Detection of intraepidermal malignant melanoma in vivo by confocal scanning laser microscopy.

The early detection of malignant melanoma remains challenging for physicians. New techniques are being explored in order to improve diagnostic accuracy. Confocal scanning laser microscopy (CSLM) represents one such novel imaging modality. It allows in vivo microscopic analysis of skin lesions at a level of resolution approaching histological detail. Therefore, interpretation of optical sections represents in principle a histopathological analysis. Pigmented lesions are particularly amenable to examination by CSLM, since melanin pigment provides endogenous contrast, facilitating the recognition of melanocytes and their distribution within the epidermis. As a first step to explore the use of CSLM in the detection of melanoma, we sought to determine whether images obtained by CSLM are suitable for analysis by established histopathological criteria for the diagnosis of melanoma. We examined five pigmented lesions clinically suspicious for melanoma from five individual patients. Following imaging by CSLM, the clinical lesions were excised for examination by conventional histology. The melanocytes in the confocal images were recognized within the epidermis by their bright cytoplasmic signal intensity. They were round to oval in shape and frequently showed dendritic processes of various lengths. Confocal images of melanoma showed an increased number of intraepidermal melanocytes in solitary units at all layers of the epidermis, including the upper spinous and granular cell layers. Our results demonstrate that intraepidermal melanoma can be recognized by CSLM through analysis of the intraepidermal growth patterns of melanocytes using the same criteria as established for conventional histology. Thus, the application of CSLM represents a new tool for non-invasive screening of intraepidermal pigmented lesions in vivo and offers the opportunity to bring histopathological analysis to the bedside.

Association of reversible alopecia with occupational topical exposure to common borax-containing solutions.

Boron is widely used in industrial materials, most frequently as the salt borax. Systemic exposure (eg, ingestion) to boron in boric acid been associated with reversible toxic alopecia among other manifestations. There is scant clinical literature on alopecia caused by topical exposure to boron. We observed a series of 3 patients in 2 workplaces who suffered reversible alopecia from cutaneous boron exposure. The scalp alopecia was global in 1 patient and patchy in 2 patients. Alopecia was completely reversed by elimination or reduction of exposure to boron-containing materials in all 3 patients. We conclude that occupational topical exposure to boron in solutions may cause reversible alopecia.

The distribution of melanocytes in the leptomeninges of the human brain.

The purpose of this study was to determine the qualitative and quantitative distribution of melanocytes in human leptomeninges by histochemical and ultrastructural techniques and to search for melanocytes in the mesothelial linings of the pleural and peritoneal cavities. Knowledge of the extracutaneous distribution of pigment cells will facilitate the interpretation of systemic symptoms in depigmentation disorders, such as vitiligo and the Vogt-Koyanagi-Harada syndrome. In 15 brains examined, leptomeningeal pigment cells were found principally over the ventrolateral surfaces of the medulla oblongata. Only isolated pigment-containing cells were found in the meninges covering other parts of the brain. The mean number of pigment cells in the medullary meninges of 5 brains was 325/mm2 +/- 96. The presence of melanosomes as single, membrane-bound granules in all stages of melanization confirms that the melanin-containing dendritic cells of the leptomeninges are melanocytes and not macrophages. No pigmented cells were observed in the pleural or peritoneal samples examined.

The microbial evaluation of acute cellulitis.

Twenty consecutive patients with acute cellulitis were studied by retrospective chart review. Patients with suffusion and edema, with or without vesicles, were included. Patients with breaks in the skin, with focal suppurations or with concurrent antimicrobial therapy were excluded. In nineteen of the twenty patients, aspirates (95 percent) failed to grow organisms. Pasteurella multocida was grown from subcutaneous aspirate and blood cultures of a single patient; he was immunocompromised by Waldenström's macroglobulinemia and chlorambucil therapy. Two of the nineteen patients with negative aspirate cultures had positive blood cultures, one for type B Hemophilus influenzae and the other for a probably spurious Campylobacter fetus. All twenty patients, including the two immunocompromised patients, responded completely to appropriate empiric antimicrobial therapy. There were no complications of the needle aspirate technique observed. Needle aspiration is indicated early in the course of acute cellulitis in the immunocompromised, the young child with facial cellulitis, those with open wounds, and those who fail to respond to conventional antimicrobial therapy. For the otherwise well patient with intact host defenses, it is of extremely low sensitivity.

Hydroa vacciniforme: diagnosis and therapy.

Hydroa vacciniforme is a rare, chronic photodermatosis with onset in childhood. Multiple exposures to UV-A reproduced the symptoms and the vesicular and scarring lesions typical of the sun-induced disease in our patient. Treatment with hydroxychloroquine sulfate, but not indomethacin, reduced the photosensitivity both to sunlight and to artificial UV-A light. Serum complement levels were low while the disease was active and returned to normal after treatment of the patient with hydroxychloroquine.

An unusual and fatal case of disseminated cutaneous herpes simplex. Infection in a patient with cutaneous T cell lymphoma (mycosis fungoides).

A patient with plaque stage mycosis fungoides (MF) developed an atypical disseminated cutaneous herpes simplex virus (HSV) infection manifested by polycyclic cutaneous ulcers. Although Tzanck preparations and serial antibody titers to herpes virus were negative, the diagnosis was readily established by viral culture and histologic examination of the skin lesions. Following adenine arabinoside therapy, the viral cultures of the ulcers became negative and the spread of virus-induced ulcerations ceased. In an immunocompromised host with rapidly advancing, sharply punched-out polycyclic cutaneous ulcerations, herpes simplex infection should be considered even though the classical vesicular lesions are absent.