bluuebunny/crossref_metadata_2025 huggingface dataset:
EB virus‐related angiocentric T‐cell lymphoma
Authors: Ken‐ichi Isoda  , Mizutani Hitoshi , Nishiguchi Takeshi , Shimizu Masayuki
Published: March 2003

A 61‐year‐old woman developed an asymptomatic tumor on her right cheek. She had a history of surgical removal of a similar tumor on her left arm 2 years earlier. The facial lesions were flesh‐colored, with 2×2 cm ulcers (Fig. 1). The left arm had ulcerative nodular lesions around the operation scar. Laboratory examinations revealed marked leukocytosis (19,510/μL) with lymphocytosis (54.6%). A few abnormal blastoid cells with large nuclei were detected by hemogram (Fig. 2). The red blood cell count, platelet count, coagulation tests, liver, and renal functions, including serum lysozyme, lipase, α1anti‐trypsin, and angiotensin‐converting enzyme activities, were normal, but a moderate elevation of thymidinekinase activity was observed. Anti‐nuclear human T‐cell leukemia virus type 1 (HTLV‐1), human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) antibodies were not detected. Mantoux reaction was negative and no DNA of tuberculosis was detected by polymerase chain reaction. Epstein–Barr virus (EBV) titers revealed EBV viral capsid antigen (VCA)‐immunoglobulin G (IgG): ×160; VCA‐IgM: undetectable level; early antigen (EA)‐IgG: ×10; and EBNA: ×80. The lymphocytes showed normal proliferation responses to lectins.

The tumor biopsy specimen revealed marked lymphocyte infiltration around vessels and focal necrosis in the deep dermis (Fig. 3a). The infiltrate was composed mainly of large blastoid lymphocytes with mitotic figures. Around the destroyed dermal vessels, tumor cells and denatured endothelial cells concentrated characteristically and formed glomeruloid lesions (Fig. 3b). Many auto‐phagocytes forming “bean bag cells” were electron microscopically detected in the tumor.

The proliferated cells in the dermis were CD3+, CD4+, CD7+, CD2+, CD5+, WT31+, and CD45RO+; however, CD1, CD8, TCRd1, CD16, CD56, CD57, CD19, CD20, CD10, L26, and LMP‐1 were negative. Bone marrow cells showed lymphocytosis (39%) mixed with abnormal lymphoid cells. Rearrangement of T cell receptor (TCR)‐β or TCR‐γ chain was not detected in the samples from dermal tumors and peripheral blood.

EBV‐encoded small nuclear RNA (EBER) was detected in the tumor cells from the forearm by in situ hybridization.

Thus, the patient was diagnosed as having EB virus‐related angiocentric lymphoma with leukemic change, and was treated with bi‐weekly cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) combination chemotherapy. The facial tumor responded to CHOP markedly, and the peripheral blood leukemic cell count declined after two cycles of CHOP. After the sixth cycle of CHOP, however, the patient developed acute interstitial pneumonitis, and died from an intracranial hemorrhage.

The autopsy specimens revealed thickening of the alveolar wall, septal fibrosis, and alveolar epithelial necrosis with focal lymphocyte infiltration. The bone marrow was hypocellular, but infiltrated with blastoid tumor cells.
Skin surgery in patients 90 years of age and over
Authors: Taniguchi Yoshiki , Shimizu Yoshiharu , Inachi Shin , Shimizu Masayuki
Published: March 2003

Background The number of aged people is increasing. It is conceivable that we will be treating considerably more aged patients with more surgical risk factors in the very near future.

Methods During the period between 1976 and 1996, 212 patients of 80 years of age and older underwent skin surgery at the Mie University Hospital, Japan. Among them, 25 patients of 90 years of age and over were studied.

Results Fourteen patients (56.0%) have undergone skin surgery in the past 5 years; 22 patients (88.0%) had skin tumors on the face and ears; squamous cell carcinoma was found in 17 patients (68.0%), while basal cell carcinoma was seen in four patients (16.0%). Despite their advanced ages, half of the patients had no medical contraindications to performing surgery.

Conclusions Careful preoperative management may allow more cutaneous surgery to be carried out in aged people.
Autologous epidermal grafting with PUVA‐irradiated donor skin for the treatment of vitiligo
Authors: Lee Ai‐Young , Jang Jeong‐Hoon
Published: March 2003

Background Epidermal autografting has been used to treat vitiligo. The pigmentation achieved at the recipient site can be variegated and incomplete compared with that of the surrounding normal skin, and sometimes remains that way for a fairly long time.

Objective We investigated whether the clinical results from epidermal autografting are related to a change in the number of melanocytes. This was performed by counting the number of melanocytes in the epidermis obtained from biopsy and suction with and without psoralen plus UVA (PUVA) exposure of the donor sites before grafting.

Methods The numbers of melanocytes in the epidermis were counted after staining with dopa. The epidermis from suction and biopsy was included. The biopsied specimen was treated with NaBr for dermo–epidermal separation before staining, whereas the epidermis obtained from suction was stained directly.

Results The epidermis obtained from suction contained 40–60% of the number of melanocytes found in the biopsied epidermis. Melanocytes around the hair follicles seemed to be omitted. Treatment with PUVA 10–21 times caused the number of melanocytes to increase by 1.5–2 times the normal level with a promising clinical result.

Conclusions The preparation of donor sites with PUVA before the treatment of vitiligo by epidermal autografting induced an increased number of melanocytes and improved the clinical result.
Outbreak of rat mite dermatitis in medical students
Authors: Chung Sang Lip , Hwang Sung Joo , Kwon Soon Baek , Kim Do Won , Jun Jae Bok , Cho Baik Kee
Published: March 2003

Background The tropical rat mite, Ornithonyssus bacoti (O. bacoti), is an ectoparasite on many rodents, but when the rodent is not available, humans may become the victim of the mite's bite. The bite induces a nonspecific dermatitis; therefore, it is not easy to diagnose rat mite dermatitis unless the parasites are found.

Materials and methods Ten cases of rat mite dermatitis were found in medical students who had studied in the same room of the library. Their nonspecific dermatitis consisted of small papules, and parasites were found in the skin or in the environment. The mites were collected and identified as O. bacoti, female. Histopathologic studies showed moderate perivascular lymphohistiocytic infiltrations intermingled with some eosinophils. The presence of rodents in or around the room was confirmed by the students, but there had been no preceding rodent eradication. Although the rats were not captured in the library, insecticides were sprayed, and no further problem with either mites or dermatitis developed during the follow‐up period.

Conclusions Rat mite dermatitis can occur in clusters that involve a common source of exposure to the rat mite epidemiologically. Prompt identification of rat mites and the eradication of mites and rodents from the environment can prevent further spreading of the disease.
Scrofuloderma
Authors: Özkan SÛebnem , Gürler Nalan , Fetil Emel , E Atabey Neş. , Günes Ali Tahsin
Published: March 2003

A 60‐year‐old woman presented to the Dermatology Department of Dokuz Eylül University Faculty of Medicine with complaints of hardened reddenings and inflammatory drainage on her right armpit, groin, and hips. These lesions appeared 2 months after a cholecystectomy operation, which had been performed 4 years ago, and showed unilateral progression. The patient had been treated unnecessarily with prednisolone (5 mg every other day) for 7 years because of arthralgia.

Dermatologic examination revealed erythematous induration, fistulas with central serous or purulent drainage, and conical‐shaped scars on the regio axillaris dextra, regio abdominalis lateralis dextra, and regio lumbalis dextra. A linear operative scar with observable fistula located distally on the regio abdominalis lateralis dextra and another scar in a lateral position were observed. There were also abscesses, fistulas, and scars on the regio inguinalis and regio glutealis dextra (Fig. 1). Systemic examination was normal.

Clinical picture before treatment

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A tuberculin test showed erythema (9 cm) and induration in 72 h. Bacterial, mycotic, and tuberculous cultures of the vacuum and smear samples from the lesions and urine showed no reproduction.

A histopathologic examination of the biopsy material revealed nonspecific slight acanthosis, perivascular mononuclear cellular infiltration in the superficial dermis, and a dense mononuclear cellular infiltration in the subcutis.

The deoxyribonucleic acid obtained from the pus liquid by the phenol–chloroform method for the detection of mycobacterium tuberculosis with polymerase chain reaction was amplified using primers specific to microorganisms in the mycobacterium tuberculosis complex and also specific to the IS 6110 region. At the end of the molecular analysis, a product of amplification of 123 bp specific to mycobacterium tuberculosis was found.

The erythrocyte sedimentation rate was 92 mm/h. All other laboratory values were normal, including biochemical analysis, anti‐human immunodeficiency virus, venereal disease research laboratory test, and rheumatoid factor. X‐Ray and high‐resolution computerized tomography examination of the chest, rectosigmoidoscopy, esophagus, stomach, duodenum, and small intestine passage X‐ray examinations, and vaginal smear inspections, performed to investigate other organ tuberculosis, did not show any pathologic finding. The arthralgic complaints of the patient were assessed as degenerative arthrosis by considering the bone–joint X‐ray examinations.

Isoniazid 300 mg/day and rifampicin 600 mg/day were given to the patient and, since the sixth week of administration, no drainage from fistulas was observed. At the end of 9 months of treatment, the lesions improved, with scar formation, and no new lesions were observed (Fig. 2). The improvement has continued in the 4 months following the completion of therapy.

Clinical picture after treatment

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Atypical cutaneous lymphoproliferative disorder in patients with HIV infection
Authors: Friedler Suzanne , Parisi Mary T.. , Waldo Elaine , Wieczorek Rosemary , Sidhu Gurdip , Rico M. Joyce
Published: March 2003

Background An inflammatory pruritic eruption which is characterized histologically by CD8+, atypical lymphocytes has been described in human immunodeficiency virus (HIV)‐infected patients. This disorder has been described as “pseudo‐Sezary” or a “cutaneous T cell lymphoma (CTCL)‐simulant”, however, as these patients do not resemble CTCL clinically, and the relationship between this entity and CTCL is unclear, a more descriptive term is “atypical cutaneous lymphoproliferative disorder” (ACLD). The purpose of this study is to categorize the clinical, histologic, and immunophenotypic features of 16 HIV‐infected patients with this skin disorder seen at the New York Department of Veterans Affairs Medical Center.

Methods A retrospective chart review was conducted on 16 HIV‐infected patients with a histologic diagnosis of an atypical cutaneous lymphoproliferative infiltrate on skin biopsy. Skin biopsies were reviewed, and histologic features noted. Immunophenotyping was performed on 14 out of 16 samples; electron microscopy was performed on samples from five patients. Clinical manifestations, disease course, medication history, and response to treatment were noted.

Results The patients presented with a pruritic, persistent, generalized, papular eruption. Pigment changes, including hyperpigmentation and hypopigmentation were common. Histologically, lesional biopsies were characterized by a superficial and deep polymorphous infiltrate with atypical lymphocytes which were CD8+ predominant, Ki‐1 negative, and occasionally CD7 antigen depleted. Sezary‐like cells were present in the infiltrate in four out of five patients by electron microscopy. None of the patients has systemic manifestations of lymphoma; however, one of the 16 patients eventually developed frank CTCL.

Conclusions HIV‐infected patients can present with a pruritic, widespread disorder, often with pigment changes characterized by an atypical cutaneous lymphocytic infiltrate. This clinicopathologic disorder is a rare, reactive inflammatory condition which generally occurs in late stage HIV infection and rarely progresses to frank lymphoma.
Detection of Mycobacterium tuberculosis DNA using polymerase chain reaction in cutaneous tuberculosis and tuberculids
Authors: Tan Suat Hoon , Med Int , DipR . , Tan Boon Huan , PhD . , Goh Chee Leok , Med Int , Tan Kong Chong , Mcrp . , Tan Meng Fong , Ng Wee Chit , PhD . , Tan Wan Cheng
Published: March 2003

Background The objective of this study was to explore the role of the polymerase chain reaction (PCR) for the detection of Mycobacterium tuberculosis DNA as a diagnostic aid in cutaneous tuberculosis, using routinely processed skin biopsy specimens.

Methods and results A wide range of clinical specimens representing different forms of cutaneous tuberculosis and so‐called tuberculids were studied. A sensitive and specific PCR assay targeting the sequence IS6110 of Mycobacterium tuberculosis complex was used. The specimens were categorized as follows.

1 Acid‐fast bacilli (AFB) positive on biopsy (nine specimens from seven patients who were immunocompromised).

PCR was positive in five specimens. Of these, one specimen was culture positive and three specimens were culture negative.

2 AFB negative on biopsy:

(a) tuberculosis verrucosa cutis (23 specimens);

(b) lupus vulgaris (three specimens);

(c) cutaneous tuberculosis clinically suspected (six specimens).

PCR was negative in all specimens.

3“Tuberculids.”

(a) erythema induratum/nodular vasculitis (20 specimens);

(b) papulonecrotic tuberculid (two specimens);

(c) erythema nodosum (20 specimens).

PCR was negative in all specimens.

Conclusions The role of PCR in clinical dermatologic practice, at this stage, may be in differentiating between cutaneous tuberculosis and atypical mycobacterial infections in the context of an immunocompromised patient where AFB can be demonstrated on biopsy and cultures may be negative. In this clinical situation, PCR allows the prompt diagnosis and early institution of appropriate therapy. We have not found PCR to be a useful complement to the clinical and histologic diagnosis of “paucibacillary” forms of cutaneous tuberculosis.
Relevance of complement fixing antinuclear antibodies
Authors: Fang Yisheng V.. , PhD . , Cyran Stanley J.. , Albini Boris , Rostami Rezvan , Ms . , Binder Walter L.. , PhD . , Beutner Ernst H.. , PhD .
Published: March 2003

Background Connective tissue diseases (CTDs) are a heterogeneous group of disorders defined by the association of a variety of clinical manifestations with immunologic and other laboratory findings. Overlap of syndromes and aberrant findings appear rather frequently.

Methods Sera of eight antinuclear antibody (ANA) negative, cases of subacute cutaneous lupus erythematosus (SCLE) with antibodies to Ro (SS‐A) and a ninth case with clinical and laboratory signs of Sjögren’s syndrome and systemic lupus erythematosus (SLE) were tested for complement (C′) fixing antinuclear antibodies (C‐ANAs). The ninth case was examined in depth by direct immunofluorescence (DIF) and a two‐step “C + DIF” test of biopsies for C′ fixation to in vivo bound ANAs, as well as serum tests for C‐ANA, ANA, and SCLE markers.

Results Sera of five of the eight ANA negative, Ro(SS‐A) positive SCLE cases had C‐ANAs. The ninth case, a 50‐year‐old woman with clinical and laboratory signs of Sjögren’s syndrome and SLE, gave a strong positive C + DIF reaction in the skin biopsy for in vivo bound ANAs that fix C′, but negative ANAs and C‐ANAs in routine serum tests; they revealed antimitochondrial antibodies. Serum tests on normal skin, however, revealed weak ANA and strong C‐ANA reactions with in vitro fixed C′.

Conclusions ANA negative cases of SCLE or Sjögren’s syndrome may have C‐ANAs. A case with Sjögren’s syndrome and signs of SLE had both in vivo and in vitro C′ fixing ANAs. C‐ANA tests can aid in the identification of such cases.
Human gnathostomiasis (nodular migratory eosonophilic panniculitis)
Authors: Ruiz‐Maldonado Ramón , Mosqueda‐Cabrera Miguel A.
Published: March 2003

A 42‐year‐old woman was first seen in January 1996 with a 7‐cm diameter erythematous–edematous, pruritic plaque on her right shoulder. The lesion had first appeared 3 weeks previously on the right side of the thorax and migrated to the shoulder. The patient had eaten raw fish (sashimi) in Japanese restaurants two or three times a year during the past few years.

The presence of a migrating, pruritic, erythematous, and edematous plaque was clinically suggestive of nodular migratory eosinophilic panniculitis, also known as deep larva migrans or gnathostomiasis. The suspicion was further strengthened by the presence of 12% eosonophilia in the blood cell count.

The patient was given albendazole, 400 mg/day for 7 days. Seven days after treatment, the lesion disappeared. Three months later the patient returned with a new lesion that had evolved over 1 month, similar to the previous one, but on the left side of the thorax. This time there was no history of the ingestion of raw fish, and therefore a relapse of gnathostomiasis was suspected. The patient was given 200 μg of ivermectin orally for two consecutive days. Again, 1 week after treatment the lesion disappeared, only to relapse 2 months later. This time the lesion evolved over 12 h. When the patient was seen, a 2‐cm diameter excoriated, urticaria‐like, pruritic nodule was present in the left scapular area (Fig. 1A). In an attempt to remove the parasite, a deep, 8‐mm punch biopsy was performed in the center of the lesion. A sagittal cut of the complete parasite was present in one of the histopathologic slides (Fig. 1B). Based on the epidemiologic and morphologic characteristics, the parasite was classified as Gnathostoma spingerum. After removal of the parasite, the patient has remained free of symptoms for over 2 years.

(A) Excoriated, pruritic, urticaria‐like nodule in the scapular area. (B) Sagittal cut of Gnathostoma spingerum in a skin biopsy surrounded by a heavy inflammatory cell infiltrate: (a) head bulb; (b) intestine (hematoxylin and eosin, 10×)

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The profile of atopic dermatitis in a tertiary dermatology outpatient clinic in Singapore
Authors: Tay Yong‐Kwang , Khoo Boo‐Peng , Goh Chee‐Leok
Published: March 2003

Background Atopic dermatitis is a common, chronic, relapsing, pruritic, eczematous skin condition occurring in patients with a personal or family history of atopy. The aim of this study is to describe the profile of atopic dermatitis seen at a tertiary referral skin center in a tropical multiracial country.

Methods A retrospective chart review was conducted of all the patients with atopic dermatitis seen during the first six months of 1994.

Results There were 492 patients, age range from 1 month to 74 years, with an equal sex ratio. The prevalence was 2%. The onset of the disease occurred before the age of 10 years in 61.2% of patients. In 13.6% of patients, the onset was after the age of 21 years. Two hundred and fifty four patients (52%) had “pure” atopic dermatitis without concomitant respiratory allergies; 238 patients (48%) suffered from a “mixed” type, with 23% having allergic rhinitis, 12% having asthma, and 13% having both asthma and allergic rhinitis; 231 patients (47%) had at least one first‐degree family member with atopy: atopic dermatitis (17%), asthma (15%), and allergic rhinitis (15%). Most of the patients, 416 (84.5%), had subacute dermatitis at presentation. Ichthyosis vulgaris was present in 38 patients (8%) and pityriasis alba in 13 patients (3%). The most common infective complication was bacterial infection (impetiginized dermatitis, folliculitis, cellulitis) present in 95 patients (19%), followed by viral infections (dermatitis herpeticum, viral warts, and molluscum contagiosum) in 17 patients (3%). Allergies were noted in 43 patients (9%). The most common was drug allergy (penicillin and cotrimoxazole) in 28 patients, followed by food allergy in 11 patients. Common aggravating factors reported included heat, sweating, stress, thick clothing, and grass intolerance. Most patients could be controlled with a fairly simple regimen of moisturizers, topical steroids, and antibiotics for acute flares. Short courses of systemic steroids were used in 78 patients (16%). Three patients were treated with phototherapy: two on combined UVA and UVB (UVAB) and one on oral psoralen photochemotherapy (PUVA).

Conclusions The pattern of atopic dermatitis in Singapore is similar to that reported in the Western literature, except for a lower prevalence and a significant proportion of adult‐onset atopic dermatitis.
Peeling skin syndrome
Authors: Taştan Halis B. , Akar Ahmet , Gür Ali Rıza , Deveci Salih
Published: March 2003

A 26‐year‐old white man presented with migratory peeling patches that had been present since birth. He stated that his condition was continuous and asymptomatic. There was no marked seasonal variation. Parental consanguinity was present.

His parents were first cousins, but were unaffected by peeling skin syndrome. He had four brothers and two sisters. The only affected brother, an 18‐year‐old man, had an identical history and clinical findings.

Physical examination showed widespread discrete peeling skin patches of variable size and shape with underlying erythema ( Fig. 1). The palms and soles were also involved. Peeling of the skin was produced easily by rubbing or stroking of the skin. Sheets of superficial epidermis could easily be peeled without bleeding or pain. The oral mucous

Peeling skin patches on left arm

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membrane, teeth, hair, and nails showed no abnormalities. He was in good general health.

A complete blood count, urinalysis, and routine blood chemistry were within normal limits. Serum iron and copper levels were also normal. Plasma and urinary amino acids analyzed by paper chromatography did not show deviations. There was no eosinophilia.

A skin biopsy specimen showed slight hyperkeratosis and thinning of the granular cell layer. Parakeratosis, acanthosis, and spongiosis were absent. The stratum corneum was separated from the underlying stratum granulosum. Hyperpigmentation was observed at the basal cell layer. A perivascular lymphocytic infiltrate and a few eosinophils were found in the upper dermis ( Fig. 2). Direct immunofluorescence studies did not reveal any immunoglobulin or complement deposition.

Superficial perivascular lymphocytic infiltrate, and separation of the stratum corneum from the underlying stratum granulosum (hematoxylin and eosin, ×100)

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Lobomycosis in three Venezuelan patients
Authors: Brun Ana M.
Published: March 2003

Case 1. A 52‐year‐old Brazilian man consulted us for a growth on his forehead (Fig. 1). He came from the Amazon region, had been a gold miner for many years, and had noticed a papule on his forehead that had grown slowly for 3 years. On inspection, a 3‐cm, smooth, shiny, elastic nodule was found, the same color as the skin. The clinical diagnosis was lobomycosis; a small sample was taken with a scalpel blade, placed in KOH 20%, and numerous round cells in small chains were seen. Biopsy confirmed the diagnosis. He was treated with surgical excision and was lost to follow‐up.

Case 1: growth on the forehead

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Case 2. An 83‐year‐old Venezuelan man was brought to us by his daughter for an ulcerated verrucous plaque, measuring 6 cm by 4 cm, on his right sole (Fig. 2). The lesion was firm, had started at the age of 63 years as a papule, and later became a plaque which had ulcerated recently. He had been a gold and diamond miner for most of his life, in the southeastern Venezuelan state of Bolívar. The clinical diagnosis was epithelioma cuniculatum. The histology showed pseudoepitheliomatous hyperplasia, numerous cells in giant cells, and histiocytes; Grocott stain showed chains of uniform round to oval cells (Fig. 3 and 4). Over the years, he was treated with ketoconazole and itraconazole to no avail; new nodules appeared on the dorsum of the foot and on his leg (Fig. 5). He is now 98 years old, and fit except for lobomycosis. He has no lymphadenopathy and no neoplastic degeneration of his lesions.

Case 2: ulcerated verrucous plaque on the sole

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Case 2: histology (hematoxylin and eosin)

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Case 2: nodules on the foot

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Case 3. A 64‐year‐old man from the gold mining region of El Callao, in Bolívar state, was hospitalized for severe heart failure; a mass of nodules was noticed on his right arm (Fig. 6) and we were asked for a consultation. He had worked for many years in the underground gold mines and the lesions had been present for more than 25 years. On inspection, a mass of smooth, shiny, firm, pedunculated, and sessile nodules was seen on the posterior lateral aspect of his right arm; some were hypopigmented, others hyperpigmented. The impression was of a bunch of plums, measuring 6 cm by 12 cm. The clinical diagnosis was plexiform neurofibromas vs angiofibromas. The biopsy showed atrophic epidermis, numerous round cells in giant cells, and no lymphocytic infiltrate; Grocott stain showed single budding with chain formation. The patient was treated with partial surgical excision, but was lost to follow‐up.

Case 3: mass of nodules on right arm

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Discussion
An epidemic outbreak of Malassezia folliculitis in three adult patients in an intensive care unit: a previously unrecognized nosocomial infection
Authors: Archer‐Dubon Carla , Icaza‐Chivez Maria Eugenia , Orozco‐Topete Rocio , Reyes Edgardo , Baez‐Martinez Rosa , De León Samuel Ponce
Published: March 2003

Background
Malassezia is a lipophilic fungus commonly found in normal human skin. Infection of the hair follicle by Malassezia furfur occurs in patients with predisposing factors such as diabetes or immunosuppression, or who are undergoing antibiotic treatment. Malassezia furfur folliculitis is an infrequent nosocomial infection which may be associated with fomite transmission.

Methods We reviewed the clinical files of three adult patients from an intensive care unit (ICU) who simultaneously developed folliculitis through Malassezia infection. We specifically analysed predisposing factors, possible transmission modes, characteristics of skin lesions, results of biopsies and cultures, treatment, and patient outcome.

Results The three male patients were in neighboring beds and they all had factors that predisposed them to underlying immunosupression. Simultaneously, and within hours of each other, they developed erythematous follicular papules and pustules on the face and chest. The skin biopsies revealed an acute folliculitis with abundant round to oval yeasts of up to 5 μm in diameter. Stains for fungi (Schiff’s peryodic acid, Grocott and silver methenamine) revealed numerous unipolar budding yeasts without hyphae, consistent with M. furfur. Conventional cultures were negative. The diagnosis of folliculitis by M. furfur was established and antifinigal treatment initiated, with adequate outcome of the dermatosis. After this outbreak, the aseptic and hygienic measures of the health care personnel of the ICU were reviewed and corrected.

Conclusions The simultaneous emergence of this superficial infection by M. furfur suggests fomite participation. This dermatomycosis is an infrequent nosocomial infection in adults, which to our knowledge has not been previously reported.
The microbiology of infected and noninfected leg ulcers
Authors: Bowler Philip G. , Davies Barry J.
Published: March 2003

Background A clinical study was undertaken to investigate and compare specifically the aerobic and anaerobic microbiology of infected and noninfected leg ulcers.

Methods Leg ulcers, defined as being infected on the basis of clinical signs, were swab sampled and investigated for aerobic and anaerobic microorganisms using stringent isolation and identification techniques.

Results Two hundred and twenty isolates were cultured from 44 infected leg ulcers, in comparison with 110 isolates from 30 noninfected leg ulcers. Statistical analysis indicated a significantly greater mean number of anaerobic bacteria per infected ulcer (particularly Peptostreptococcus spp. and Prevotella spp.) in comparison with the noninfected ulcer group (2.5 vs. 1.3, respectively) (P < 0.05). Also, anaerobes represented 49% of the total microbial composition in infected leg ulcers compared with 36% in noninfected leg ulcers. The mean numbers of aerobes per wound in the two ulcer groups were not statistically different (P > 0.05). The study failed to demonstrate a clear correlation between commonly implicated facultative pathogens and wound infection. The isolation rate of Pseudomonas aeruginosa was generally low and, although Staphylococcus aureus was a frequent isolate in both wound types, it was more prevalent in noninfected leg ulcers.

Conclusions This study has demonstrated the complex aerobic–anaerobic microflora which exists in leg ulcers, the prevalence of anaerobes in infected wounds, and a poor correlation between the presence of specific aerobic pathogens and wound infection. In view of these findings, the role of microbial synergistic interactions in the pathogenesis of chronic wound infection may be of greater clinical importance than the isolated involvement of any specific potential pathogen.
Pemphigus vegetans in association with human immunodeficiency virus
Authors: Lateef Aslam , Packles Michelle R. , White Soren M. , Don Philip C. , Weinberg Jeffrey M.
Published: March 2003

A 23‐year‐old black man presented with a 2‐year history of blistering eruptions involving the skin and mucous membranes. Risk factors for human immunodeficiency virus (HIV) infection included sexual encounters with prostitutes. He had no additional past medical history and denied any family history of autoimmune blistering disorders. Over the last 2 years the patient had undergone multiple admissions at various medical centers with a diagnosis of pemphigus vegetans (PV). He was treated with a variety of topical and systemic medications, including steroids and antimicrobials, but he always relapsed within a few months. The patient presented to the Metropolitan Hospital Center with malaise, blisters, and vegetative lesions of several days’ duration.

On physical examination, erosions, pustules, nodules, and verrucous, vegetating papules were noted in the axillae, groin ( Fig. 1), scrotal, and anal areas. There were erosions and crusts on the lower lips. The tongue showed mild desquamation and had a cerebriform appearance
(
Fig. 2). Paronychial crust and scale were noted on the hands and feet and an intact vesicle was noted on one finger. Inguinal, submandibular, cervical, and axillary lymphadenopathy was present. Hyperpigmented macules and patches were noted on the trunk and extremities.

Erosions, crust, and verrucous papules in the groin

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Cerebriform appearance of the tongue in association with crusts and erosions on the lips

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A biopsy specimen of a verrucous papule from the left axilla showed marked spongiosis, intraepidermal acantholysis, and numerous eosinophils within the acantholytic vesicle ( Fig. 3). In addition, there was a marked superficial dermal infiltrate with eosinophils, plasma cells, and lymphocytes. A biopsy specimen of a pustule in the left axilla showed marked spongiosis, intraepidermal vesicle formation, superficial dermal edema, perivascular infiltration with lymphocytes and plasma cells, and exocytosis of neutrophils and eosinophils in the dermis and epidermis.

Histopathology of vegetating lesion showing acantholysis and a dense eosinophilic infiltrate (hematoxylin and eosin, ×100)

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Direct immunofluorescence showed immunoglobulin G (IgG) and weak C3 on the intercellular junctions in the epidermis. Indirect immunofluorescence showed a high titer (>1 : 1280) of circulating antibodies with an intercellular pattern. Viral culture from the mouth and skin was negative for herpes simplex virus. Bacterial culture from the skin of the groin was positive for Proteus mirabilis. Blood cultures were negative. Laboratory tests on admission showed a normocytic anemia, and the CD4 count was 372 cells/mm3 (normal, 537–1571 cells/mm3 ). The urine on admission was positive for opiates and cocaine. The results of HIV‐1 testing by enzyme‐linked immunoabsorbent assay and immunoblotting were positive.
Erythroderma: a comparison between HIV positive and negative patients
Authors: Morar Nilesh , Dlova Ncoza , Gupta Aditya K. , Naidoo Dayalan K. , Aboobaker Jamila , Ramdial Pratistadevi K.
Published: March 2003

Background Erythroderma has protean underlying causes. There have been isolated case reports suggesting an association between erythroderma and the human immunodeficiency virus (HIV).

Objective To describe and characterize further the prevalence, etiology, and metabolic sequelae of erythroderma in HIV positive and negative patients. In a subset of patients, clinicopathologic correlation was performed.

Method One hundred and thirty‐eight consecutive patients were prospectively recruited over a one and a half year period at the skin clinic of King Edward VIII Hospital. Demographic, clinical, biochemical, and histologic data were recorded.

Results Seventy‐five per cent of the patients were black, 22.5% Indian, and 2.5% white. The men to women ratio was 1.9 : 1. The mean age was 34.7 years (range, 1 month to 85 years). Forty‐three per cent of patients were HIV positive, of whom 90% were black. The commonest causes of erythroderma in the total sample were atopic dermatitis (23.9%), psoriasis (23.9%), and drug reactions (22.5%). The commonest cause in the HIV positive group was drug reactions (40.6%), the commonest being ethambutol (30.8%). HIV positive patients had a significantly lower (P <  0.05) white cell count (7.6 vs. 10.5 ×  109/L), hemoglobin (11.1 vs. 12.6 g/dL), platelets (278.3 vs. 378.0 ×  109/L), and albumin (25.4 vs. 28.7 g/L) and significantly higher serum urates (0.6 vs. 0.4 m
m/L) than HIV negative patients. HIV positive patients did not have a significant increase in the number of episodes of erythroderma. Clinicopathologic correlation was greatest with psoriasis in the HIV negative group and with psoriasis and drug reactions in the HIV positive group.

Conclusions A large proportion of erythrodermic patients in this study were HIV positive. Inflammatory dermatoses were the commonest cause of erythroderma in all the patients studied. Drug reactions were the commonest cause in HIV positive patients. In the young black patient, erythroderma may be a marker for HIV infection.
Cytokines in the pruritic papular eruption of HIV
Authors: Aires Juliana Machado , Rosatelli Jacy Berti , De Castro Figueiredo José Fernando , Roselino Ana Maria F.
Published: March 2003

Abstract

Background  The immunopathogenic mechanism of the pruritic papular eruption (PPE) of patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) is poorly understood, and the objective of the present study was to determine the concentration of the serum cytokines interleukin‐2 (IL‐2), IL‐4, IL‐5, IL‐10, IL‐12, and γ‐interferon (γ‐IFN) in an attempt to recognize the pattern of CD4+/CD8+ lymphocytes occurring in this dermatosis.

Materials and methods  The study was conducted on 11 HIV‐positive PPE patients, matched for sex and age with eight HIV‐infected patients with no dermatosis and 10 healthy HIV‐negative individuals. Cytokines were quantified by enzyme‐linked immunoabsorbent assay (ELISA) using monoclonal antibodies (R & D Systems) and the data were analyzed by the Mann–Whitney, Kruskall–Wallis, and Spearman correlation tests.

Results  An increased concentration of IL‐2 was observed in both the HIV‐positive (77.65 pg/mL, P < 0.001) and PPE (20.42 pg/mL, P < 0.05) groups when compared with the HIV‐negative group (9.50 pg/mL). The IL‐2 concentration was significantly higher (P < 0.05) in the HIV‐positive group than in the PPE group. Similarly, the γ‐IFN concentration was higher in the HIV‐positive (14.97 pg/mL) and PPE (12.67 pg/mL) groups when compared with the HIV‐negative group (8.58 pg/mL). The IL‐12 concentration was similar in the PPE and HIV‐positive groups (1.82 and 1.68 pg/mL, respectively), but higher than in the HIV‐negative group (1.17 pg/mL). The same occurred with IL‐5 (17.78, 17.79, and 15.74 pg/mL, respectively). There was no significant difference in IL‐4 concentration among the PPE, HIV‐positive, and HIV‐negative groups (10.95, 7.88, and 10.16 pg/mL, respectively), and the same was observed for IL‐10 (22.41, 21.13, and 20.92, respectively). There was a negative correlation between serum γ‐IFN concentration and peripheral CD4+ lymphocyte number (r = − 0.6256) in the PPE group (P < 0.05).

Conclusions  The lower levels of IL‐2 and γ‐IFN and the negative correlation between γ‐IFN and peripheral CD4+ lymphocytes may indicate an early phase of immunosuppression in PPE.
Management of endemic outbreaks of scabies with allethrin, permethrin, and ivermectin
Authors: Paasch Uwe ,   md, Haustein Uwe‐Frithjof ,   md
Published: March 2003

Background At three residences for the elderly, recurrent scabies infestations became out

of control. Due to the failure of repeated, nonsynchronized therapeutic efforts with

conventional external anti‐scabies treatments, an eradication program had to be developed. We describe a protocol for the management of outbreaks of scabies.

Methods According to the clinical examination and microscopically identified mites, all individuals of the population (IOP: patients, staff, and family members) were divided into two groups: (a) healthy and infested IOP; and (b) cases with crusted scabies. The first group was treated simultaneously once with external scabicides (allethrin or permethrin). All others were hospitalized and treated either with systemic ivermectin or with the latter in combination with permethrin.

Results In 252 IOP living in three residences for the elderly, clinical signs of scabies were reported in 91.5%, 78.5%, and 15.4% of the patients (age 55–97 years; mean, 80.5 years), 54.1%, 32.9%, and 16.6% of staff members, and in 7%, 3%, and 0% of family members. The infested IOP showed crusted scabies (index cases) in 5.3%, 5.0%, and 1.7%, common scabies in 43.1%, 36.7%, and 7.1%, and postscabiotic dermatitis in 10.3%, 7.6%, and 3.5%. In 99.2% of the synchronously treated IOP in group (a) (n = 240), the conventional treatment with permethrin cream 5% or allethrin spray was effective. Group (b) (n = 12) received ivermectin (12 mg) once (n = 5) or twice (n = 7) after an interval of 8 days. One index case received permethrin three times.

Conclusions Outbreaks of scabies in populations of elderly people require special management for disease control. Synchronous treatment with external permethrin cream 5% or allethrin spray, including all IOP once, and close control offers a time‐saving, cheap, and reliable method. Crusted scabies should be treated by oral administration of ivermectin once or twice after an interval of 8 days. Additional applications of permethrin and mechanical clearing of hyperkeratotic subungual areas shorten the course.
Overexpression of transforming growth factor‐β3 immunohistochemical staining in extramammary Paget's disease, but downregulated expression in Bowen's disease
Authors: Kawakami Tamihiro , Soma Yoshinao , Mizoguchi Masaho , Saito Ryuzo
Published: March 2003

Abstract

Background  The role of transforming growth factor‐β (TGF‐β) in carcinogenesis is complex, with some reports indicating a tumor inhibition role and others indicating a tumor promotion role. In particular, TGF‐β3 is thought to play a key role in controlling epithelial homeostasis. Immunopositive p53 has been demonstrated in a variety of human malignant tumors and its role in oncogenesis and tumor progression is thought to be important. Extramammary Paget's disease (EPD) and Bowen's disease are skin cancers of unknown histogenesis.

Objective  To clarify the role of TGF‐β3 and p53 in EPD and Bowen's disease and to better understand the origin of these disorders.

Methods  Specimens were obtained from 12 patients with EPD and 12 patients with Bowen's disease seen at our clinic between 1993 and 2000. TGF‐β3 and p53 immunohistochemical staining was performed.

Results  In three of the 12 EPD patients and five of the 12 Bowen's disease patients, positive p53 staining was detected. In contrast, TGF‐β3 overexpression was detected in all EPD patients, whereas downregulated TGF‐β3 expression was detected in all Bowen's disease patients.

Conclusions  The present data suggest different roles for TGF‐β3 in abnormal epidermal cells in EPD and Bowen's disease. Thus, TGF‐β3 expression may be modulated differently via a p53‐dependent or ‐independent pathway in the pathogenesis of EPD and Bowen's disease. Moreover, high TGF‐β expression appears to be a useful indicator of tumor activity in EPD.
Dermatomyositis and mucinosis
Authors: Del Pozo Jesús , Almagro Manuel , Martínez Walter , Yebra‐Pimentel Mariá Teresa , García‐Silva Jesús , Peña‐Penabad Carmen , Fonseca Edwardo
Published: March 2003

Abstract

Background  Mucin deposition is a common feature in autoimmune collagen diseases including dermatomyositis. Nevertheless, clinical manifestations of mucinosis are uncommon in patients with dermatomyositis. Two cases of mucinosis associated with dermatomyositis are reported.

Patients  A 53‐year‐old woman presented with symmetrical plaques on the upper limbs formed by the coalescence of small, violaceous papules. In addition, she showed the typical cutaneous and muscle features of dermatomyositis. A 44‐year‐old woman with dermatomyositis of 5 years' evolution developed linear, flesh‐colored papules across the flexural creases of her palms and fingers.

Results  Skin biopsy of the upper limb lesions in the first patient showed epidermal changes compatible with dermatomyositis and dermal mucin deposition. Histopathologic examination of the palmar lesions of the second patient showed less intense epidermal changes of dermatomyositis and dermal mucin deposition.

Conclusions  Mucin deposition in patients with dermatomyositis may have an unusual clinical presentation, and it should be considered in the differential diagnosis of atypical cutaneous lesions in these patients.
Association of juvenile xanthogranuloma with café‐au‐lait macules
Authors: Thami Gurvinder P. , Kaur Sukhjot , Kanwar Amrinder J.
Published: March 2003

A 2‐year‐old boy was referred to the dermatology services for the evaluation of yellowish‐brown raised lesions over the face of 3 months' duration. In addition, he had multiple asymptomatic hyperpigmented spots over the trunk, which his parents had noticed at the time of birth. His physical and mental milestones of development were normal. Apart from the cutaneous lesions, the child was otherwise well and there was no history of seizures. He was the only child born to nonconsanguineous parents. No family history of similar lesions was available.

The boy weighed 14 kg, had a height of 88 cm, and a head circumference of 48 cm. General physical and systemic examination was normal. Cutaneous examination revealed multiple, yellowish‐brown papules over the forehead, sides of the face, and shoulders. The papules measured 0.5–0.8 cm in diameter, were discrete, well defined, oval and flat topped without any surface changes (Fig. 1). Multiple café‐au‐lait macules varying from 0.5 to 3.0 cm in diameter were present over the trunk (Fig. 2). There was no freckling in the axillary or the inguinal regions and no neurofibromas were present. A diagnosis of juvenile xanthogranuloma was considered.

Papular lesions of juvenile xanthogranuloma on the left side of the face

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Multiple café‐au‐lait macules over the back

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Complete blood counts, urine analysis, hepatic and renal function tests, and serum lipid levels were normal. A skin biopsy from a papule over the shoulder revealed a dense infiltrate in the dermis underlying a normal epidermis. The infiltrate was well demarcated and comprised lymphocytes, eosinophils, and foamy histiocytes along with Touton giant cells and proliferating fibroblasts. This confirmed the diagnosis of juvenile xanthogranuloma. The parents were informed about the benign and self‐limiting nature of the disorder and were advised to bring the child for regular follow‐up.
Multiple lesions of granuloma annulare following BCG vaccination: case report and review of the literature
Authors: Kakurai Maki , Kiyosawa Tomoharu , Ohtsuki Mamitaro , Nakagawa Hidemi
Published: March 2003

A 12‐year‐old Japanese boy presented with asymptomatic, multiple annular, erythematous, infiltrated lesions on his left upper arm and right knee as well as the lateral side of the right ankle joint. He had noted these erythematous lesions five days after bacille Calmette‐Guerin (BCG) vaccination. The lesions gradually enlarged and increased in number. Topical corticosteroid therapy for several weeks failed to improve the lesions. There was no familial history of pulmonary tuberculosis.

Physical examination revealed extensively disseminated, round, erythematous plaques and papules. Some plaques showed an annular configuration, varying in diameter from 5 to 45 mm, on his left upper arm, right knee and the lateral side of the right ankle joint (Fig. 1). One month after BCG vaccination, reddish‐brown, infiltrated erythema with crusts was observed at the BCG vaccination site (Fig. 2). Tuberculin test showed an erythema with induration measuring 2.5 cm in diameter at 48 h. Routine laboratory tests including complete blood cell count, erythrocyte sedimentation rate and biochemical analysis were within normal limits. Serum glucose level and GhbA1c were also normal.

Annular erythematous lesion on left lateral malleolus

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Multiple, grouped, erythematous papules with crust, exactly corresponding to previous multipuncture BCG site

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Histopathologically, a biopsy specimen obtained from an annular erythematous plaque on the lateral side of his right ankle joint revealed marked pale staining, well‐circumscribed degenerated collagen bundles surrounded by palisading histiocytes and lymphocytes in the dermis (Fig. 3). Alcian blue stain was positive among degenerated collagen fibers. An immunofluorescence study revealed IgG and C3 deposits in dermal vessels. These histologic features were consistent with granuloma annulare.

Area of degenerated collagen surrounded by palisaded histiocytes

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Two months later, the margins of the erythematous lesions had spontaneously faded and, within 7 months, had completely resolved. Reddish‐brown erythema at the BCG vaccination site had not disappeared.