Falsely elevated human chorionic gonadotropin leading to unnecessary therapy.

BACKGROUND: Analysis of serum beta-hCG aids diagnosis and treatment of intrauterine pregnancies, ectopic gestations, and gestational trophoblastic neoplasia. beta-hCG concentrations are specific for trophoblastic tissue, thus are rarely questioned. CASES: An 18-year-old nullipara had bleeding and a positive beta-hCG. Ultrasound identified no pregnancy. She passed tissue and stopped bleeding. Serum beta-hCG remained elevated despite uterine curettage and three courses of methotrexate. Results of urine beta-hCG were negative, as was reference laboratory serum assay. A 31-year-old nullipara had a spontaneous abortion, but serum beta-hCG remained elevated. Uterine curettage found secretory endometrium, yet elevated serum beta-hCG persisted. Urine beta-hCG was negative, as was reference laboratory serum assay. CONCLUSION: Patients with histories incongruent with serum beta-hCG findings should have urine beta-hCG analysis.

Primary peritoneal carcinoma presenting on routine papanicolaou smear.

BACKGROUND: Primary peritoneal carcinoma is an uncommon disease, characterized by peritoneal carcinomatosis without other identifiable primary tumor. It typically presents resembling ovarian cancer, with abdominal pain and distention and in an advanced stage. We report a unique presentation of this disease. CASE: A 76-year-old woman had severe glandular dysplasia on a screening Papanicolaou smear. An ectocervical lesion was biopsied, revealing moderately differentiated adenocarcinoma. Cervical stenosis prevented sampling of the endocervix and endometrium. Colonoscopy and mammography did not reveal malignancy. Total abdominal hysterectomy with bilateral salpingo-oophrectomy was performed. Surgery revealed surface implants on the pelvic organs, with minimal involvement of the ovaries. Histologic examination revealed adenocarcinoma with papillary serous differentiation. Surgical and microscopic findings were consistent with a diagnosis of primary peritoneal carcinoma. CONCLUSION: Primary peritoneal carcinoma usually presents in a manner similar to that of ovarian cancer, but atypical presentations also occur. While a Papanicolaou smear suggestive of carcinoma usually represents a primary cervical malignancy, this case serves as a reminder that other metastatic malignancies should be considered.

Solitary cutaneous plexiform neurilemmoma (schwannoma): a clinicopathologic, immunohistochemical, and ultrastructural study of 11 cases.

Plexiform neurilemmoma (PN) is a rare benign peripheral nerve sheath tumor. The tumor is an uncommon nodular variant of schwannoma. Eleven cases of cutaneous plexiform neurilemmoma (CPN) were studied by clinicopathologic correlation, immunohistochemistry, and electron microscopy. The patients' ages ranged from 6 to 80 yr; the median age was 37 yr. The tumors were presented as single, soft to rubbery, movable, nontender, and sometimes painful nodules ranging from 0.5 cm to 2.5 cm. in diameter. The lesions were most commonly located on the extremities. The overlying skin surface was intact. These tumors were not associated with von Recklinghausen's neurofibromatosis or neurilemmomatosis. On gross examination the cut surface of the tumors showed grayish-white to yellow or tan coloration and had a well-defined border, but there was no evidence of a plexiform growth pattern. The microscopic features were characterized by single or multiple well-circumscribed nodules of spindle-shaped tumor cells. The nuclei were irregular and elongated, and the cytoplasm was eosinophilic and fibrillary without distinct cytoplasmic borders. Nuclear palisading was prominent, and Verocay bodies were present. Mitotic figures were rare (fewer than 2 per 20 high-power fields). Bodian stain showed presence of nerve fibers at the periphery of the tumor. The adjacent tissue showed wavy, spindle-shaped cells and collagen fibers in a myxoid stroma rich in hyaluronic acid, a pattern reminiscent of neurofibroma. The tumor cells showed positive reactivity with anti-S-100 protein in both the nuclei and cytoplasm. Glial fibrillary acid protein was focally positive, and neuron-specific enolase was negative. Electron microscopy displayed features of Schwann cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment and prevention of basal cell carcinoma with oral isotretinoin.

Twelve patients with multiple basal cell carcinomas resulting from varying causes were treated with high-dose oral isotretinoin (mean daily dosage: 3.1 mg/kg/day) for a mean of 8 months. Of the 270 tumors monitored in these patients, only 8% underwent complete clinical and histologic regression. All patients developed moderate to severe acute toxicities, leading five patients to withdraw from the study. Retinoid skeletal toxicity was identified in two patients who were examined after long-term therapy. Lower doses of isotretinoin (0.25 to 1.5 mg/kg/day) were ineffective for chemotherapy but demonstrated a chemopreventive effect in a subset of three patients who received these lower doses for 3 to 8 years. Two of these three patients have been observed after discontinuation of therapy. In one patient with a history of arsenic exposure, only one new tumor has appeared in a 27-month posttreatment observation period; in the other patient with the nevoid basal cell carcinoma syndrome, 29 new tumors have appeared within a 13-month period. This suggests that the need for long-term maintenance therapy with isotretinoin for chemoprevention of basal cell carcinoma may depend on the underlying cause of the skin cancers.

An experimental study to compare methods of eyelash ablation.

Epilation, electrolysis, cryotherapy, and argon laser thermal ablation were used to remove eyelashes of rabbits. Epilation and electrolysis were done in the standard fashion. Nitrous oxide cryotherapy was applied in a double rapid-freeze/slow-thaw manner for either 30 or 60 seconds. Argon laser settings were 1 W, 50-micron spot size, and durations of 0.2, 0.5, or 1.0 second. The rabbits were euthanized immediately, 24 hours, 2 weeks, or 3 months after the procedure. Epilation was followed by total regrowth of eyelashes within 2 weeks. Electrolysis showed focal destruction of follicles with variable regrowth. Cryotherapy resulted in moderate-to-severe eyelid scarring with minimal regrowth. Argon laser thermal ablation produced focal necrosis and variable follicle destruction. Argon laser thermal ablation may be a suitable alternative to electrolysis or cryotherapy in selected cases of trichiasis.

Skin cancer screening--a local experience.

During a local voluntary Melanoma/Skin Cancer Detection Week, 983 participants were screened with 356 (36%) referrals made to exclude possible malignancy of the skin. The median age of the screened participants was 59 years, with actinic keratosis (62%) the most common referral diagnosis. Referrals for presumptive clinical diagnoses of basal cell carcinomas and malignant melanomas numbered 28% and 8%, respectively. Through the support of the local media and a central organized format, local skin cancer detection programs can successfully screen large numbers of participants. These examinations provide maximum visibility for dermatologists while meeting the primary goals of early disease detection and enhancing public awareness of skin cancer and the harmful effects of actinic radiation.

Renin in angiolymphoid hyperplasia with eosinophilia. Its possible effect on vascular proliferation.

A hypertensive man became normotensive after the surgical removal of two subcutaneous masses of angiolymphoid hyperplasia with eosinophilia. To demonstrate that angiolymphoid hyperplasia with eosinophilia is a renin-producing pathologic condition, Bowie stain for juxtaglomerular cell granules and immunohistochemistry for human renin were used. Bowie stain was positive in cells showing cytoplasmic granules similar to those found in the juxtaglomerular cells of the kidney. Immunohistochemical staining using antiserum against human renin showed the presence of renin-containing cells. This staining was not seen after substitution of the specific renin antiserum by preimmune serum, by the renin antiserum preabsorbed with pure human renin, or with plasma from a patient with high-plasma renin activity. Renin-containing cells were located in areas surrounding vascular structures and were apparently neither endothelial, mast, nor lymphoid cells. Six of eight additional cases of angiolymphoid hyperplasia with eosinophilia were positive for renin-containing cells. Renin has been described in several other histologically highly vascularized tumors. Since a product of renin, angiotensin II, has been found to have angiogenic properties, it is possible to postulate that renin, through angiotensin II, may stimulate the proliferation of vessels and, therefore, may be involved in the pathogenesis of angiolymphoid hyperplasia with eosinophilia.

Angiolymphoid hyperplasia with eosinophilia. A clinicopathologic study of 116 patients.

The clinicopathologic spectrum of angiolymphoid hyperplasia with eosinophilia (ALHE) is reported through a study of 116 cases (67 male and 49 female) submitted to the Armed Forces Institute of Pathology. The lesions are most common in the head-neck region and are characterized by single or multiple smooth-top papules or plaques of varying color. Microscopically, ALHE consists of anomalous vascular proliferations and varying degrees of nodular and diffuse lymphocytic infiltrates with eosinophils at all levels of the corium and subcutaneous tissue. In fifty-three cases an arterial structure, confirmed by the presence of an internal elastic lamina, was observed in close association with venular structures or was the site of endothelial cell proliferation. ALHE comprises a spectrum of unusual vascular proliferation with inflammation, encompassing such entities as inflammatory angiomatous nodules, pseudo or atypical pyogenic granuloma, histiocytoid hemangioma, epithelioid hemangioma, and Kimura's disease. The existence of arterial structures among venules and endothelial cell proliferations suggests the presence of arteriovenous (AV) shunts, which may help explain the pathogenesis and biologic behavior of this condition.

Disseminated xanthosiderohistiocytosis, a variant of xanthoma disseminatum, in a patient with a plasma cell dyscrasia.

A 57-year-old man was evaluated for infiltrative sclerotic nodules and plaques of the skin, the oral cavity, and the eye. Skin biopsy revealed a proliferation of mature histiocytes and extensive hemosiderin deposition, findings most consistent with xanthoma disseminatum and its variant, disseminated xanthosiderohistiocytosis. The subsequent development of a plasma cell dyscrasia was consistent with previous reports and suggests that xanthoma disseminatum is a marker for plasma cell disorders.

Erythema gyratum repens with associated squamous cell carcinoma of the lung.

A 63-year-old man with erythema gyratum repens (EGR) was found to have an underlying squamous cell carcinoma of the lung. Neither radiation nor chemotherapy had any effect on the extensive eruption. EGR is the most distinctive of the figurate erythemas, and continues to be one of the most consistent cutaneous signs of an associated visceral malignancy.

Metastatic epidermotropic squamous cell carcinoma of the vagina.

Epidermotropic carcinomas are neoplasms with an unusual but specific propensity for invading and intimately associating with the epidermis. A unique case of squamous cell carcinoma of the vagina with epidermotropic cutaneous metastases is described.

Invasive squamous cell carcinoma initially diagnosed as a giant keratoacanthoma.

Keratoacanthoma (KA) is currently considered a benign epithelial neoplasm. We report a patient with a lesion diagnosed as a KA that behaved aggressively like a squamous cell carcinoma (SCC). Similar reports are not uncommon in the literature. Because there are currently no criteria by which KA can be differentiated from SCC in all instances, we prefer to group KAs within the spectrum of well-differentiated SCC. We emphasize excisional surgery as the treatment modality of choice.

Contact exposure to elemental iron causing chromonychia.

An orange-brown chromonychia developed on the toenails of a woman after a geographic move resulted in exposure to rural well water. Samples of the water and qualitative and quantitative examination of nail clippings confirmed the fact that the source for the discoloration was contact exposure to elemental iron. Installation of water purification equipment resulted in resolution of the nail stain over a six-week period of time.

Pruritic urticarial papules and plaques of pregnancy. A case report.

A 30-year-old woman developed pruritic urticarial papules and plaques of pregnancy (PUPPP). The eruption, characterized by generalized edematous, erythematous plaques and nonexcoriated papules, began in the third trimester of pregnancy and was responsive to oral corticosteroids. While the etiology of PUPPP is unknown and the clinical features (urticarial plaques) sometimes overlap with those of other dermatoses of pregnancy, we regard PUPPP as a distinct entity. Utilization of a broad base of clinicopathologic and laboratory criteria is important in the workup of a patient with an eruption of pregnancy.

Therapy of acne.

Today acne vulgaris is a disease which can be well controlled using a combination of topical, systemic, and physical therapeutic modalities. However, successful acne management depends to a large extent on physician interest and the ability of the physician to apply therapy to the evolutionary stage of the disease and to the disturbed pathogenetic mechanisms. It is this author's opinion that grades I and II comedonal and papulopustular acne can be effectively treated solely with topical preparations, particularly the concurrent use of tretinoin with benzoyl peroxide or topical antibiotics. The majority of patients with grades III and IV inflammatory disease require oral antibiotics in addition to aggressive topical treatments. Intralesional steroids can be effective in all grades of acne when lesions develop an inflammatory nodulocystic quality. The physician should consider the use of estrogen (in females) or oral vitamin A in the small group of patients with grades III and IV inflammatory-cystic acne that has been unresponsive to conventional therapy. Combined systemic therapies of high-dose antibiotics, systemic corticosteroids, and sulfones clearly take precedence over topical preparations in conglobate acne and acne fulminans. Finally, oral isotretinoin, alone and perhaps in combination with more conventional modalities, should play an important role in the future management of severe inflammatory-cystic acne.

Isotretinoin versus placebo in the treatment of cystic acne. A randomized double-blind study.

Thirty-three patients with treatment-resistant cystic and conglobate acne entered a randomized, double-blind protocol testing the efficacy of isotretinoin versus placebo. There was an overall 57% increase in the number of cystic lesions in seventeen patients who initially received placebo. Sixteen of these seventeen patients then received isotretinoin, with a resultant 98% improvement. The sixteen patients who had been randomly assigned to receive initial therapy with isotretinoin had a 95% improvement. Twenty-seven of the thirty-two patients treated with isotretinoin cleared completely. The average maximum dosage of isotretinoin received by these patients was 1.2 mg/kg/day. Eighteen patients received only one 4-month course of isotretinoin. Fifteen patients received two courses. These included twelve patients with predominantly truncal acne who responded partially to the first course, and three patients who had cleared completely after one course of therapy but had mild relapses after an average of six months off of treatment. All patients are now in remission averaging 38 months in duration. Skin biopsies and quantitative measurement of sebum production during therapy indicated a profound inhibition of sebaceous gland size and function, which may be central to the mechanism of action of isotretinoin in acne.

Acute urinary tract obstruction in dyskeratosis congenita.

Dyskeratosis congenita is a multisystem disease affecting internal organs as well as the skin, nails, and mucous membranes. Tumors of the skin, tongue, cervix, and esophagus may develop in the disease. In this report we describe acute urinary retention that developed due to congenital meatal atresia and small foci of white plaques constricting the urethral meatus in a 27-year-old man with dyskeratosis congenita.

Blepharoconjunctivitis: a side effect of 13-cis-retinoic acid therapy for dermatologic diseases.

Blepharoconjunctivitis developed as a side-effect of treatment of patients with basal cell carcinomas, keratinizing dermatoses, and cystic acne with oral 13-cis-retinoic acid. Forty-two of the 97 dermatologic patients had signs and symptoms of blepharoconjunctivitis that were dose related and abated one week after discontinuation of the medication. About half of the patients had a history of similar symptoms prior to treatment. Staphylococcus aureus was present in eye cultures of 73% to 79% of the patients, whether symptomatic or not. Patients whose clinical appearance was that of staphylococcal blepharoconjunctivitis and whose cultures grew S aureus were successfully treated with topical erythromycin ointment to the lids even while being treated with the 13-cis-retinoic acid.