Pesticide-associated pemphigus vulgaris.

We present a 40-year-old man with occupation-induced pemphigus vulgaris (PV). He developed PV within days of a one-time heavy exposure to fumes of burning glyphosate, a broad-spectrum nonselective pesticide. This exposure suggests acute cutaneous contact as a stimulus in the development of his pemphigus. While the patient initially required mycophenolate mofetil and prednisone therapy, he has since eliminated contact with pesticides and has been successfully tapered off systemic medication. We discuss the case and review concepts of inducible PV by pesticides and physical cutaneous injury.

Current concepts of metastasis in melanoma.

The main cause of death in melanoma patients is widespread metastases. Staging of melanoma is based on the primary tumor thickness, ulceration, lymph node and distant metastases. Metastases develop in regional lymph nodes, as satellite or in-transit lesions, or in distant organs. Lymph flow and chemotaxis is responsible for the homing of melanoma cells to different sites. Standard pathologic evaluation of sentinel lymph nodes fails to find occult melanoma in a significant proportion of cases. Detection of small numbers of malignant melanoma cells in these and other sites, such as adjacent to the primary site, bone marrow or the systemic circulation, may be enhanced by immunohistochemistry, reverse transcription PCR, evaluation of lymphatic vessel invasion and proteomics. In the organs to which melanoma cells metastasize, extravasation of melanoma cells is regulated by adhesion molecules, matrix metalloproteases, chemokines and growth factors. Melanoma cells may travel along external vessel lattices. After settling in the metastatic sites, melanoma cells develop mechanisms that protect them against the attack of the immune system. It is thought that one of the reasons why melanoma cells are especially resistant to killing is the fact that melanocytes (cells from which melanoma cells derive) are resistant to such noxious factors as ultraviolet light and reactive oxygen species. Targeted melanoma therapies are, so far, largely unsuccessful, and new ones, such as adjuvant inhibition of melanogenesis, are under development.

Ruptured umbilical hernia in a case of alcoholic cirrhosis with massive ascites.

Umbilical hernias are common in patients with cirrhosis of the liver and ascites. However, spontaneous rupture of the hernia is not frequently seen. This is a serious complication and carries a high mortality. A search of the literature shows that patients have been managed both operatively and nonoperatively for this condition. We present a case of spontaneous rupture of an umbilical hernia in a patient with cirrhosis and ascites which was managed successfully with hernia repair.