Focal Neurotoxicity Associated With Topical 5-Fluorouracil.

Topical 5-Fluorouracil (5-FU) is an antineoplastic chemotherapy drug used to treat precancerous and cancerous skin growths, such as actinic keratoses (AKs), squamous cell carcinoma in situ, and superficial basal cell carcinoma. The topical agent may rarely cause neurotoxic adverse effects. Multiple cases of systemic 5-FU and capecitabine chemotherapy-induced neuropathies have been reported. However, until now, the topical administration of the drug has not been reported to cause neurotoxicity. We present a case of an 83-year-old male who was prescribed topical 5-FU 5% cream to treat AKs on the left anterior scalp and returned weeks later with the development of focal neurotoxicity in the treatment area. He presented with focal paralysis of the left medial frontalis muscle, with initial loss of sensation followed by intermittent pain and paresthesias, persisting four months after the cessation of therapy. He was referred to a neurologist and received a diagnosis of supraorbital neuralgia. The temporal relationship of symptom onset and the localization of symptoms to the treated area strongly suggests that the medication contributed to the observed neurologic effects. These effects are more likely to be observed in patients with a genetic deficiency of dihydropyrimidine dehydrogenase (DPD), which is responsible for the majority of 5-FU degradation (80%), therefore potentially leading to toxic levels of unmetabolized 5-FU. Providers should be aware of the potentially neurotoxic effects of topical 5-FU in order to properly counsel patients and to consider this as a possible etiology of neurologic deficits in patients using this drug.

Pathergy of a Medial Heel Schwannoma.

Schwannomas are benign soft-tissue tumors derived from Schwann cells of the peripheral nervous system. They typically appear on the head, neck, or trunk, and are often asymptomatic or present with mild tenderness to palpation and numbness due to nerve compression. A 17-year-old male was referred to our dermatology clinic for evaluation and treatment of an asymptomatic, pink, flesh-colored subcutaneous nodule on the medial right heel. A biopsy was performed to rule out malignancy, with the pathology report consistent with the diagnosis of schwannoma. Following the biopsy, the patient developed a persistent, non-healing red-violaceous ulcerative plaque at the biopsy site, which persisted following additional electrodessication and silver nitrate application. Repeat biopsy showed persistent schwannoma and notably the absence of a pyogenic granuloma. The persistent ulceration following the initial biopsy is consistent with the phenomenon known as pathergy, which refers to exaggerated tissue reactivity in response to trauma. The patient eventually required surgical excision and a keystone flap for definitive treatment of the lesion. Although rare, we have demonstrated that pathergy can occur during surgical procedures on suspected schwannomas. Physicians should be aware of this possible complication so that they can provide anticipatory guidance for patients undergoing surgical procedures on undiagnosed cutaneous neoplasms for which a schwannoma is in the differential diagnosis.

Cutaneous Metastasis of Lung Adenocarcinoma: Initially Mimicking and Misdiagnosed as Keloids.

Cutaneous metastases have distinct morphologic features that can aid in making the diagnosis clinically even prior to biopsy. Lesions often have a nodular appearance and are firm, fixed, and range from flesh-colored to reddish-purple. A 73-year-old female with a history of lung adenocarcinoma status-post neoadjuvant chemotherapy and lobectomy 20 months prior was referred to our dermatology clinic for evaluation and treatment of suspected keloids on the left flank. The lesions were firm, plum-colored, fibrotic nodules, and were diagnosed clinically in the office as cutaneous metastases of internal malignancy. Punch biopsy was performed and revealed a proliferation of atypical epithelial cells arranged in cords and strands, with neoplastic cells positive for CK7 and TTF-1, confirming the diagnosis of metastatic adenocarcinoma. The patient was referred for chemotherapy and is still alive nine months following the prompt clinical diagnosis of cutaneous metastasis. Cutaneous metastasis signifies a poor prognosis, but knowledge of the clinical characteristics of these lesions can lead to earlier detection and more prompt initiation of treatment.

Endovascular management of HIV vasculopathy.

HIV is a multisystem disease process that can affect the cardiovascular system resulting in vasculopathy. As highly active anti-retroviral therapy has allowed patients to live longer with the disease, vascular complications such as aneurysms, occlusive disease, spontaneous arteriovenous fistulae, and arterial dissections have been described. The pathogenesis of vascular-related complications in HIV is poorly understood but is thought to involve an interplay between viral-induced inflammation, vascular smooth muscle changes, endothelial alterations, and circulating blood factors. The most well-described management strategies for symptomatic aneurysm-related complications are surgical in nature, with mostly anecdotal reports of endovascular intervention. We present a case of a 24-year-old male who was found to have findings consistent with HIV vasculopathy on angiography after presenting with acute GI hemorrhage secondary to left gastric artery bleeding. Our patient was managed with endovascular embolization. Although studies have shown promise regarding the endovascular management of HIV-related aneurysmal complications in the short term, more research is needed to evaluate the long-term success of these interventions.

Combined transhepatic and transjugular approach for mechanical thrombectomy of massive TIPS thrombosis.

Transjugular intrahepatic portosystemic shunt (TIPS) is a well-validated decompressive therapy option to manage ascites and variceal bleeding secondary to portal hypertension. Complications following TIPS procedures include hepatic encephalopathy, liver failure, and TIPS dysfunction. TIPS dysfunction is due to occlusion or stenosis of the TIPS shunt and can be caused by acute or chronic thrombosis. TIPS thrombosis is often treated with mechanical thrombectomy or catheter-directed thrombolytic therapy. Most cases of in-stent occlusion can be treated via a transjugular approach with recanalization or placement of additional stents. We present a case of a 72-year-old female who presented with worsening ascites 17 months after initial TIPS procedure; she was found to have a large thrombus completely occluding the TIPS stent. In our case, a combined transhepatic and transjugular approach was required for TIPS revision given the extent of well-organized clot located near the hepatic venous end of the stent, resulting from prolonged stent occlusion. This was an extremely challenging scenario with two overlapping covered stents and a bare metal stent at the hepatic venous end in the setting of chronic thrombosis and a well-organized fibrous cap. The case highlights the need for optimal initial placement of the primary TIPS shunt to avoid the need for subsequent complex interventions to maintain TIPS shunt patency.

Seurat Spleen: A Pathognomonic Sign in Angiography.

Splenic injury commonly occurs following abdominal trauma and can result in severe complications and death if it goes unrecognized. The Seurat spleen is a term used to describe the angiographic appearance of splenic injury following blunt trauma, given its resemblance to the pointillistic artwork of French neo-impressionist Georges Seurat. We present a case of a 43-year-old man who presented following a motor vehicle collision and was found to have multiple punctate foci of contrast extravasation in the spleen consistent with the Seurat spleen angiographic sign. This angiographic pattern can be used as a pathognomonic sign to identify splenic injury, with early identification crucial to preventing further complications of the injury.