Basal cell carcinoma or not? Histological variants and mimics of the most common cutaneous malignancy.

Basal cell carcinomas are the most common cutaneous malignancy encountered by dermatologists. Although most basal cell carcinomas have typical features and are easily diagnosed histologically, some basal cell carcinomas are problematic. Because the best evidence suggests that basal cell carcinomas arise from primitive stem cells that differentiate along follicular lines, it is not uncommon that this tumor may resemble and be confused with a variety of benign and malignant follicular and sweat gland tumors. This article will focus on some common and rare histological variants that may produce confusion, as well as salient features that will allow the correct diagnosis to be made.

Comparison testing of the irritancy of children's liquid bubble bath using a modified human repeat insult patch test.

BACKGROUND: Bubble baths are common products used by parents with young children. Some dermatologists and pediatricians do not recommend the use of these products. OBJECTIVE: The purpose of this study was to compare the irritancy of nine children's liquid bubble bath solutions. METHODS: A modified human repeat insult patch test (HRIPT) was used to rank order the irritancy of nine bubble bath preparations. Erythema, scaling, and fissuring were evaluated at the patch test sites. RESULTS: The nine products tested varied in their ability to cause irritation. Based on the degree of erythema, the least irritation was produced with Sesame Street Fresh Apple Splash bubble bath. CONCLUSION: This study suggests that there are differences in the irritancy of brands of children's liquid bubble bath and that recommendations can be made by both dermatologists and pediatricians when parents choose to use these products on their children.

Waldenström macroglobulinemia-induced bullous dermatosis.

BACKGROUND: Waldenström macroglobulinemia is a plasma cell dyscrasia of undetermined cause characterized by the monoclonal proliferation of lymphoplasmacytes in the bone marrow, lymph nodes, and spleen and elevated circulating levels and tissue deposition of monoclonal IgM produced by these aberrant cells. Rarely, cutaneous manifestations of this disease have been reported. OBSERVATIONS: We report the case of a patient with bullous dermatosis induced by Waldenström macroglobulinemia and demonstrate the subepidermal location of the separation and the presence of IgM and kappa light chains by immunoperoxidase, immunofluorescent techniques, and electron microscopy with immunogold staining. Immunoblotting revealed a strong band at the 290-kd area. CONCLUSIONS: The demonstration of the separation in the upper dermis at the site of IgM deposits suggests that these deposits may be an etiologic factor in this rare manifestation.

Persistent cutaneous larva migrans due to Ancylostoma species.

Cutaneous larva migrans is considered to be a self-limited parasitic infection of about 2 to 8 weeks' duration, though it has been reported to persist for as long as 55 weeks. In this case, a healthy 47-year-old white man had multiple serpiginous lesions typical of cutaneous larva migrans for 18 months. A biopsy taken 2 months before presentation showed a parasite consistent with Ancylostoma species deep in a hair follicle. The patient initially responded to topical thiabendazole, but relapse occurred when therapy was discontinued. Oral thiabendazole cured the problem after 22 months of infestation. Cutaneous larva migrans may sometimes be long-standing, here almost 2 years, even in a healthy patient. Organisms may reside deep in the hair follicles. Topical thiabendazole may not penetrate to this depth, necessitating oral thiabendazole therapy.

Proposal for a pathogenesis-based classification of tumoral calcinosis.

BACKGROUND: Deposition of calcium in skin is currently categorized into a group of disorders referred to as calcinosis cutis. Divisions between types and subtypes within this confusing classification are predominantly based on morphologic differences in the calcification and serve to obscure pathogenesis. This is especially evident in a subtype of calcinosis cutis, known as tumoral calcinosis. Calcifications in cases of tumoral calcinosis share the following characteristics, but without evidence of a common pathogenesis: large size, juxtaarticular location, progressive enlargement over time, a tendency to recur after surgical removal, and an ability to encase adjacent normal structures. The goal of this study was to formulate a pathogenesis-based classification for cases of tumoral calcinosis. METHODS: In a literature review 121 cases of tumoral calcinosis were identified. These cases, along with a case evaluated in our clinic, were reviewed retrospectively, and their features compared. RESULTS: Analysis suggests three pathogenetically distinct subtypes of tumoral calcinosis: (1) Primary normophosphatemic tumoral calcinosis: patients have normal serum phosphate, normal serum calcium, and no evidence of disorders previously associated with soft tissue calcification; (2) primary hyperphosphatemic tumoral calcinosis: patents have elevated serum phosphate, normal serum calcium, and no evidence of disorders previously associated with soft tissue calcification; and (3) secondary tumoral calcinosis: patients have a concurrent disease capable of causing soft tissue calcification. Justification for this classification is based on the presence or absence of disorders known to promote soft tissue calcification and statistically significant differences in family history, mean calcification number, mean serum phosphate level, and calcification recurrence after excision. CONCLUSIONS: A classification for tumoral calcinosis is devised that outlines potential pathogenetic mechanisms and predicts response to therapy and prognosis. Analysis of other forms of calcinosis cutis may reveal definable pathogenetic differences that suggest a coherent classification for all cutaneous calcinoses.

Sjögren's syndrome plasma cell panniculitis and hidradenitis.

We present a 42-year-old woman with primary Sjögren's syndrome and a polyclonal gammopathy who presented with pretibial petechiae, purpura, and tender indurated plaques. The indurated plaques revealed a lobular plasma cell panniculitis, and thus Sjögren's syndrome should be added to the short list of collagen vascular diseases that can present as plasma cell panniculitis. Her biopsies also demonstrated intense perieccrine plasma cell infiltrates that may account for Sjögren's syndrome-associated hypohidrosis. We also observed occasional vascular occlusion of vessels with an amorphous, eosinophilic material possibly related to her hypergammaglobulinemic purpura.

Cutaneous manifestations of African trypanosomiasis.

BACKGROUND: Dermatologists may evaluate patients with African trypanosomiasis. The currently available dermatologic literature does not review the cutaneous manifestations of African trypanosomiasis. OBSERVATION: We describe an American man who acquired African trypanosomiasis while hunting in Tanzania, and we review and classify the cutaneous findings of this disease. This article reports the results of the first biopsy of a trypanid and depicts trypanosomes on the first touch preparation done from a trypanid biopsy specimen. Rare color photographs of trypanids are shown. CONCLUSIONS: Recognition of the unique cutaneous manifestations of African trypanosomiasis may allow dermatologists to make a rapid diagnosis that is essential for timely treatment and survival. Classifying the disease with primary chancriform, secondary hemolymphatic, and tertiary central nervous system stages should improve the understanding of the complex natural history of African trypanosomiasis.

Opioid use in HIV patients with neurological changes.

The neurological changes that are common in the HIV population may complicate the use of analgesics, particularly opioids. These changes, in combination with care providers' fear of opioids, often lead to the inappropriate use of antagonists, such as naloxone. Used injudiciously, naloxone can lead to withdrawal syndrome, return of severe pain, and other adverse effects. The authors describe the many disease and treatment-related causes for pain in patients with HIV disease, as well as common neurologic conditions that alter cognition and complicate the use of opioids. A case study is included to illustrate the dangers of inappropriate naloxone use.

Deep dermatophyte infection with chronic draining nodules in an immunocompromised patient.

Chronic superficial dermatophyte infection may predispose the immunocompromised patient to invasive or disseminated involvement. We report a case of deep dermatophyte infection in a patient treated with long-term corticosteroid therapy for lung disease. The patient responded well to oral griseofulvin. Previously reported cases are reviewed along with recent investigative findings in the pathogenesis of chronic dermatophyte infections. Recommendations are made for diagnosis and therapy.

Tularemia.

Clinical and histologic characteristics of tularemia are reviewed in this report of a 65-year-old man who presented with fever, cutaneous ulceration, and regional lymphadenopathy. Examination of a biopsy specimen failed to demonstrate the granulomatous inflammation one would expect according to the current dermatologic literature. We review the diagnostic implications of this finding.

Chronic septic arthritis caused by Borrelia burgdorferi.

Chronic arthritis occurs in 10% of Lyme disease patients. A patient had chronic septic Lyme arthritis of the knee for seven years despite multiple antibiotic trials and multiple arthroscopic and open synovectomies. Spirochetes were documented in synovium and synovial fluid (SF). Polymerase chain reaction (PCR) analysis of the SF was consistent with Borrelia infection. Persistent infection should be excluded with silver stains and cultures in any patient with chronic monoarticular arthritis and a history of Lyme disease.

Calcinosis cutis following electromyographic examination.

We report the first case of calcinosis cutis following electromyographic examination. All previously reported cases of iatrogenic calcinosis cutis occurred following electroencephalographic examination using calcium-containing electrode compounds or following the extravasation of calcium-containing solutions along infiltrated intravenous lines. We also review the literature on calcinosis cutis due to iatrogenic and occupational exposure to calcium salts. The clinical presentation of calcinosis cutis is variable, but the histologic appearance is diagnostic. This entity may be underreported because of its benign, self-limited course and lack of recognition by physicians. Calcinosis cutis should be recognized by family practitioners, dermatologists, and subspecialists who encounter patients who have undergone prolonged monitoring studies that involve the use of electrodes.