Widespread cutaneous vascular papules associated with peripheral blood eosinophilia and prominent inguinal lymphadenopathy.

A new section entitled "Dermatology Grand Rounds at the NIH" appears this month. The idea behind it is to provide a unique look at instructive dermatologic cases being presented at the weekly Dermatology Branch Grand Rounds at the National Cancer Institute, National Institutes of Health (NIH), Bethesda, Maryland. Patients seen at the NIH Clinical Center (which includes the NIH inpatient wards and outpatient clinics) are indeed unusual. To be evaluated here, they must be referred by an outside physician and must be placed in a research protocol. In other words, by this criterion, all NIH patients are considered research subjects. The diseases studied at the NIH range from the common to the obscure. Similarly, the dermatologic manifestations of these diseases are equally as diverse. Thus the purpose of this new section is to share some of these fascinating cases with the dermatologic community at large, as well as to provide a glimpse of exciting translational research that has relevance to clinical dermatologists. The format will be simple. Cases will be presented as unknowns, including relevant results from the history, physical examination, and histopathologic analyses. This will be done to challenge the clinicopathologic skills of the readers; authors will make every attempt to make the color clinical and pathologic photographs of the highest quality possible to assist readers in making the correct diagnoses. The discussion will be brief, focusing on the key teaching points of each case. These teaching points will vary from cases to case, covering clinical and histologic information, treatment issues, and/or novel laboratory advances with clinical relevance. Authors will emphasize brevity and clarity in all subsections of the case report, which I hope will promote a good learning experience for dermatology residents and busy practitioners alike. This section will initially be published 4 times annually. Finally, because the section is new to the JAAD, I welcome comments and suggestions to improve the quality of the articles.-Andrew Blauvelt, MD Feature Editor

Papillary and follicular thyroid carcinoma metastatic to the skin: a case report and review of the literature.

Cutaneous metastases from thyroid cancers are rare. We report the case of an otherwise asymptomatic 81-year-old woman with an enlarging scalp lesion. Her solitary skin metastasis was the presenting feature of thyroid carcinoma. Routine histopathology of the lesion was notable for an atypical clear cell neoplasm. Immunohistochemistry was positive for thyroglobulin. Subsequent resection of the thyroid gland identified separate foci (< 1 cm) for both papillary and follicular carcinoma. Although such immunohistochemical staining has been used previously, it has never been reported to provide the definitive diagnosis for a solitary cutaneous metastasis from the thyroid. Previous tumors had anatomic features in a clinical context that permitted identification by routine light microscopy. Clear cell features found in the follicular focus of carcinoma in the thyroid suggest that it is the primary. A worldwide literature review reveals that follicular carcinoma has a greater preponderance than papillary carcinoma for cutaneous metastasis and that the majority of skin metastases from either papillary or follicular thyroid cancer are localized to the head and neck.

Marjolin's ulcer arising in a burn scar.

Marjolin's ulcer-a term used to describe a malignancy arising in chronic ulcers of the skin, sinuses, scar tissue, and especially burns scars-occurs in two forms: an acute variant in which the malignant changes occur within a year of injury, and a chronic form in which the injury may precede the malignancy by decades. Illustrating the more common chronic form, we present the case of a 32-year old Haitian woman with an extensive squamous cell carcinoma arising from a burn scar on the dorsum of her right hand, with a review of the literature pertaining to burn scar carcinoma.

Melanoma of the soft parts (clear cell sarcoma): a case report and review of the literature.

Melanoma of the soft parts (clear cell sarcoma) is an uncommon soft tissue sarcoma that occurs in tendons and aponeuroses, usually of the lower extremity and is believed to be of neural crest origin. Although the exact histogenesis of this tumor is unknown and some controversy still exists, the generally accepted view is that it arises from neural crest cells that have the capability to produce melanin. Because melanin or melanosomes can be demonstrated in a majority of these cases, the term melanoma of the soft parts (MSP) has been advanced. These tumors commonly metastasize and have a very poor prognosis.

Mycobacterium fortuitum infection occurring after a punch biopsy procedure.

Mycobacterium fortuitum is a rapidly growing atypical mycobacterium frequently reported as a postsurgical wound complication from a major surgical procedure. We present a unique case of M. fortuitum infection occurring in a 4-year-old boy after a minor punch biopsy surgical procedure. As far as we know there has been no published case of M. fortuitum occurring after a punch biopsy procedure.

Trichostasis spinulosa: a clinical simulant of acne open comedones.

Trichostasis spinulosa is a disorder of the pilosebaceous follicles that may simulate acne open comedones. It is a commonly reported cosmetic annoyance in adults but not children. A review of the literature and a case of trichostasis spinulosa in a 13-year-old black girl with a history of onset at 18 months of age are presented.

Toxic sock syndrome.

Candida is a common part of the normal flora in several noncutaneous body sites, but invasion of the skin can occur under certain conditions. A case is presented in which the prolonged wearing of combat boots and damp socks caused an acutely inflamed papulopustular candidiasis of the feet.

An atypical piloleiomyoma presenting as a nonhealing ulcerated nodule.

Piloleiomyomas are benign smooth muscle tumors arising from the arrectores pilorum muscles in the skin. They vary in size and number, and are often spontaneously painful or sensitive to touch and cold. An unusual case of an ulcerated and painless piloleiomyoma is presented.

Loose anagen hair syndrome mimicking the uncombable hair syndrome.

A 7-year-old female presented with messy, difficult to manage scalp hair and mild, diffuse alopecia. Hair pull specimens, diagnostic for loose anagen hair syndrome, also showed hair shaft abnormalities described in the uncombable hair syndrome. We suggest that dysmorphic hair shafts observed on our patient account for her clinically unmanageable hair. Pertinent clinical, pathologic, and diagnostic features of both syndromes are reviewed.

Unilateral Beau's lines associated with a fractured and immobilized wrist.

Beau's lines are transverse depressions of the nail plates. They are usually bilateral and result from a temporary cessation in the growth of the nail plate during severe systemic illnesses. Although transverse grooves can occur on the nails of one extremity, this has not been a commonly reported phenomenon. An unusual case of unilateral Beau's line associated with a metaphyseal fracture of the distal radius extending into the growth plate with wrist immobilization is presented. Other related causes of Beau's line are reviewed.

Knuckle pads.

Knuckle pads are well circumscribed thickenings of the skin over the metacarpophalangeal and, more commonly, the proximal interphalangeal joints. Although the association with several other clinical syndromes including Dupuytren's disease is well documented, most cases are idiopathic. We present a case of knuckle pads and briefly review the history and course of this disease.

Xanthomatized atypical T cells in a patient with mycosis fungoides and hyperlipidemia.

BACKGROUND: Lipoprotein-T-cell interactions are being reported with increasing frequency, and there is evidence that lipoproteins play a role in immunoregulation. We describe a patient with mycosis fungoides and hyperlipidemia who developed xanthomatization in one preexisting plaque. The case is unique in that some of the lipidized cells were atypical T cells. In previously reported cases of mycosis fungoides with dystrophic xanthomatosis, the lipid-containing cells have been identified only as histiocytes. OBSERVATIONS: Immunopathologic features, electron microscopy, and lipid stains of the xanthomatized plaque demonstrated that some of the lipid-laden cells were atypical T cells. CONCLUSIONS: In mycosis fungoides, malignant T cells may be intimately involved in processing of tissue lipids. We suggest that low-density lipoprotein receptors on activated T cells facilitated the cytoplasmic lipidization in this case.

Waldenström macroglobulinemia with an IgM-kappa antiepidermal basement membrane zone antibody.

BACKGROUND: Waldenström macroglobulinemia, a lymphoplasmacytoid cell malignant neoplasm associated with a monoclonal IgM paraprotein, has been associated with a number of cutaneous manifestations. On rare occasions, IgM deposits have been demonstrated in the epidermal basement zone of patients with WM. OBSERVATIONS: We report the case of a patient with Waldenström macroglobulinemia and IgM-kappa paraprotein who had development of an eruption of pruritic papules and demonstrated the following unusual immunopathologic findings: (1) deposits of IgM-kappa in the epidermal basement membrane zone of lesional and nonlesional skin; (2) a circulating IgM-kappa antiepidermal basement membrane zone antibody; and (3) binding of this circulating IgM-kappa antiepidermal basement membrane zone antibody to both sides of 1 mol/L sodium chloride split skin. The cutaneous eruption cleared completely with oral psoralen with long-wave UV radiation in the A range (PUVA) therapy. CONCLUSIONS: We present a patient with Waldenström macroglobulinemia who had a distinctive papular eruption and immunopathologic findings suggesting that his paraprotein has specificity for the epidermal basement membrane zone.

Localized, perifollicular cold urticaria.

Cold urticaria is a condition with many clinical variants. We present the case of a young woman with a localized, perifollicular form that we believe represents a new and distinct clinical subtype of cold urticaria. We review other established clinical subtypes of cold urticaria.