Infantile hemangiomas: speculation on placental trophoblastic origin.

BACKGROUND: The unique immunobiology of the placental trophoblast and the increased incidence of hemangiomas in infants born after chorionic villus sampling suggest that an immunologically regulated ectopic focus of trophoblasts could be the cell of origin for proliferative infantile hemangiomas. OBJECTIVE: To compare tissue from infantile hemangiomas with that of other vascular lesions for the presence of selected placental trophoblast-specific cellular markers. DESIGN AND PATIENTS: Twelve tissue specimens taken from infantile hemangiomas on patients aged 5 days to 2 years were retrospectively confirmed clinically and histologically. Negative controls were similarly confirmed, including 6 pyogenic granulomas and 4 vascular-lymphatic malformations. These tissues were used for immunohistochemical analysis of selected trophoblastic markers including human placental lactogen, placental alkaline phosphatase, and cytokeratins 7, 8, and 17. SETTING: Tissue submitted from patients seen at Saint Louis University Department of Dermatology and Cardinal Glennon Children's Hospital in St Louis, Mo, between January 1, 1997, and October 31, 1999. MAIN OUTCOME MEASURE: Differential staining for trophoblastic markers in infantile hemangiomas compared with control tissues. RESULTS: The 12 infantile hemangiomas were uniformly negative for all markers tested. Control tissues were also negative for these markers. Four of the 5 histochemical markers did recognize specific nonvascular, cutaneous elements: placental alkaline phosphatase stained smooth and striated muscle, cytokeratins 7 and 8 stained eccrine glands, and cytokeratin 17 stained pilosebaceous units. CONCLUSIONS: Our results do not support the placental trophoblast as the cell of origin for infantile hemangiomas, but we hope our observations and speculation will stimulate further study of this hypothesis.

Inpatient dermatology consultation.

Common dermatologic conditions and skin signs of systemic disease are routinely present in hospitalized patients. Rapid detection and identification of these changes can have a significant impact on the patient's hospital course. Inpatient dermatology consultation can improve diagnostic accuracy, efficiency, and treatment of hospitalized patients with cutaneous findings. This article discusses the clinical aspects of inpatient dermatology consultation and the features of effective consultation.

Antiphospholipid antibodies and the antiphospholipid antibody syndrome.

The antiphospholipid antibody syndrome is a multisystem disorder characterized by persistently elevated antiphospholipid antibodies and/or arterial or venous thrombosis, thrombocytopenia and recurrent spontaneous abortion. Anticardiolipin antibodies and the lupus anticoagulant are different classes of antiphospholipid antibodies associated with this disorder. Various hematologic, neurologic, obstetric and cutaneous abnormalities are manifest in this syndrome. This article reviews the characteristic features of the antiphospholipid antibody syndrome.

Primary cutaneous T-cell-rich B-cell lymphomas with flow cytometric immunophenotypic findings. Report of 3 cases and review of the literature.

BACKGROUND: Primary cutaneous T-cell-rich B-cell lymphoma is a relatively rare entity that has been diagnosed most commonly using immunohistochemical and molecular techniques. Flow cytometric immunophenotyping (FCI) has not been described in this entity. We report the demonstration of B-cell monoclonality by FCI in 3 cases of primary cutaneous T-cell-rich B-cell lymphoma. METHODS: Clinical and pathologic data were recorded for 3 cases of primary cutaneous T-cell-rich B-cell lymphoma. Immunohistochemical and FCI data were available in all cases; DNA analysis was performed in 1 case. RESULTS: Flow cytometric immunophenotyping revealed a monoclonal B-cell population exclusively in the monocyte (large cell) region in all 3 cases. Immunohistochemistry confirmed the T-cell richness of the infiltrates within the cutaneous lymphomas; T cells accounted for 65% to greater than 90% of the cells within the infiltrates. DNA analysis by polymerase chain reaction in 1 case did not demonstrate a monoclonal rearrangement of the immunoglobulin heavy-chain gene. CONCLUSIONS: Flow cytometric immunophenotyping in primary cutaneous T-cell-rich B-cell lymphoma may be useful in demonstrating monoclonality in these cases, especially if there is selective gating on the relatively small population of cells in the large cell region. The FCI data should be correlated with histology and immunohistochemistry.

Extracorporeal photochemotherapy does not suppress T- or B-cell responses to novel or recall antigens.

BACKGROUND: Extracorporeal photopheresis (ExP) is an effective therapy for several conditions including cutaneous T-cell lymphoma, scleroderma, and allograft rejection. Experimental animal models suggest that ExP may induce antigen-specific immunosuppression. OBJECTIVE: Our purpose was to determine the effect of photopheresis on humoral and cell-mediated immunity in human subjects. METHODS: Recall and primary immune responses of patients with scleroderma receiving monthly ExP treatments were assessed by delayed type hypersensitivity skin tests, T-cell proliferative responses after immunizations with tetanus toxoid and keyhole limpet hemocyanin, and serum antibody titers against common viral pathogens. RESULTS: After 6 months of ExP, viral antibody titers and delayed type hypersensitivity responses were not significantly different from baseline values in all 7 patients tested. T-cell responses to tetanus toxoid remained normal in 3 of 3 patients tested for a minimum of 6 months after booster immunization. Immunization with the protein antigen keyhole limpet hemocyanin after initiation of ExP therapy resulted in sustained T-cell proliferative responses up to 6 months in 3 of 3 patients. CONCLUSION: These results, along with the observation of no increased incidence of opportunistic infections or neoplasms, suggest that ExP is not broadly immunosuppressive and does not prevent primary responses to vaccination or other antigenic challenges.

Oxalate kinetics and reversal of the complications after orthotopic liver transplantation in a patient with primary hyperoxalosis type 1 awaiting renal transplantation.

We present the case of a young woman with end-stage renal disease secondary to primary hyperoxaluria type 1, who after 3 years and 6 months of maintenance hemodialysis, and despite intensification of the dialytic treatment, developed severe livedo reticularis in her extremities leading to ischemic cutaneous ulcerations, necessitating continuous intravenous infusion of narcotics for pain control. She received a liver transplant after native hepatectomy. However, due to positive crossmatch, she could not receive a kidney from that donor. After transplantation, following serial serum oxalate levels, the hemodialysis regimen was safely reduced from 4 h daily to 3 h three times weekly. Over the course of 6 weeks after liver transplantation, her livedo reticularis resolved, the ischemic ulcers markedly improved, she was weaned off all pain medications, and her erythropoietin-resistant anemia resolved. Our results suggest that in patients with primary hyperoxaluria type 1, who have received a liver transplant and are on maintenance hemodialysis, after serial serum oxalate determinations, some may safely be changed to a thrice-weekly maintenance hemodialysis regimen. Moreover, with this regimen the complications of systemic oxalosis can reverse.

Clinical reactogenicity of intradermal bacille Calmette-Guérin vaccination.

Clinical, microbiological, and immunologic responses were evaluated in volunteers vaccinated intradermally with bacille Calmette-Guérin (BCG). Most volunteers (98%) developed ulcerative lesions that drained for a mean +/- SE of 4.3 +/- 0.29 weeks. Mycobacterial DNA was detected by a polymerase chain reaction-based amplification technique in biopsy specimens from BCG ulcers 2 weeks after vaccination and in blood specimens 3 days after vaccination. Mycobacteria were cultured from ulcer drainage 2 months after vaccination, demonstrating a prolonged potential risk of contact spread of the vaccine strain. The duration of ulcer drainage was inversely correlated with prevaccination lymphoproliferative (r = -0.515; P < .002) and interferon gamma (r = -0.841; P < .002) responses specific to mycobacteria and directly correlated with postvaccination increases in lymphoproliferative (r = 0.498; P < .002) and interferon gamma (r = 0.688; P < .02) responses specific to mycobacteria. These results demonstrate the clinical reactogenicity of BCG and the potential risk of contact spread of the vaccine strain and suggest that clinical reactogenicity is a trade-off for the induction of protective mycobacterial immunity.

Fluoroscopy-induced radiodermatitis after transjugular intrahepatic portosystemic shunt.

Transjugular intrahepatic portosystemic shunt is a nonsurgical procedure used to manage the complications of portal hypertension. This report describes three cases of fluoroscopy-induced radiodermatitis after transjugular intrahepatic portosystemic shunt and reviews the characteristics and treatment of radiation-induced skin reactions.

Acute radiodermatitis after radiofrequency catheter ablation.

Radiofrequency (RF) catheter ablation is used in the treatment of a variety of arrhythmias. This report describes the development of acute radiodermatitis after two prolonged RF catheter ablation procedures for supraventricular tachycardia. It also reviews the characteristics and treatment of radiation-induced skin reactions.

Antiphospholipid antibodies and the antiphospholipid antibody syndrome.

The antiphospholipid antibody syndrome is a multiple-system disorder characterized by persistently elevated antiphospholipid antibodies and/or arterial or venous thrombosis, thrombocytopenia, or recurrent spontaneous abortion. Anticardiolipin antibodies and the lupus anticoagulant are different classes of antiphospholipid antibodies associated with this disorder. Cutaneous manifestations are common and may be the presenting sign of the underlying disease. This article reviews the clinical manifestations, laboratory assays, histopathologic features, and treatment of the antiphospholipid antibody syndrome.

Cutaneous reactions following herpes zoster infections: report of three cases and a review of the literature.

Three patients, one healthy and two immunocompromised, developed cutaneous reactions that histologically mimicked granuloma annulare at sites of resolved varicella-zoster virus (VZV) reactivation infections. Variable latency periods between the infection and the granulomatous reaction were noted. As in other case reports, the presence of VZV DNA in these lesions was inconsistently demonstrated by the polymerase chain reaction (PCR) and appears more common in early, as opposed to late, post-zoster granulomas. In addition to various granulomatous reactions, vasculitic and neoplastic eruptions following resolved VZV infections have been described and are reviewed here. Therapeutically, topical, intralesional and systemic corticosteroids, as well as acyclovir, have been tried with inconsistent results. Although the pathogenesis remains unclear, the presence of VZV DNA in early lesions that histologically do not display viral cytopathic changes, suggests the virus induces an atypical delayed hypersensitivity reaction not affected by antiviral therapy.

Prevalence of cutaneous findings in hospitalized medical patients.

BACKGROUND: Cutaneous signs may represent a systemic process or a primary cutaneous disorder. Prompt observation and identification of cutaneous abnormalities should improve care of hospitalized medical patients. OBJECTIVE: Our purpose was to determine the prevalence of cutaneous abnormalities in newly hospitalized medical patients and the frequency with which these findings were noted by the admitting team. METHODS: All new medical patients were offered a complete skin examination within 48 hours after admission to the hospital, and 231 participated. Cutaneous diagnoses were based on characteristic clinical features or skin biopsy in patients in whom a diagnosis could not be made clinically. RESULTS: Ninety-three cutaneous findings were present in 83 (35.9%) of 231 patients. In 31 (13.4%) we found cutaneous signs related to the reason for hospitalization or associated with a systemic disorder. These were not noted by the admitting medical service in 14 patients. In two patients, one with metastatic adenocarcinoma and one with sclerosis, the cutaneous findings were manifestations of the new diagnosis. In 52 patients (22.5%) we found 62 primary cutaneous disorders. Fifty-eight disorders (93.5%), including 10 nonmelanoma skin cancers, were unrecognized at the time of admission. CONCLUSION: Cutaneous findings representative of systemic disease or primary cutaneous disorders are commonly present and frequently overlooked in medical patients newly admitted to the hospital. These data suggest that a complete skin examination is necessary in all newly hospitalized medical patients.