Acute scurvy during treatment with interleukin-2.

The association of vitamin C deficiency with nutritional factors is commonly recognized. However, an acute form of scurvy can occur in patients with an acute systemic inflammatory response, which is produced by sepsis, medications, cancer or acute inflammation. The frequency of acute hypovitaminosis C in hospitalized patients is higher than previously recognized. We report the occurrence of acute signs and symptoms of scurvy (perifollicular petechiae, erythema, gingivitis and bleeding) in a patient hospitalized for treatment of metastatic renal-cell carcinoma with high-dose interleukin-2. Concomitantly, serum vitamin C levels decreased to below normal. Better diets and longer lifespan may result a lower frequency of acute scurvy and a higher frequency of scurvy associated with systemic inflammatory responses. Therefore, increased awareness of this condition can lead to early recognition of the cutaneous signs of acute scurvy in hospitalized patients with acute illnesses or in receipt of biological agents, and prevent subsequent morbidity such as bleeding, anaemia, impaired immune defences, oedema or neurological symptoms.

Congenital lacrimal sac fistula: a case report and review.

The lacrimal system is crucial for vision and comprises the lacrimal glands, which produce tears, and the lacrimal drainage system, which drains tears away from the eyes. While various disease processes affect the lacrimal glands, the lacrimal drainage system is commonly prone to congenital abnormalities such as lacrimal sac fistula. We describe a case with classic findings and review dermatologic manifestations of this entity.

Mycobacterium marinum with associated bursitis.

BACKGROUND: Mycobacterium marinum infections have been reported for over 50 years, mostly in association with trauma in the setting of water exposure. OBJECTIVE: The differential diagnosis for nodules in a sporotrichoid distribution with simultaneous bursitis is discussed. Mycobacterium marinum treatment regimens for skin and joint involvement are reviewed. METHODS: Mycobacterium marinum was identified by skin tissue culture with Lowenstein-Jensen medium at 32 degrees C. Histopathologic findings support mycobacterial infection. RESULTS: Bursitis and nodules resolved in the first 2 months of a 6-month course of minocycline treatment. CONCLUSION: Bursitis is an extremely rare but significant complication of M. marinum.

An environmental hazard assessment of low-level dermal exposure to hexavalent chromium in solution among chromium-sensitized volunteers.

To evaluate the potential for elicitation of allergic contact dermatitis from contact with standing water in the environment, 26 persons known to be allergic to hexavalent chromium [Cr(VI)] were exposed to 25 to 29 mg/L Cr(VI) by immersion of one arm for 30 minutes per day on 3 consecutive days in a potassium dichromate bath. Sixteen of the 26 volunteers demonstrated either no or an equivocal response to the Cr(VI) challenge. Ten of the volunteers developed a few papules or vesicles (1 to approximately 15), mild redness, and pruritus on the Cr(VI)-challenged arm. Histopathological examination of the papules revealed spongiosis and perieccrine and perivascular inflammation. The responses were diagnosed as acute perieccrine reactions. It was concluded that exposure to similar concentrations of Cr(VI) in the environment does not pose an allergic contact dermatitis hazard, even to Cr-sensitized persons.

Solitary mastocytoma arising at a hepatitis B vaccination site.

On the first day of life, a healthy infant was given a recombinant hepatitis B vaccine. Over the following year, a 3 by 4.5 cm, well-defined, erythematous patch with an overlying white, reticulated, smaller plaque gradually appeared on her thigh at the vaccination site. Darier's sign was elicited at the site. Examination of a biopsy specimen showed an upper dermal mast cell infiltrate. This is the first reported case of a solitary mastocytoma appearing in a vaccination site.

Graves' disease presenting as localized myxedema in a thigh donor graft site.

Pretibial myxedema, exophthalmus, and thyroid acropachy are the classic manifestations of Graves' Disease. However, myxedema in Graves' Disease can occur in locations other than the pretibial surfaces. Furthermore, with systemic symptoms, localized myxedema may occur at sites of trauma or scarring. We describe a patient with localized myxedema on the thigh at the site of a donor skin graft as the initial presentation of Graves' Disease.

Learning and memory difficulties after environmental exposure to waterways containing toxin-producing Pfiesteria or Pfiesteria-like dinoflagellates.

BACKGROUND: At the beginning of autumn, 1996, fish with "punched-out" skin lesions and erratic behaviour associated with exposure to toxins produced by Pfiesteria piscicida or Pfiesteria-like dinoflagellate species were seen in the Pocomoke River and adjacent waterways on the eastern shore of the Chesapeake Bay in Maryland, USA. In August, 1997, fish kills associated with Pfiesteria occurred in these same areas. People who had had contact with affected waterways reported symptoms, including memory difficulties, which raises questions about the human-health impact of environmental exposure to Pfiesteria toxins. METHODS: We assessed 24 people who had been exposed. We collected data on exposure history and symptoms, did a complete medical and laboratory assessment (13 people), and carried out a neuropsychological screening battery. Performance on neuropsychological measures was compared with a matched control group. RESULTS: People with high exposure were significantly more likely than occupationally matched controls to complain of neuropsychological symptoms (including new or increased forgetfulness); headache; and skin lesions or a burning sensation of skin on contact with water. No consistent physical or laboratory abnormalities were found. However, exposed people had significantly reduced scores on the Rey Auditory Verbal Learning and Stroop Color-Word tests (indicative of difficulties with learning and higher cognitive function), and the Grooved Pegboard task. There was a dose-response effect with the lowest scores among people with the highest exposure. By 3-6 months after cessation of exposure, all those assessed had test scores that had returned to within normal ranges. INTERPRETATION: People with environmental exposure to waterways in which Pfiesteria toxins are present are at risk of developing a reversible clinical syndrome characterised by difficulties with learning and higher cognitive functions. Risk of illness is directly related to degree of exposure, with the most prominent symptoms and signs occurring among people with chronic daily exposure to affected waterways.

Pfiesteria and the skin: a practical update for the clinician.

Skin complaints, including an episodic burning sensation on contact with river water, were common among 13 persons with exposure to Maryland's Pocomoke River in the summer of 1997. While the majority of findings on dermatologic examination were unrelated to toxic dinoflagellate exposure, a subset of patients demonstrated otherwise unexplained erythematous, edematous papules on the trunk or extremities. Histopathologic findings were suggestive of an inflammatory, toxic, or allergic process. It may be speculated that these otherwise unexplained cutaneous findings represent a cutaneous reaction to Pfiesteria or Pfiesteria-like toxin; however, further evaluation of future affected persons will be warranted.

Teledermatology and in-person examinations: a comparison of patient and physician perceptions and diagnostic agreement.

OBJECTIVE: To compare physician and patient impressions and interphysician diagnostic agreement between live teledermatology and in-person examinations. DESIGN: Paired video and in-person examinations with different dermatologists. SETTING: An urban Veterans Affairs dermatology clinic. PATIENTS: One hundred thirty-nine patients. MAIN OUTCOME MEASURES: Satisfaction questionnaires and interphysician diagnostic agreement. RESULTS: Patient and physician satisfaction was high. Agreement between video and in-person diagnoses was 80%. CONCLUSIONS: Physicians and patients were satisfied with teledermatology examinations. Diagnostic agreement between in-person and video dermatologists was high.

Metastatic inflammatory carcinoma of the rectum: tumor spread by three routes.

We report a case of a patient with adenocarcinoma of the rectum with inflammatory metastases to the skin who was treated with radiation therapy and subsequently developed lymphatic obstruction with resultant extensive lymphedema of the lower extremities. Histopathologic examination and immunohistochemistry showed intralymphatic, intravascular, and interstitial malignant cells in the dermis. To our knowledge, this is the second reported case of inflammatory carcinoma arising from metastatic carcinoma of the rectum. However, tumor cell spread to the skin by three routes has not previously been demonstrated.

Lymphomatoid contact dermatitis caused by nickel.

Lymphomatoid contact dermatitis is a rarely reported entity consisting of allergic contact dermatitis that resembles mycosis fungoides pathologically. Although the histopathology has been previously described, there have been no attempts to reproduce the dermatitis for pathologic evaluation. A 68-year-old woman presented with a papular rash on her neck after exposure to a nickel-containing necklace. A biopsy specimen was suspicious for mycosis fungoides. However, the dermatitis responded quickly to topical steroids and avoidance of the necklace. A patch test to nickel was positive, and a biopsy specimen from the patch test site had no findings of mycosis fungoides. Although we were able to reproduce the contact dermatitis at a distant site, the disease was dissimilar. Lymphomatoid contact dermatitis has an excellent prognosis and resolves completely simply by avoiding the offending agent.

Manual resurfacing and trichloroacetic acid for the treatment of patients with widespread actinic damage. Clinical and histologic observations.

BACKGROUND: A facial resurfacing regimen combining manual abrasion of the skin and 25% trichloroacetic acid has been reported to produce excellent results, but the histologic depth of injury produced by this technique has not been studied. OBJECTIVE: To describe our experience with this technique treating patients with extensive actinic damage and to determine the histologic depth of injury produced. METHOD: We treated 40 patients using manual resurfacing and trichloroacetic acid, primarily for widespread actinic keratoses. Resurfacing tools included silicone carbide sandpaper, drywall screen, electrocautery tip cleaners, abrasive pads, scalpel blades, and curettes. Four patients underwent sequential biopsies to evaluate the depth of wounding using this technique. RESULTS: Manual resurfacing combined with trichloroacetic acid consistently produced excellent cosmetic results and nearly complete eradication of actinic keratoses. Histologically, treated areas showed replacement of the dermal elastotic band by newly formed collagen, a significantly deeper level of wounding than the Jessner's/35% trichloroacetic acid peel. There was no evidence for foreign body granulomas clinically or histologically as a result of the abrasive materials. CONCLUSIONS: The deeper level of this peel explains the improved cosmetic outcome and greater eradication of actinic keratoses. This treatment is particularly well suited for patients with extensive photodamage and widespread actinic keratoses.