Dermatologic complications from levamisole-contaminated cocaine: a case report and review of the literature.

Levamisole is a veterinary anthelmintic drug with immunomodulatory properties in humans. It has become increasingly common as a contaminant in cocaine and is now detected in the majority of cocaine seized in the United States. A variety of adverse reactions have been reported in association with levamisole, the most severe being agranulocytosis, vascular occlusive disease, and thrombotic vasculopathy, with or without vasculitis. The combination of rapidly progressive cutaneous ecchymosis and purpura leading to necrosis, often affecting the ears and cheeks; neutropenia or agranulocytosis; serologic autoantibodies; and thrombotic vasculopathy, with or without associated vasculitis, in a patient who has recently used cocaine is characteristic of exposure to contaminant levamisole. We report the case of a 54-year-old man who presented with the clinical findings of levamisole-contaminated cocaine use and review the literature regarding cutaneous reactions associated with levamisole. Our case highlights this important public health issue and represents a clinical course that is unusually severe.

Metastatic melanoma and melanogenuria.

We report a case of a 70-year-old Hawaiian man with an exophytic black nodule on the left suprascapular region of several years' duration. Histopathologic examination of the excised lesion showed a nodular melanoma with 17-mm Breslow thickness. The patient had firm fixed lymph nodes circumferentially around his neck. He underwent palliative cervical lymph node dissection to remove the compressive nodes but declined further therapy. One year later, the patient's skin was noted to have a generalized uniformly gray-brown color. Physical examination showed ulcerated masses on his trunk, right arm, and both axillae. A urine specimen initially was dark yellow but turned black after exposure to air at room temperature and ambient light for several minutes. Black urine, termed melanuria, is a rare finding in patients with disseminated melanoma. In melanogenuria, the urine is yellow and darkens as the colorless melanin precursors oxidize in the presence of air. Detection of these urinary melanin precursors may someday help determine the prognosis of melanoma and monitor response to treatment.

Cutaneous granulomatous vasculitis associated with chronic lymphocytic leukemia: case report and review of literature of a rare entity.

Cutaneous granulomatous vasculitis associated with lymphoproliferative disorders is a rare entity, with only 14 cases previously reported in the English literature. Patients generally present with nodules or ulcers involving the extremities, which can appear months or years before or after onset of systemic disease. Granulomatous vasculitis has a poor prognosis when associated with underlying lymphoproliferative disorders, with the majority of reported cases fatal. Knowledge of this unusual entity is important to allow for proper clinical evaluation, follow-up, and therapy. We report a 77-year-old female with chronic lymphocytic leukemia and granulomatous vasculitis, which highlights the features of this association, and expands the clinical data.

Incidental cutaneous reaction patterns: epidermolytic hyperkeratosis, acantholytic dyskeratosis, and hailey-hailey-like acantholysis: a potential marker of premalignant skin change.

Focal acantholytic dyskeratosis (FAD), epidermolytic hyperkeratosis (EHK), and Hailey-Hailey-like acantholysis (HH) represent unique histology reaction patterns, which can be associated with defined phenotypic and genotypic alterations. Incidental microscopic foci demonstrating these patterns have been identified in skin and mucosal specimens in association with a gamut of disease processes. These changes, when secondary, are of unclear etiology and significance. The following study further analyzes the incidence and association of these histologic patterns in a routine pathology/dermatopathology practice.

Onychomatricoma: case report of an unusual subungual tumor with literature review.

Onychomatricoma is rare subungual tumor of nail matrix origin. We report a 40-year-old white man with an onychomatricoma of the left index finger that highlights the characteristic clinical and pathological features and expands the known case material. We also review the published medical literature on the subject.

Papular spongiotic dermatitis of smallpox vaccination: report of 2 cases with review of the literature.

We report 2 cases of nonspecific postvaccinial dermatitis following smallpox vaccination. The patients presented with diffuse, pruritic, erythematous macules and papules 11 days (case 1) and 7 days (case 2) following routine smallpox vaccination. Biopsies of the lesions demonstrated spongiotic dermatitis without evidence of viral cytopathic changes. One case showed a pityriasis rosea-like histologic pattern. The exanthema resolved without sequelae with symptomatic treatment (case 1). Review of historical literature demonstrated the association of a variety of nonspecific cutaneous complications with vaccinia inoculation, including erythema multiforme, urticaria, and pityriasis rosea. The association of these various dermatitides with smallpox immunization is not well known and is likely underreported.

Fine-needle aspiration of renal angiosarcoma.

Angiosarcoma of the kidney is an unusual neoplasm, and primary renal angiosarcoma is exceedingly rare, with fewer than 11 well-documented cases reported to date. To our knowledge, no publication to date has correlated the fine-needle aspiration cytologic findings in renal angiosarcoma with the gross, histologic, and immunohistochemical findings. A 50-year-old man presented with a left kidney mass and multiple liver and pulmonary nodules. Computed tomography-guided fine-needle aspiration biopsies of the renal mass and a hepatic nodule were performed and demonstrated malignant spindle cells consistent with angiosarcoma. The diagnosis was confirmed at autopsy through histologic examination and associated ancillary studies. This case presents the fine-needle aspiration cytologic findings in renal angiosarcoma and correlates these findings with the gross pathologic, histologic, and immunohistochemical findings.