Primary cutaneous anaplastic large cell lymphoma presenting as multiple keratoacanthoma-like lesions.

Primary cutaneous anaplastic large cell lymphoma (C-ALCL) is categorized as primary cutaneous CD30+ lymphoproliferative disorders, according to the recent WHO-EORTC classification of cutaneous lymphomas. This group includes primary C-ALCL, lymphomatoid papulosis (LyP). Most patients of C-ALCL present with solitary or localized nodules or papules, and often show ulceration. Multiple keratoacanthoma-like lesions are unusual. As far as we know, there are five reported cases. Currently, there is no universally accepted standard therapeutic approach for cases of multifocal C-ALCL. The combination chemotherapy is considered the most appropriate first-line treatment. We present a rare case of C-ALCL with multifocal keratoacathoma-like tumors with a challenging treatment regimen. A 56-year-old Thai woman developed multiple asymptomatic ulcerated nodules on her trunk, and extremities for 5 months. The provisional diagnosis was keratoacanthoma but histopathology and immunohistochemical studies revealed CD30+ ALCL. She received many regimens of chemotherapy, but responded well to the ESHAP (etoposide, methylprednisolone, cisplatin, cytosar) regimen.

Histopathologic aid to diagnosis of sarcoidosis: report of 8 cases.

Sarcoidosis is a multisystemic disease of unknown etiology. The disease is common in blacks and is very rare in Thailand. It presents as one of the most variable manifestations usually affecting the lungs and intrathoracic lymph nodes. Other organs such as liver, spleen, joints and eyes including skin are also involved The common cutaneous lesions are maculopapular, erythematous plaque, subcutaneous nodule, scar and lupus pernio. No reliable indicator is useful for diagnosis except the histopathologic change which is the only way for approaching this disease. Sarcoidosis is the disease of exclusion. Various infections producing granulomas should be excluded histologically. The ultimate diagnosis requires clinical correlation, laboratory investigations, chest X-ray as well as available tissue culture. Herein, the authors reported eight cases of sarcoidosis by retrospective study primarily diagnosed by histopathological findings at Siriraj Hospital from January, 1997 to December, 2004 with many different clinical presentations. Despite the diverse clinical pictures, interestingly, the presented patients almost had the same histopathologic findings as small, uniform, discrete naked granulomas usually without necrosis. These findings act as a hallmark for diagnosis of this disease.

Detection and identification of Mycobacterium species by polymerase chain reaction (PCR) from paraffin-embedded tissue compare to AFB staining in pathological sections.

BACKGROUND: Polymerase chain reaction (PCR) is a recent, rapid and reliable method in the detection of causative organism. The authors tried to determine the possibility of using PCR technique as an alternative way to detect mycobacterial DNA from paraffin-embedded tissue to avoid repeated biopsy from the patient. MATERIAL AND METHOD: Paraffin-embedded tissue blocks, the corresponding histopathologic slides, and cultural results were retrospectively searched for according to the patient's records, the granuloma clinic, Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand from 1994-2000. One hundred and thirty-one tissue blocks and slides were found but only 120 cultural results were retrieved Histologic sections were reviewed for AFB findings and PCR was done using 16S rRNA sequences to detect M. tuberculosis by one-tube nested technique and multiplex PCR for M. marinum and M. fortuitum complex. RESULTS: The causative organisms were identified by AFB staining in pathologic sections 31.29%, by PCR 35.87%, and by culture 30.00% of tested samples. The sensitivity of PCR when compared to AFB result was 29.26%, specificity 61.11% but when compared to cultural results, the sensitivity of PCR was 66.67% and AFB sensitivity was 41.66% with specificity 76.19% and 72.61% respectively. CONCLUSION: The low sensitivity of the PCR method may be due to formalin fixation, deparaffinization process, DNA extraction method, the use of 16S rRNA-based primers and the length of the expected product, and the tissue type that may have Taq polymerase inhibitor. Therefore, PCR should be used to augment the information of the conventional method in the diagnosis of mycobacterial infection.

Mycobacterial skin infections: comparison between histopathologic features and detection of acid fast bacilli in pathologic section.

BACKGROUND: Detection of acid fast bacilli (AFB) in chronic granulomatous inflammation is an important clue for mycobacterial infection. DESIGN: A retrospective review of 104 pathologic sections (from 1994 to 2001) of suspected cases of mycobacterial (tuberculous and nontuberculous) skin infections to study histopathologic features and the correlation with the presence of AFB in the section was performed. RESULTS: All cases showed granulomatous inflammations that can be categorized into 4 types: mixed cell, suppurative, tuberculoid and palisading granuloma. AFB was found in 32 sections (30.77%). Ninety five specimens from 104 specimens were simultaneously cultured. AFB positive cases yielded higher positive cultural results, 17 from 29 cases (58.62%) compared to the AFB negative group, 23 from 66 cases, (34.85%). Mixed cell granuloma was the most common histologic feature, but suppurative granuloma was the most common histological feature (56.25%) in which AFB could be found, which was statistically significantly different from other types of granuloma. Tuberculoid granuloma was more common in the AFB negative group (20.83%) compared to the AFB positive group (9.37%) but the difference was not statistically significant. In cases that AFB could not be found, the inflammation tended to be located in the upper half of the dermis. CONCLUSION: AFB can be more frequently detected in suppurative granuloma that might be located in any portion of the dermis. This finding was not species specific.

A man with chronic recurrent ulcers at the axillac and groins.

Langerhans cell histiocytosis is an uncommon disease. There are various skin manifestations of this disorder. We report a 15 year-old patient with Langerhams cell histiocytosis, who first presented with polyuria, polydipsia and right elbow pain. A few years later, he developed chronic recurrent ulcers at his axillae and groins, simulating hidradenitis suppurativa. Histopathology and ultramicroscopic study showed Langerhans cells infiltrating the lesions. He also had fingernail changes without any evidence of fungal infection. Hidradenitis suppurative-like lesions with nail changes are rare manifestations of this disorder.

An actor with fatal violaceous plaques.

We report a case of homosexual Thai AIDS patient who presented with mucocutaneous Kaposi\'s sarcoma (KS) and developed pulmonary involvement which rapidly progressed to a fatal outcome. Although AIDS-KS has been reported as the most common cancer occurring in HIV-infected patients, it has rarely been reported in Thai patients. The characteristic mucocutaneous lesions, histopathological and bronchoscopic findings are demonstrated. Tha clinical differentiation and management are discussed.

Nontuberculous mycobacterial skin infections: clinical and bacteriological studies.

OBJECTIVE: Nontuberculous mycobacterial (NTM) skin infections were analysed in terms of clinical manifestation in different species to provide clues for the clinical diagnosis and sensitivity patterns of these species were studied for planning appropriate therapy. DESIGN: A retrospective study was performed in 123 suspected cases of NTM infections from January 1994 to December 2000. NTM infection was documented by culture result of the infected tissue obtained by skin biopsy. Drug susceptibility test was done as requested. RESULT: Rapid growers (M. fortuitum-chelonae) were found in 26 cases (65%) and M. marinum was responsible for 12 cases (30%) and caused only localized skin lesions on arms or legs as indurated plaque, Disseminated skin infections manifested as multiple abscesses were found in 2 cases caused by M. avium in an HIV-infected male patient and mixed infection of M. szulgai and M. terrae in an immunocompetent female patient after a dental procedure. Both sexes were affected equally in overall number but male predominated in M. marinum infection and females predominated in rapid growers. All ages can be affected but most cases were middle aged. Scrofuloderma-like cervical lymphadenitis and cutaneous abscesses were the common manifestation of rapid grower infections. Hyperkeratotic verrucous plaques (tuberculosis verrucosa cutis-like) and sporotrichoid lesions were the common manifestations of M. marinum infection. M. marinum is sensitive to minocyclin, clarithromycin, amikacin, rifampicin and ethambutol and a good clinical response was obtained with doxycyclin 100 mg orally twice a day for 3 months. Clarithromycin and amikacin showed in vitro activity against the same strain of M. fortuitum but most strains of rapid growers resisted antituberculous drugs and also various antibiotics. CONCLUSION: Clinical manifestations can be used as clues for diagnosis. Medical therapy is recommended for M. marinum infection and surgical treatment is recommended for rapid growers.

Pathergy test in Thai patients with behcet's disease: A clinical, histopathological and direct immunofluorescence study.

To evaluate the clinical, histopathological and immunopathological findings of the pathergy test in Thai patients with Behcet's disease. Methods : A pathergy test using the needle prick method with a 20G disposable needle after cleaning with 70% alcohol was performed in 5 patients (4 females and 1 male), with Behcet's disease according to International Study Group (ISG) criteria. The skin was pricked making a 45oangle with the skin surface to a depth of 3 mm at an avascular and hairless point of both forearms symmetrically. After 4 and 48 hours the test sites were evaluated clinically and skin biopsies were performed at a prick site on the right forearm after 4 hours for direct immunofluorescence study and after 48 hours at the prick site on the left forearm for histopathological study. Results : Clinical pathergy tests were positive (a single papular lesion at the needle prick site) in 3 out of 5 patients at 48 hours. No response was observed at 4 hours. Direct immunoflurorescence study showed no deposition of immnoglobulins (IgG, IgM, IgA) and C3 in any case. The histopathological findings 48 hours after the test revealed definite neutrophilic infiltration around a superficial vascular plexus in 4 cases, in addition, one of these had endothelial cell swelling with red blood cell extravasation. The rest (1 case) showed nonspecific finding. Conclusion : We conclude that the pathergy test is a useful tool for the diagnosis of Behcet's disease. The intradermal needle prick method using 20G disposable needle after cleaning the skin with 70% alcohol, yields results of moderately high sensitivity.

Disseminated penicilliosis marneffei in immunocompetent hosts.

Two cases of disseminated Penicilliosis marneffei are reported; both were middle-aged female patients from the central part of Thailand who presented with multiple cystic skin lesion. Their systemic symptoms included chronic fever, weight loss, malaise, anemia, cervical lymphadenopathy and osteolytic bone lesions. They had no underlying disease causing immunosupression and both were HIV-negative. Skin manifestations occurred frequently in disseminated penicilliosis and abscesses were the most common manifestation in HIV-negative patients whereas umbillicated papules were common in HIV-positive ones. A biopsy from the skin lesions was good specimens for histopathological study and frequently yielded positive culture results. The characteristic histopathological feature is granulomatous inflammation with macrophages containing yeast-like organisms with septa which show a lack of budding. The characteristic mycologic feature of P.marneffei is a thermally dimorphic fungus which produces a mycelial phase colony appearing within 2 days at room temperature (25-30oC) and which produces a bright, purple-red, water-soluble pigment into the surrounding agar. The yeast form grows at 37oC as a whitish colony produced in 4 days and this produces less red pigment compared with the mycelial form. The first case was treated with oral itraconazole intermittently as a result of multiple recurrent episodes until she died of the disease after one year. The second case was treated with amphotercin B intravenously followed by oral itraconazole with a satisfactory result.

Fatal pneumocystis carinii pneumonia in AIDS : A case report.

The human lower respiratory system begins to form about day 26-27 after conception, and is first indicated by a median larngotracheal groove in the caudal and of the ventral wall of the larynx, trachea, bronchi and the pulmonary lining epithelium. The connective tissue, the cartilage and the smooth muscle of these structures develop from the splanchnic mesoderm surrounding the foregut. In studying the development of the respiratory system at the Department of Anatomy, Siriraj Hospital, Medical students should trace the serial section of 10 mm and 15 mm pig embryos. In doing this, they be able to observe the layngotracheal groove at the floor of the pharynx and when, tracing the sections caudally, they will be able to observe the trachea, esophagus and the bifurcation of the trachea to from primary bronchi as well as the smaller branches of bronchi. The present study attempts to show the development of the respiratory system of rat embryos in order to find the most suitable stage which can be used as a laboratory model for use by students. A 6 mm rat embryo can be used instead of a pig embryo for studying the development of the respiratory system, if pig embryos are not available.

Systemic fungal infection: A study of 138 autopsies.

A study of 138 autopsy cases with deep fungal infections out of a total of 3328 autopsy cases during the period 1980 to 1985 was carried out when the causal organisms were determined, 160 infections were found: 10 were caused by pathogenic fungi (Crytococcus neoformans) and the other 10 were caused by opportunistic fungi including aspergillus, candida, mucor and penicillium. A combination of more than one fungus was noted in 21 cases. The central nervous system was most likely to be affected by crytococcus, whereas the respiratory and alimentary systems were infected by aspergillus and candida, respectively. In this study, males were somewhat more commonly affected than females. Fungal infections were common in those who had underlying diseases, internal malignancies, diabetes mellitus as well as in patients with a history of prolonged use of antibiotics and corticosteroids. Compared with a previous study in the same hospital, the incidence definitely increased, although the other patterns of the systemic fungal infections showed no significant change.