Waistband Mycosis Fungoides: A New Clinical Variant of Early-Stage Disease.

Case 1: A 17-year-old white man was referred for evaluation of biopsy-proven patch-stage mycosis fungoides (MF) that had first appeared 5 years previously. Asymptomatic "bruises" had appeared under his football padding in a waistband distribution, and these lesions improved during each offseason but never fully resolved. His exposure history was only positive for swimming pool water and his athletic pads. On physical examination, large, irregular, geometric tan-colored patches were present along his waistband area, in areas of contact with his football padding, with an involved body surface area (BSA) of 23.7% (Figure 1A). Examination of scale for fungal hyphae under potassium hydroxide was negative. No lymphadenopathy was present.

A Case of Cycloserine-Induced Lichenoid Drug Eruption Supported by the Lymphocyte Transformation Test.

Lichenoid drug eruption (LDE) is a rare form of delayed-type drug eruption. Among anti-tuberculosis (Tb) agents, cycloserine (CS) has been reported as a rare cause of LDE. Positive results on the lymphocyte transformation test (LTT) have not been reported in patients with LDE. In the present case, we performed LTT and a patch test, and successfully proved CS as the offending drug in this patient, who had been treated with multiple anti-Tb drugs. These observations suggest that CS should be considered a possible cause of LDE and that LTT can be an option for the diagnosis of LDE.

Lymphomatoid papulosis: Treatment response and associated lymphomas in a study of 180 patients.

BACKGROUND: Lymphomatoid papulosis (LyP) is a CD30(+) lymphoproliferative disorder, with a self-regressing clinical course and malignant histopathology. OBJECTIVE: The aim of this study was to evaluate characteristics, risk factors, associated malignancies, long-term outcome, and treatment of LyP in a large cohort representing the experience of the MD Anderson Cancer Center. METHODS: Patient charts and clinical and histopathologic data of 180 patients with LyP were retrospectively assessed. RESULTS: A total of 56.7% of patients was men. Histologic subtype A was found in 47.2%, type B in 17.2%, type C in 22.8%, type D in 7.8%, type E in 0.6%, and mixed subtype in 4.4% of the patients. One hundred fourteen lymphomas were observed in 93 patients, with mycosis fungoides (61.4%) and anaplastic large cell lymphoma (26.3%) being the most common forms. Risk factors for development of lymphoma included sex and histologic subtype. Number of lesions and symptom severity were not associated with lymphoma development. Patients with type D were less likely to have lymphomas. Treatment provided symptomatic relief but did not prevent progression to lymphoma. LIMITATIONS: The limitation of this study is the retrospective study design. CONCLUSION: Patients with LyP are at increased risk of associated lymphomas. Thorough patient counseling is needed and long follow-up periods are required to detect and treat secondary lymphomas.

A case of indeterminate dendritic cell tumor presenting with leonine facies.

BACKGROUND: Indeterminate dendritic cell tumor is an extremely rare neoplastic proliferation of dendritic cells that share immunophenotypic features of Langerhans cells and macrophages but lack Birbeck granules and Langerin expression. METHODS: We report a 55-year-old female presenting with a leonine facies and generalized multiple confluent papules, nodules and plaques on neck, upper trunk, arms and thighs. Laboratory evaluations were performed including skin biopsies, peripheral blood flow cytometry and positron emission tomography-computed tomography. RESULTS: The lesional skin biopsy showed a dense dermal and perifollicular infiltrate composed of histiocytoid cells with nuclear grooves lacking dendritic processes in a background of lymphocytes. Eosinophils were absent. The histiocytoid cells were CD68+CD1a+Langerin- and only focally S100+. Special stains including GMS, Gram and Fite were all negative for infectious organisms. Although an initial diagnosis suggesting Langerhans cell histiocytosis was proposed due to CD1a positivity, a diagnosis of indeterminate dendritic cell tumor was finally rendered based on the histopathological findings and the lack of expression of Langerin. CONCLUSION: This case illustrates the variegated clinical presentation of indeterminate cell tumor and the necessity of appropriate immunohistochemical workup for its diagnosis.

Fluconazole induced fixed drug eruption.

We report on a rare case of fluconazole induced fixed drug eruption in a 62-year old female patient. She was referred to our department for multiple erythematous itchy maculopatches on the face, neck, both upper arms, and trunk area, which had occurred over the previous 6 months. Her attending physician prescribed fluconazole for treatment of onychomycosis. Patch test and oral provocation were performed. The patch test showed a negative result; however, the result for oral provocation was positive, confirming this as a rare case of fluconazole induced fixed drug eruption. To the best of our knowledge, this is the first reported case in Korean dermatologic literature.

Stevens-johnson syndrome induced by vandetanib.

Vandetanib is a once-daily oral anticancer drug that selectively inhibits key signaling pathways in cancer by targeting vascular endothelial growth factor receptors, epidermal growth factor receptors tyrosine kinase, and rearranged during transfection-dependent tumor cell proliferation and survival. The most frequently reported adverse events attributed to vandetanib include diarrhea, elevated aminotransferase, asymptomatic corrected QT interval prolongation, and hypertension. Though a number of randomized, doubleblind studies, including cutaneous adverse events attributed to vandetanib, have been reported along with these general symptoms, no case of Stevens-Johnson syndrome (SJS) has been reported. This paper demonstrates a case of SJS induced by vandetanib.

Malignant Acanthosis Nigricans Associated with Ovarian Cancer.

Malignant acanthosis nigricans is a cutaneous eruption characterized by symmetric hyperpigmented hyperkeratosis, dermal papillomatosis, and mucosal involvement associated with internal malignancies. Tripe palms refers to a characteristic velvety thickening of the palms, with exaggeration of normal skin markings. We present the second case of ovarian cancer in association with two coexisting paraneoplastic dermatoses occurring in a 57-year-old Korean female. The presence of acanthosis nigricans in conjunction with tripe palms in a female patient is highly suggestive of an internal malignancy including an ovarian cancer and demands an extensive search for the hidden ovarian cancer.

Treatment of oral lichen sclerosus with 1% pimecrolimus cream.

Lichen sclerosus is a chronic inflammatory mucocutaneous disorder predominately affecting prepubertal girls and postmenopausal women. Isolated lichen sclerosus affecting the oral mucosa is exceedingly rare, and only 13 patients with biopsy-proved isolated oral disease have been reported in the literature. We report on a 7-year-old Korean girl with a well-demarcated 1.2x1.2 cm atrophic white plaque with an erythematous border and focal telangiectasia on the left vermillion lip, extending to the labial mucosa. No other cutaneous surfaces, including genitalia, were involved. An incisional biopsy of the plaque on the lip revealed a patchy lichenoid infiltrate of lymphocytes associated with sclerosis of the papillary dermis and a thinned epidermis consistent with a diagnosis of linear orofacial lichen sclerosus. Treatment with a short course of 1% pimecrolimus cream effectively prevented the progression of this lesion.

Cutaneous malignant melanoma associated with papillary thyroid cancer.

As the survival from cutaneous malignant melanoma and its clinical concerns have been steadily increasing, the possibility has been raised of an increased risk of second primary cancers in the patients with malignant melanoma. Especially, recent studies have identified an association between cutaneous malignant melanoma and thyroid carcinoma. We here report on a case of cutaneous malignant melanoma that developed in a 61-year-old female patient who had hypothyroidism caused by papillary thyroid carcinoma. We suggest that the individuals who have cutaneous malignant melanoma may be predisposed to other primary cancers and especially thyroid carcinoma. Continuous monitoring of the thyroid function in melanoma patients is required because hypothyroidism can worsen due to malignant melanoma and this is probably associated with thyroid carcinoma.

P27 and mib1 expression in actinic keratosis, Bowen disease, and squamous cell carcinoma.

The histologic boundary between actinic keratosis, Bowen disease, and invasive squamous cell carcinoma is not clear in many cases. We determined nuclear expression of p27 (a protein associated with cellular quiescence) and Ki-67 (a marker of proliferation) immunohistochemically in actinic keratosis, Bowen disease, and squamous cell carcinoma to see if differential patterns of expression for p27 exist and how these might correlate with Ki-67 expression. We determined a labeling index for p27-stained nuclei and assessed the pattern of Ki-67 expression. The student's t test was used to evaluate the p27 labeling index. The p27 labeling index was decreased in invasive aggregates of squamous cell carcinoma (76.9+/- 1.1%) when compared with those of normal epidermis (97.2+/- 2.4%), actinic keratosis (95.3 +/- 1.4%), and Bowen disease (98.0+/- 0.5%). Ki-67 was expressed in a scattered to confluent linear pattern in the basal/parabasal cell layer of normal epidermis and actinic keratosis. Keratinocytes in squamous cell carcinoma exhibited Ki-67 in the peripheral layers of the neoplasm and frequently within the tumor aggregates. Ki-67 was observed in nuclei throughout the full thickness of the epidermis in Bowen disease. The staining pattern of Ki-67 in Bowen disease separated this entity from others under study. The combination pattern of p27 and Ki-67 staining can be used to support differentiation of actinic keratosis, Bowen disease, and squamous cell carcinoma.

A case suggesting lymphocytic vasculitis as a presenting sign of early undifferentiated connective tissue disease.

A previously healthy 14-year-old Korean male presented with striking hemorrhagic acral livedo associated with anti-ribonucleoprotein antibodies. His skin biopsy revealed a striking lymphocytic vascular reaction with mild superficial perivascular lymphocytic infiltrates, perivascular extravasation of red blood cells, and leukocytoclastic debris. Lymphocytic vasculitis (LV) is defined in different ways by different authors. The above biopsy findings do not fulfill the criteria for LV of all authors. Chronic lymphocyte-mediated endothelial cell injury may play an important role in the pathogenesis of collagen vascular disease. Cell-mediated cytotoxicity against endothelial cells or other vessel wall components is thought to be the possible pathologic mechanism of LV. We present a patient with early undifferentiated connective tissue disease (EUCTD) with hemorrhagic acral livedo, who finally developed systemic lupus erythematosus. Even though the histopathologic findings do not meet the most rigorous definition of LV, LV may a presenting sign of EUCTD. The purpose of this report is to suggest reconsideration of the diagnostic criteria of lymphocytic vasculitis.

Gianotti-Crosti syndrome following Japanese encephalitis vaccination.

We report a three-year-old Korean boy who presented with itching symmetrical erythematous macules and papules on his face, trunk, and extremities for 1 week. Lymphadenopathies were detected on physical examination. He was vaccinated against Japanese B Encephalitis (JE) 1 day before developing skin rashes. The patient s serum JE antibody titer by hemagglutinin inhibition (HI) test was 1:40. Under the diagnosis of Gianotti-Crosti syndrome following JE vaccination, he was conservatively treated with an antihistamine agent, and his symptoms were all cleared 2 weeks after treatment.