Post-surgical thyroid bed pyoderma gangrenosum mimicking recurrent papillary thyroid carcinoma

Background: Pyoderma gangrenosum (PG) is a rare inflammatory disease presenting with chronic-recurrent cutaneous ulcers histopathologically hallmarked by neutrophilic infiltrates, which may occur more frequently at sites of surgical traumas. The disease is habitually limited to the skin, but it can virtually involve any organ. Nevertheless, no prior cases of PG involving the thyroid bed have ever been reported. Case Report: A bilateral PG of the breast was diagnosed in a 51-year-old woman and treated with intravenous methylprednisolone pulse-therapy and cyclosporine, with partial improvement. During the hospitalization, cytological examination of two hypoechoic thyroid nodules by fine-needle aspiration (FNA) was consistent with thyroid carcinoma. After total thyroidectomy, histopathology confirmed a papillary thyroid cancer (PTC), and radioactive iodine ablation was performed. At 12-month ultrasonographic follow-up, two hypoechoic avascular areas localized in the empty thyroid bed raised the suspect of PTC recurrence. However, (i) undetectable levels of thyroglobulin without anti-thyroglobulin antibodies, (ii) neutrophilia and increased inflammatory marker levels, and (iii) cytological examination of FNA showing numerous neutrophils induced to suspect thyroid bed PG infiltration. An ex juvantibus approach with high-dose methylprednisolone led to dimensional reduction of the hypoechoic areas on ultrasonography, thus confirming the hypothesis of thyroid bed PG. Conclusion: This case of thyroid bed PG supports the idea that PG reflects a cutaneous phenotype encompassed in the spectrum of systemic neutrophilic diseases. Endocrinologists should be aware that thyroid bed PG involvement is an albeit rare differential diagnosis to consider in patients who had undergone thyroid surgery, especially with a history of PG

Treatment of Autoimmune Bullous Diseases During Pregnancy and Lactation : A Review Focusing on Pemphigus and Pemphigoid Gestationis

Pregnancy may induce the onset or exacerbation of autoimmune bullous diseases such as pemphigus or pemphigoid gestationis. A shift toward T helper (Th) 2 immune response and the influence of hormonal changes have been evoked as possible triggering factors. Therapeutic management of this setting of patients may represent a challenge, mainly due to safety concerns of some immunosuppressive drugs during pregnancy and lactation. In this narrative review, we provided a comprehensive overview of the therapeutic management of autoimmune bullous diseases in pregnant and breastfeeding women, focusing on pemphigus and pemphigoid gestationis

Lichenoid cutaneous chronic GvHD following Blaschko lines.

Lichenoid chronic GvHD following Blaschko lines is a rare variant of chronic, localized GvHD.Two patterns of distribution of localized chronic GvHD have been reported in the literature: Blaschko-linear and dermatomal; this last one corresponding to the area of previous zoster infection.Sanli et al.3 described a patient who developed lichenoid GvHD after herpes zoster infection involving the right neck, shoulder, chest, and scapular area, corresponding to the C3–C4 dermatomes. In post-zoster lichenoid GvHD, it has been hypothe- sized that viral proteins could play a role by altering the surface antigenicity of keratinocytes, thus triggering hypersensitivity reactions at these loci minoris resistentiae, as better documented in other dermatoses developed after a previous herpes zoster infection.3,6,7 The linear or whorled distribution following Blaschko lines, as in our case, could be better explained by the unmasking of a genetic mosaicism due to the donor’s lymphocytes and previously tolerated by the patient’s own lymphocytes.8 This hypothesis is also supported by Happle, who emphasizes the Blaschko-linear rather than dermatomalarrangement of localized GvHD and defines this disorder as polygenic, thus suggesting the preferable definition of a superimposed segmental manifestation. This implies that a segmental involvement could precede the appearance of non-segmental lesions, which fortunately did not happen in our reported case.

Chronic localized leukocytoclastic vasculitis: Clinicopathological spectrum of granuloma faciale with and without extrafacial and mucosal involvement

Granuloma faciale (GF) is a rare cutaneous condition of unknown origin, that usually presents as one or more brownpurple papules, plaques and/or nodules, localized mostly on the face, although extrafacial lesions can also occur. Eosinophilic angiocentric fibrosis (EAF) is regarded as the mucosal counterpart of GF. Histologically, it has been described as a persistent leukocytoclastic vasculitis, with a dense polymorphous inflammatory infiltrate in the superficial and mid dermis, typically sparing the subpapillary dermis, the so called grenz zone. The presence of eosinophils is considered a characteristic feature of the disease. All the cases of GF seen at the Dermatology Unit from 2002 to 2013 were considered and reviewed, both clinically and histopathologically. Only cases with consistent clinical findings of GF, and accurate patient's history were considered. Ten cases of GF were reviewed for both histological specificity and clinicopathological correlation. Two patients presented extrafacial lesions. One patient had involvement of nasal mucosa. Two patients suffered from associated rheumatological diseases. The most frequent histopathologic features were the presence of a grenz zone and eosinophils in the infiltrate, but also adnexal involvement was often present; vascular changes were constant, yet leukocytoclastic vasculitis could be recorded only in four cases. Fibrosis or sclerosis were always absent. Clinical pictures of the patients treated demonstrated a complete remission of the lesions, without scarring. However, a complete enduring healing was observed only in two patients, and relapse or incomplete remission of the disease was the rule. In conclusion a review of clinicopathological findings of ten patients affected by GF was made and new details of the disease presented

Longitudinal deep fissure and distal onycholysis of the right thumb. Amelanotic subungual melanoma.

A 74-year-old white woman presented with an approximately 1-year history of median longitudinal ridging of the right thumb that had evolved in a deep fissure along with distal onycholysis. She had previously been diagnosed as having onychomycosis and had been treated with topical and systemic antimycotic drugs, with no improvement. The medial part of the nail plate had progressively become thin and brittle, causing median longitudinal fissuring of the whole nail and isolating 2 lateral parts of normal nail plate. The nail bed, which was exposed by onychodystrophy, was yellowish red and had a few scales. The nail fold was not involved, and the hyponychium was not ulcerated and looked only slightly hyperkeratotic. The digital pulp was normal and painless. A punch biopsy specimen of the lesion was obtained, and a total excision of the nail apparatus was subsequently performed. The specimens were stained with hematoxylin-eosin and HMB-45