Benign hypersensitivity reactions to smallpox vaccine.

BACKGROUND: With the reinstitution of smallpox vaccinations, physicians are seeing significant numbers of adverse events for the first time since the 1980s. The most common adverse events seen in our large military population are benign. We observed a clinically and histopathologically distinct reaction pattern that has not been fully characterized previously. METHODS: All smallpox-vaccinated patients at Fort Hood, Texas with adverse cutaneous reactions were referred to the dermatology clinic at Darnall Army Community Hospital. Patients were evaluated by a staff dermatologist who performed a skin biopsy and took clinical photographs. If the patients had intact vesicles or pustules, direct fluorescent antibody testing, viral and bacterial cultures, and polymerase chain reaction (PCR) assays were also performed. RESULTS: Three hypersensitivity reaction patterns were seen: exanthematous, erythema multiforme-like (EM-like), and urticarial. The patterns had distinct clinical and histopathologic findings. Of the 11,058 vaccinees, six had the exanthematous reaction pattern, two had the urticarial reaction pattern, and one had the EM-like pattern. CONCLUSIONS: We describe a new exanthematous type of hypersensitivity reaction to the smallpox vaccine. Hypersensitivity reactions occur at a rate higher than previously reported. In a carefully screened military population, these three hypersensitivity reactions are much more common than life-threatening or serious reactions. Although the reactions have distinct clinical and pathologic features, they are all characterized by mild or absent systemic symptoms and a benign outcome.

Conjugal transfer vaccinia.

Two cases of conjugal contact transfer vaccinia are described. Each patient had intimate contact after their respective partners, active-duty military personnel, received the smallpox vaccination.

Mohs micrographic surgery for granular cell tumor using S-100 immunostain.

BACKGROUND: Granular cell tumor (GCT) is an uncommon tumor of neural origin. Most commonly it is found in the head and neck region and rarely on the foot. The pathologic diagnosis is often confirmed by immunohistochemical staining for S-100 protein. The standard treatment is complete excision. Two previous cases of GCTs treated by Mohs micrographic surgery (MMS) have been reported in the English literature. The immunohistochemical stain S-100 was not used in these cases. OBJECTIVE: Describe the use of S-100 immunohistochemical stain on MMS frozen sections in clearing a GCT of the foot with extension along nerves without involvement of perineurium. METHODS: Tissue was embedded and cut using standard Mohs surgical methodology. Frozen sections were stained with hematoxylin and eosin and with an immunoperoxidase method for S-100 protein using a Ventana automated stainer. RESULTS: MMS in combination with S-100 was successfully performed on a GCT on the plantar surface of our patient's foot. The S-100 immunohistochemical stain was helpful in tracking the extension along nerves of the GCT which was not evident with hematoxylin and eosin alone. CONCLUSION: Using S-100 immunohistochemical stain on the MMS frozen sections can increase the diagnostic accuracy for complete removal of GCT.

Gloves and socks syndrome: early and late histopathologic features.

BACKGROUND: Gloves and socks syndrome (GSS) is a recently described exanthem, most commonly caused by parvovirus B19. OBJECTIVE: Our purpose was to describe both early and late histopathologic features of GSS. METHODS: We performed histopathologic examination of biopsy specimens from a case of GSS and reviewed all the English-language literature reports of GSS to compare the reported histologic descriptions. RESULTS: A total of 46 cases of GSS have been reported in the English-language literature. In 18 of those, the pathologic features were described. The histologic features of the current case evolved from a nonspecific superficial perivascular lymphocytic infiltrate to a vacuolar interface dermatitis with necrotic keratinocytes, erythrocyte extravasation, and a superficial perivascular and interstitial lymphocytic infiltrate. CONCLUSION: Early lesions of GSS show nonspecific features common to viral exanthems. The late features, of a fully evolved exanthem, demonstrate a vacuolar interface dermatitis with necrotic keratinocytes, a superficial perivascular and interstitial infiltrate, and dermal hemorrhage. These late pathologic features, together with the clinical appearance of GSS, may help distinguish it from other entities.

Mohs micrographic surgery for melanoma: a case series, a comparative study of immunostains, an informative case report, and a unique mapping technique.

BACKGROUND: Mohs micrographic surgery (MMS) has been established as an alternative to standard surgical excision for local cutaneous malignant melanoma (MM) and melanoma in situ (MIS). The use of melanocyte-specific immunohistochemical stains may improve the diagnostic accuracy of MMS frozen sections. OBJECTIVE: We used MMS with immunostains to determine the maximum and minimum margins required to clear 52 melanomas, mostly MIS of the head and neck. We sought to identify the most sensitive melanocyte immunostain for use in MMS frozen sections and to improve the clinicopathologic correlation of perilesional pigmented lesions. METHODS: We studied 52 consecutive cases of invasive melanoma (n = 10) and MIS (n = 42), tabulating the maximum and minimum margins required for complete tumor resection in any one direction during MMS. In 10 of these cases we studied the relative sensitivity of the immunostains MART-1, S-100, and HMB-45 in Mohs frozen sections. We describe a case highlighting the importance of the increased sensitivity of MART-1. In 12 patients we used a unique mapping technique to help determine the clinical relevance of a total of 35 perilesional pigmented foci. RESULTS: The maximum margin averaged 10.1 mm (range 3-26 mm) for MM and 9.4 mm (range 3-18 mm) for MIS. The minimum margin averaged 7.0 mm (range 3-13 mm) for MM and 5.5 mm (range 3-11 mm) for MIS. For individual tumors, the difference between the minimum and maximum margin averaged 3.7 mm (range 0-13 mm). This difference was >or=5 mm in 38% (20/52) and >or=10 mm in 10% (5/52), highlighting that subclinical tumor extension is often broad and asymmetric. While five of six MM less than 1.0 mm in depth would have been cleared with a routine 1 cm excision, a standard 5 mm margin would have cleared less than one-quarter of the cases of MIS (10/42). In Mohs frozen sections, MART-1 proved superior in sensitivity to both HMB-45 and S-100. Our mapping technique provided clinically relevant histologic correlation for perilesional pigmented lesions, improving the Mohs surgeon's ability to evaluate equivocal foci in frozen sections. CONCLUSION: MM, especially MIS on the head and neck, often exhibits an asymmetric growth pattern, making it quite suitable for treatment with MMS. The use of MART-1 immunostain may improve the diagnostic accuracy of Mohs surgeons. We believe that HMB-45 should not be used to rule out the diagnosis of MIS in equivocal sections because of its inferior sensitivity. We introduce a new mapping technique as an adjunctive measure to aid in the clinicopathologic evaluation of perilesional skin.

Lichen sclerosus: an atypical presentation.

We describe the case of a 66-year-old Hispanic man with an atypical presentation of lichen sclerosus (LS). The unusual presentation included bilateral axilla involvement (not previously reported to our knowledge), scrotal involvement (not common in men, despite common vulvar involvement in women), and an uncommonly thick plaque on his back.