A case of cutaneous localized cryptococcosis

A 65-year-old Japanese male with cutaneous localized cryptococcosis, which was developed as an erythematous infiltrated plaque on the right side of the face, was reported. The biopsy specimen taken from the lesion showed a granulomatous change with many spores in the dermis. Culture of the biopsy specimen gave Cryptococcus neoformans serotype D. There were no cryptococcal infections in the other organs. The skin lesion was improved by a systemic administration of miconazole. This patient was unusual since the cryptococcal lesion was limited to the skin, nevertheless he was under a severe cellular immunity deficiency. The reason for this may be that the infected C. neoformans strain belonged to serotype D.     

Multiple Inflamed Nevi in a Child with Oculocutaneous Albinism: What Lessons can be Learned?

Abstract:   We report a 12-year-old girl with oculocutaneous albinism who developed nonitchy and nontender erythematous spots. A skin biopsy specimen of one of the spots confirmed that the lesion was an inflamed melanocytic nevus. We emphasize the atypical presentation of nevi in individuals with albinism.     

Is the cyclic AMP in psoriatic epidermis low?*

A deficiency of epidermal cyclic adenosine 3', 5'-monophosphate (cyclic AMP) has been implicated as the cause of the incomplete differentiation, increased mitosis and increased glycogen concentration which characterize the psoriatic lesion. This communication contains our data on the epidermal concentration of cyclic AMP in the lesional and 'normal' (non-involved) skin of patients with psoriasis. In these studies we have introduced the following improvement in methodology: (1) Local ischaemia in the biopsy specimens was prevented by not giving any injections prior to removal of the tissues and by freezing the tissues prior to removal. (2) The epidermis was microdissected from the dermis prior to cyclic AMP assay as as to give as pure an epidermal specimen as possible. Epidermal cyclic AMP was found to be 20-25% higher in the skin lesion than in the uninvolved skin when compared on a dry weight or protein basis but essentially when compared on the basis of DNA content. Our conclusion is that the cyclic AMP level in the psoriatic lesion is not lower than that in the 'normal' skin and thus these characteristics in psoriatic lesions cannot be related simply to a cyclic AMP deficiency.     

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.     

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.     

The Rash of Measles Is Caused by a Viral Infection in the Cells of the Skin: A Case Report

Measles skin rash was immunohistochemically examined in an effort to detect virus antigen in skin samples taken from a 15-year-old girl with measles. A sectioned specimen obtained by punch biopsy from a 2nd-day skin lesion showed localized parakeratosis and acanthosis with multinucleated giant cells in the epidermis, thickening and cellular edema of epithelia in the hair follicles, and vascular dilatation in the papillary plexus. Measles virus antigen was detected by ABC immunoperoxidase in the epidermis, follicular epithelia, and lympho-histiocytic cell infiltrates in the upper part of the dermis. This rash was deemed to be caused in part by direct viral infection of the epidermal cells.     

Dermatomyositis with Multiple Skin Ulcers Showing Vasculitis and Membrano-cystic Lesion

A 63-year-old woman with dermatomyositis (DM) developed multiple punched-out ulcers of the skin. She had not only a past history of gastric cancer 10 years prior to the onset of DM, but also a familial history of cancer. A skin biopsy from one of the ulcers revealed both vasculitis and membrano-cystic lesion in the same specimen. She died of interstitial pneumonitis one year after the onset of DM. Vasculitis and membrano-cystic lesion may be an important marker of a poor prognosis in DM.     

Margins in Skin Excision Biopsies: Principles and Guidelines

Skin biopsies are usually undertaken to confirm a clinical diagnosis, to remove a lesion, and to determine the adequacy of excised tissue margin. A surgical margin is technically defined as the “edge” of the tissue removed. The term is especially pertinent when the tissue excised is suspected of being involved by a malignant process. One of the most important predictive and prognostic factors of a malignant lesion is whether the margins of the resected specimen are involved by the tumor or not. The purpose of this review is to provide an insight into grossing of a skin biopsy specimen with emphasis on techniques and reporting of excision biopsy margins.     

Atrophic dermatofibroma and dermatofibrosarcoma protuberans

Dermatofibroma and dermatofibrosarcoma protuberans usually are seen as firm nodules in the skin. We have observed several patients, all female, with an atrophic or depressed lesion on the chest or back. When biopsy was done, the biopsy punch was often noted to sink into the lesion. In each case the biopsy specimen showed a cellular dermatofibroma or dermatofibrosarcoma protuberans. The correct diagnosis was rarely suspected clinically. This uncommon clinical presentation may be related to the marked cellularity of the fibrous tumors in this series.     

Preceding Annular Skin Lesions in a Patient with Hemophagocytic Lymphohistiocytosis

The cutaneous manifestations of hemophagocytic lymphohistiocytosis (HLH) are variable and nonspecific. A 42-year-old man presented with multiple annular, erythematous patches on the trunk for 3 months. Two months later, he presented with bullae along with high fever. The laboratory examination showed pancytopenia, hypertriglyceridemia, and hypofibrinogenemia. The bone marrow biopsy specimen showed an active hemophagocytosis. On the basis of these findings, a diagnosis of HLH was concluded. After five cycles of chemotherapy, his skin lesion completely resolved. Taking the results together, we suggest that annular skin lesion can be added to the list of cutaneous manifestations of HLH.     

Role of skin biopsy to confirm suspected acute graft-vs-host disease: results of decision analysis

OBJECTIVE: To estimate the value of skin biopsy in the evaluation of suspected acute cutaneous graft-vs-host disease (GVHD) after allogeneic stem cell transplantation. DESIGN: Decision analysis using parameters specified by expert opinion for skin biopsy characteristics, prevalence of acute GVHD, and value of potential outcomes. One-, 2-, and 3-way sensitivity analyses were performed. SETTING: Major stem cell transplantation centers in the United States. PATIENTS: Hypothetical cohort of patients with suspected acute cutaneous GVHD after stem cell transplantation. INTERVENTIONS: The following 3 interventions were compared: treat immediately for GVHD without performing a skin biopsy, perform a skin biopsy and treat immediately but stop treatment if skin biopsy specimen findings are inconsistent with GVHD, and perform a skin biopsy and await results of the skin biopsy specimen before treating. MAIN OUTCOME MEASURES: Number of patients appropriately and inappropriately treated with each intervention, consistency of physician-reported behavior, individualized decision analyses, and preferred intervention based on the aggregate estimates of respondents. RESULTS: The decision to treat immediately for GVHD without performing a skin biopsy yielded the best clinical outcome for the specified clinical setting and under the parameters specified by expert opinion. One-way sensitivity analyses showed that these conclusions are robust if the prevalence of acute cutaneous GVHD in stem cell recipients with rash is greater than 50%, if the sensitivity of skin biopsy specimen is less than 0.8, and the specificity of skin biopsy specimen is less than 0.9. Only 25% of physicians interviewed chose an intervention consistent with their estimates of prevalence, test characteristics, and outcome evaluations, indicating an opportunity to improve management of this important clinical condition. CONCLUSIONS: This decision analysis modeling technique predicts that in patient populations in which the prevalence of GVHD is 30% or greater (typical for allogeneic stem cell transplantation), the best outcomes were obtained with treatment for GVHD and no skin biopsy. In populations with prevalence of GVHD of 30% or less, obtaining a skin biopsy specimen to guide treatment was predicted to provide the best patient outcomes.     

Langerhans Cell Histiocytosis Masquerading as Lichen Aureus

We report a 13-year-old boy with localized Langerhans cell histiocytosis. The lesion was restricted to the skin of the mons pubis and clinically resembled lichen aureus. Histopathologic and electron microscopic examinations of a skin biopsy specimen of the lesion showed typical features of Langerhans cell histiocytosis. Extensive examination revealed no other organ involvement.     

Delayed cutaneous metastasis of gastric carcinoma

This paper describes a case of skin cancer resembling carcinoma en cuirasse associated with multiple bone lesions, which were both judged to be due to metastasis of poorly differentiated carcinoma of the stomach, the primary lesion excised ten years previously. Overt bone involvement had been observed for more than two years and a half. Histologic examination of a skin biopsy specimen showed that carcinoma cells had infiltrated into the middle and lower dermis, forming clusters and strands in an abundance of fibrous stromata. No primary lesion was detected in the remnant stomach at autopsy.     

PITYRIASIS ALBA: A HISTOLOGIC STUDY

Background. Pityriasis alba is a common dermatitis, but only a few histologic studies have been reported and most of these maintain that its microscopic features are those of a chronic nonspecific dermatitis. Methods. A retrospective light microscopic study was performed on biopsy specimens taken from 39 patients with localized pityriasis alba on face, arms and forearms without signs of atopy. Thirty-two patients were girls or women and seven were boys or men, with ages ranging from 7 to 37 years. The duration of illness varied from 1 month to 10 years. The clinical picture was characterized by three clinical stages: papular erythematous, papular hypochromic, and smooth hypochromic. Results. The histologic study revealed features that were suggestive, though not pathognomonic, of the diagnosis. The most remarkable changes involved the pilary apparatus, which showed horny plugs, spongiotic edema, and atrophic sebaceous glands. There was also a disturbance of melanization secondary to epithelial damage. The tissue reaction was more conspicuous in the skin lesions with follicular papules. Conclusions. A histopathologic diagnosis of pityriasis alba may be proposed when the following features are seen in a biopsy specimen taken from a skin lesion with follicular papules: (1) irregular pigmentation by melanin of the basal layer; (2) follicular plugging; (3) follicular spongiosis; and (4) atrophic sebaceous glands.     

A case of cutaneous metastases of gastric carcinoma showing peculiar clinical features.

A 52-year-old male patient presented with multiple cutaneous nodules on the face, trunk, and upper extremities. Examination of a skin biopsy specimen disclosed numerous signet ring cells throughout the dermis. Histopathologic examination of the stomach, along with gastroscopy, revealed that the cutaneous metastases were of gastric origin. The metastatic skin lesion on the shoulder and the back of the patient grew relatively rapidly, showing an erysipelas-like lesion followed by prominently large tumor masses. The clinical appearance seen in our case is thought to be rare. Radiotherapy and chemotherapy appeared to be effective in reducing some tumors and the swelling on the anterior of the neck, and in prolonging life.     

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.     

Leukemia cutis in acute lymphocytic leukemia masquerading as viral exanthem.

Leukemia cutis is a specific skin lesion caused by infiltration of leukemic cells into the skin. It is uncommon in acute lymphocytic leukemia (ALL). It typically manifests as red or violaceous papules, nodules, or plaques, mainly on the face. Leukemia cutis presenting with a generalized viral exanthem-like maculopapular eruption appears to be rare in the English literature. We report such a case. A 19 year-old man presented with a generalized purpuric maculopapular eruption of eight day's duration. Hematologic studies showed changes of acute lymphocytic leukemia, T-cell type. A skin biopsy specimen revealed a cuff-like, dense, perivascular infiltration of atypical lymphocytes in the upper and mid-dermis, consistent with leukemia cutis. The rash resolved in two weeks after chemotherapy. Our case illustrates that leukemia cutis should be considered in the differential diagnosis of a generalized morbilliform viral exanthem-like eruptions. Skin biopsy is important in establishing the diagnosis.     

Successful treatment of localized cutaneous infection caused by Mycobacterium scrofulaceum with clarithromycin

Cutaneous infection arising from Mycobacterium scrofulaceum, a nontuberculous mycobacteria, has rarely been reported, and most of the reported infections were disseminated forms in patients with AIDS or other immunocompromising illness. We describe an occurrence of localized mycobacterial skin infection caused by M. scrofulaceum in a previously healthy child that manifested as a red nodule on the cheek. A biopsy specimen of the lesion demonstrated granulomatous infiltration in the dermis. M. scrofulaceum was isolated from culture of a tissue specimen. Polymerase chain reaction amplified specific fragments for M. scrofulaceum. The patient was treated successfully with clarithromycin as monotherapy for 6 months, leading to complete healing without recurrence during a follow-up period of 2 years.     

Leukemia Cutis Presenting with Fingertip Hypertrophy

Background: Patients with leukemia often manifest cutaneous findings, which include nonspecific lesions and specific leukemic infiltrates termed leukemia cutis. Objective: A case of leukemia cutis involving distal finger pads is reported and literature describing hand involvement of specific leukemic infiltrates is reviewed. Methods and Results: An 80-year-old woman with a 10-year history of chronic lymphocytic leukemia developed painful symmetric tumors of her distal finger pads. Histopathological examination of the biopsy specimen revealed infiltration by neoplastic lymphocytes. Only a few cases of leukemia cutis involving the hands have been reported in the literature, none with this particular presentation. The clinical and histopathologic features of leukemia cutis are reviewed. Conclusion: This case emphasizes the importance of obtaining a biopsy specimen for histopathological examination of any suspicious skin lesion in a patient with leukemia.