptomatic, hyperpigmented, slowly progressive, indurated, 3 x 4 cm plaque on the left cheek for two months. Biopsy from the lesion showed features of basal cell carcinoma. The patient was treated with imiquimod 5% cream, topically three times a week for six months with complete resolution of the lesion and without any side-effects. There was no clinical or histological recurrence after three months of stopping the treatment.     

性病性淋巴肉芽肿合并皮肤鳞状细胞癌一例

患者男,53岁,冠状沟增生物2年,腹股沟包块红肿、疼痛、破溃2月余。体检：双侧腹股沟淋巴结红肿约2 cm × 1.5 cm,质硬,触痛,右侧腹股沟肿大淋巴结中心波动,其上见多处破溃及黄白色脓性分泌物流出,如喷水壶状。多个肿大或破溃淋巴结被腹股沟韧带分隔,形成明显的沟槽征。冠状沟两侧可见1 cm × 2 cm不规则疣状增生,质硬,表面角化。龟头系带处红肿,有波动,并有破溃伴黄白色脓液渗出,右侧阴囊肿胀。龟头系带处分泌物及左右侧腹股沟穿刺液多次真菌培养阴性,细菌培养阴性,抗酸染色阴性,沙眼衣原体培养初次为阴性,衣原体内源性质粒PCR检测阳性,omp1-限制性片段长度多态性（RFLP）分型为L3型。Western印迹示血清沙眼衣原体主要外膜蛋白（MOMP）抗体阳性,多形外膜蛋白H（PmpH）抗体 > 1 ∶ 800,衣原体多代培养阳性。右腹股沟疣状增生处活检示皮肤高分化鳞状细胞癌。诊断：性病性淋巴肉芽肿合并皮肤鳞状细胞癌。     

Leishmaniasis of the lip diagnosed by lymph node aspiration and treated with a combination of oral ketaconazole and intralesional sodium stibogluconate

A 26-year-old male who presented to the dermatology OPD with complaints of a swelling on his lip of 6 months' duration was on examination found to have a solitary ulcerated nodule over the lip and an enlarged submental lymph node. Skin smear and biopsy from the lesion did not yield the diagnosis. Needle aspiration from the draining lymph node revealed the diagnostic Leishman-Donovan bodies. The patient responded to treatment with a combination of oral ketoconazole and intralesional sodium stibogluconate. We report this case because of both the unusual location of the lesion and the unusual method of diagnosis and treatment.     

Eosinophilic ulcer of oral mucosa

A 41-year-old woman was seen for the examination of a painless lesion on the posterior hard palate of 2 weeks’ duration. She had no systemic symptoms. Examination of the hard palate showed a single 1 × 1 cm, round, punched out ulcer with an erythematous base; the margins of the ulcer were slightly raised and indurated ( Fig. 1 ). Other clinical findings were normal and laboratory study of a cutaneous biopsy showed necrotic ulceration with dense inflammatory cell infiltration. An extensive inflammatory cell infiltration with predominantly eosinophilic cells was present throughout the submucosa. A single application of liquid nitrogen decreased the lesion.

Figure 1 Open in figure viewer PowerPoint Ulcer found on the posterior hard palate at the time of initial visit     

Primary cutaneous zygomycosis due to Mucor circinelloides

A 62-year-old woman with myelodysplastic syndrome presented with a 4-week history of a large indurated ulcer with a black eschar on the forearm following trauma. On biopsy a diagnosis of zygomycosis was made as broad, sparsely septate, thin-walled hyphae were seen in the deep dermis and subcutaneous fat. The zygomycete fungus Mucor circinelloides was cultured from tissue. Further investigation confirmed that the infection was localized to the skin. The 6 x 4 cm lesion was excised and the defect closed with a neurovascular island flap. No other treatment was undertaken. The patient died 6 months later from her haematological disease without recurrence of the fungal infection.     

微囊肿性附属器癌1例

报告1例微囊肿性附属器癌。患者女,57岁。胸部右侧硬斑块6年,加重1年。右上胸壁可见一3cm×3cm浸润性硬斑块,其上有少量渗出,结黑褐色痂,边缘隆起,皮损与胸壁固定,中央凹陷。皮损组织病理检查示真皮内见管状结构和散在实性鳞状细胞岛,外围为基底样细胞。免疫组化染色示:AE1/AE3(++),CEA(+)。     

Sebaceous hyperplasia: a clue to the diagnosis of dermatofibroma

We describe a man with an indurated lesion on his upper back that showed a dermatofibroma with overlying sebaceous hyperplasia. Characteristic dermal features of a dermatofibroma may be sparse or absent in a lesional specimen that has been submitted subsequent to a superficial shave biopsy. Hyperplasia of sebaceous glands in a nonfacial lesion is a histologic feature that should prompt the search for a dermatofibroma in the underlying dermis.     

Metástasis acral digital ósea por adenocarcinoma renal con afectación cutánea

—Cutaneous metastases are a rare and late manifestation of the internal malignancies. The likelihood of a visceral malignant tumour producing deposits in the skin is increased if the lesion is anaplastic and of long duration. Acral metastasis are specially atypical. Most acral metastases affect bones with late secondary cutaneous involvement.We report the case of a 67-years-old female with metastatic renal cell carcinoma who presented swelling and blue-reddish discoloration in the distal part of the 2^nd finger of her left hand that had appeared four days before. On the hand X-ray there was a lytic lesion on the third phalanx of this finger. The histopathological findings showed a clear cell proliferation replacing deep dermis. A diagnosis of osseous metastases with late secondary skin involvement from renal cell carcinoma was made.     

Fluoroscopy-induced chronic radiation skin injury: a disease perhaps often overlooked

BACKGROUND: Fluoroscopy-induced chronic radiation dermatitis (FICRD) resulting from prolonged exposure to ionizing radiation during interventional procedures has been documented in the radiology and cardiology literature. However, the phenomenon has been rarely reported in the dermatologic literature. Since patients with FICRD often see a dermatologist or a primary care physician to treat their injuries, the diagnosis of FICRD is perhaps often overlooked. OBSERVATIONS: A 62-year-old man with type 2 diabetes mellitus and severe coronary artery disease was seen with a 2-year history of a pruritic, tender, telangiectatic patch lesion over his left scapula. Over the next 2 years, the lesion became indurated and eventually ulcerated. A skin biopsy specimen demonstrated changes consistent with a chronic radiation dermatitis. The patient was unaware of radiation exposure, but persistent questioning from his dermatologists revealed that he had undergone multiple fluoroscopy-guided cardiac procedures. This was confirmed by a review of his medical records. CONCLUSION: The diagnosis of FICRD should be considered for any patient who is seen with an acquired vascular lesion, a morphealike lesion, or an unexplained ulcer localized over the scapula, the back, or lateral trunk below the axilla.     

Giant melanoacanthoma mimicking malignant melanoma

Melanoacanthoma denotes a rare variant of pigmented seborrheic keratosis. A 65-year-old male farmer had pigmented, verrucous, itchy, highly painful, progressively growing irregularly oval plaque on left side of lower back for the past five years. The indurated lesion, measuring maximum diameter 10 cm × 5 cm, had no discharge, bleeding, ulceration, or associated lymphadenopathy. Dermoscopy showed regular pigmentary network and cribiform pattern of ridges without any feature of malignant melanoma. Histopathology showed well-defined islands of basaloid cells interspersed with large and richly dendritic melanocytes. The lesion was totally excised followed by skin grafting. Our patient was unique in its massive size and clinical resemblance with malignant melanoma. The diagnosis was confirmed by dermoscopy and skin biopsy.     

Acquired vulvar smooth muscle hamartoma: a case report and review of the literature

A 36-year-old Korean woman had had a flesh-colored, indurated plaque with pruritus on the labium majora for five years. The lesion was not found in association with hyperpigmented or hypertrichotic patches. Results of biopsy specimens showed an excess of haphazardly oriented smooth-muscle bundles in the mid to lower dermis with an unremarkable overlying epidermis. Our diagnosis was an acquired smooth-muscle hamartoma in the vulva. Although there have been previously reported cases of acquired smooth-muscle hamartoma, this was the first reported case in the vulva. We also describe the characteristics differing between our case and the six previously reported ones.     

Cutaneous infection by Mycobacterium fortuitum biovariant "third group"--a case report and bacteriological examination of the isolate

A 22-year-old woman with ten-year history of atopic dermatitis first noticed an erythematous ++, indurated, and fluctuant lesion on her back six month prior to visiting our hospital in February 1989. The dusky red skin lesion gradually spread to the right side of her trunk and drained small amount of purulent or serosanguineous fluid. A skin biopsy specimen showed mixed pattern of nonspecific inflammatory infiltrate and granulomatous infiltrate in the dermis. A culture of the biopsy specimen showed a rapidly growing atypical acid-fast bacteria, which was identified as Mycobacterium fortuitum and classified as biovariant "third group" by positive growth on mannitol and inositol. Minimum inhibitory concentrations (MICs) of different antimicrobial agent using broth medium showed that the isolate was susceptible to the new quinolones such as ofloxacin and ciprofloxacin. The patient responded to treatment with doxycycline followed by with ofloxacin. Subspecies classification and antibiotic susceptibilities were discussed with special reference to treatment of rapidly growing mycobacteria.     

A case report of remote cutaneous metastasis from male breast carcinoma

A 66-year-old man, who had been diagnosed with vasculitis 1 year previously, presented at our hospital with edema of the left leg and erythema of more than 1 year's duration (Fig. 1). He had been diagnosed with dermatitis and vasculitis in another hospital without being biopsied, and had been treated with topical steroids, oral antihistamines, antibacterials, hydrochlorothiazide, and Radix Salviae Miltiorrhizae, which provided some temporary benefit. He had no other complaints and denied any family history of breast cancer. No history of radiation therapy to the chest or hormone therapy was elicited. After biopsy of the skin lesion in our hospital, a breast mass was found, followed by lumpectomy for pathologic examination. The results of a physical examination showed a well-developed and well-nourished man. There was a 2-cm, palpable subareolar mass in the left breast with inguinal lymph node and axillary lymph node swelling; no discharge or tenderness was evident on breast mass palpation. The skin and nipple overlying the breast mass were normal. The right breast was unremarkable. Examination revealed solitary, nonpitting edema of the left thigh and buttock with erythema. Laboratory tests showed normal plasma alpha-l-fucosidase (AFU) and alpha-fetoprotein (AFP) and a carcinoembryonic antigen (CEA) level of 145.9 microg/L. Ultrasonography showed normal resonance in the prostate, bladder, liver, spleen, pancreas, and kidney, but abnormal resonance beside the aorta. Computed tomography (CT) showed lymph node swelling in the mediastina. The skin biopsy from the erythema of the left thigh revealed metastatic carcinoma (atypical cells in the lymphatic vessel). Pathologic examination of the breast mass revealed intraductal carcinoma (Figs 2 and 3). The breast mass was positive for presenilin-2 (PS2), c-erbB-2, and cytokeratin (CK), but negative for estrogen receptor (ER) and progesterone receptor (PR). The cutaneous metastasis was positive for CK but negative for PR, ER, PS2, and c-erbB-2.     

Cutaneous alternariosis

A 77-year-old woman had had a slowly spreading lesion of five years' duration on her left cheek. The lesion consisted of sharply demarcated, dark-red plaques with infiltration. A biopsy specimen from the lesion showed mixed-cell granulomatous infiltration in the upper to middle dermis. Hyphae were observed in the granulomatous tissue. Alternaria tenuissima was isolated from a biopsy specimen. Antimycotic susceptibility test with amphotericin B, ketoconazole, and flucytosine revealed that the isolate was sensitive to the former two drugs. The lesion was treated with intralesional infiltration of amphotericin B.     

Post-Kala-Azar-dermal-leishmaniasis: an unusual presentation from Uttarachal (a non-endemic hilly region of India)

A 26-year-old male resident of Uttaranchal had a single large, erythematous, indurated verrucous plaque on chin of 1 year duration. He had suffered from visceral leishmaniasis 4-years back for which he was treated with injection sodium antimony gluconate (SAG) i.m. OD for 20 days. He had never been to regions endemic for kala-czar (KA) or post-kala-azar-dermal leishmaniasis (PKDL). Skin biopsy showed chronic granulomatous inflammation in the dermis. Giemsa stain revealed LD bodies inside the macrophages. The patient was treated successfully with injection SAG 20 mg/kg parenterally for 60 days. To the best of our knowledge, this is probably the first case of PKDL from the hills of Uttaranchal.