Herpetic zoster folliculitis in the immunocompromised host

Introduction Exclusive involvement of herpes zoster (HZ) in the follicular epithelium occurs rarely and lacks the typical cutaneous and histopathologic findings associated with herpesvirus. We describe a patient who underwent adjuvant chemotherapy for pancreatic cancer and subsequently had a nonvesicular rash for several weeks, ultimately proving to be herpetic zoster folliculitis. Case report A 78-year-old man with adenocarcinoma of the tail of the pancreas treated with surgical resection and 1 round of adjuvant chemotherapy with gemcitabine, docetaxel, and capecitabine presented with a 3-week history of a right leg rash. He first noticed the rash 5 days after the initiation of his chemotherapy. It initially appeared on his middorsal foot, and over the next couple weeks progressed proximally along the anteromedial leg to the distal knee and medial thigh. It was not painful and was minimally pruritic. Two and a half weeks after the onset of his rash, a fever to 38.5°C developed along with back pain. At this time, he had a nondiagnostic skin biopsy by an outside dermatologist and was given diphenhydramine and topical hydrocortisone with no improvement in his rash. He also had an abdominal computed tomography (CT) performed at an outside hospital, which found a left upper quadrant fluid collection. He was subsequently admitted to Columbia Presbyterian Medical Center for evaluation. On our examination, he had purpuric patches and edematous, purpuric papules along the right dorsal foot, extending proximally up the right anteromedial leg (Fig 1). He also had a few faint pink papules along the right hip and superior buttock (Fig 2). There were no vesicles. A comprehensive metabolic panel and liver function test results were normal. Noted were a leukocytosis level of 14,400/μL with 76% neutrophils and 1% bands, an elevated lipase level of 194 U/L (3-43 U/L), and an amylase level of 95 U/L (20-96 U/L). A CT scan of the abdomen confirmed an 8.0- × 7.0-cm fluid collection of the left upper quadrant of the abdomen. A skin biopsy of the right anteromedial leg found only alteration of the basal layer epidermis with a perivascular mononuclear cell infiltrate and extravasated erythrocytes. However, deeper sections had necrotic keratinocytes and multinucleated epithelial-type giant cells with ground-glass nuclei restricted to the follicular epithelium, confirming a diagnosis of follicular herpetic infection (Fig 3, A and B). A diagnosis of HZ in the L4 and L5 dermatomes was made, and the eruption promptly resolved with a 7-day course of valganciclovir (1-g tablet 3 times a day)

Resolution of urticarial vasculitis after treatment of neurocysticercosis

Urticarial vasculitis is most often idiopathic, but may occur in association with autoimmune disease, malignancy, drugs, or infection. Parasitic infection is a rare cause of urticarial vasculitis. We report a case of urticarial vasculitis that resolved after the diagnosis and treatment of neurocysticercosis

Cell type-specific over-expression of chromosome 21 genes in fibroblasts and fetal hearts with trisomy 21

BACKGROUND: Down syndrome (DS) is caused by trisomy 21 (+21), but the aberrations in gene expression resulting from this chromosomal aneuploidy are not yet completely understood. METHODS: We used oligonucleotide microarrays to survey mRNA expression in early- and late-passage control and +21 fibroblasts and mid-gestation fetal hearts. We supplemented this analysis with northern blotting, western blotting, real-time RT-PCR, and immunohistochemistry. RESULTS: We found chromosome 21 genes consistently over-represented among the genes over-expressed in the +21 samples. However, these sets of over-expressed genes differed across the three cell/tissue types. The chromosome 21 gene MX1 was strongly over-expressed (mean 16-fold) in senescent +21 fibroblasts, a result verified by northern and western blotting. MX1 is an interferon target gene, and its mRNA was induced by interferons present in +21 fibroblast conditioned medium, suggesting an autocrine loop for its over-expression. By immunohistochemistry the p78(MX1 )protein was induced in lesional tissue of alopecia areata, an autoimmune disorder associated with DS. We found strong over-expression of the purine biosynthesis gene GART (mean 3-fold) in fetal hearts with +21 and verified this result by northern blotting and real-time RT-PCR. CONCLUSION: Different subsets of chromosome 21 genes are over-expressed in different cell types with +21, and for some genes this over-expression is non-linear (>1.5X). Hyperactive interferon signaling is a candidate pathway for cell senescence and autoimmune disorders in DS, and abnormal purine metabolism should be investigated for a potential role in cardiac defects

Case Report: Crying Blood

SIGNIFICANCE. Hemolacria (bloody tears) is a rare clinical presentation with varied underlying etiology. Thorough clinical evaluation is essential to diagnosis and management. PURPOSE. To report unilateral hemolacria in a known contact lens wearer with an occult, palpebral, conjunctival pyogenic granuloma and review the literature. CASE REPORT. A 21-year old female contact lens wearer presents following three episodes of sudden painless bloody tears from the right eye. She was referred to the oculoplastic clinic for evaluation. On everting her right upper lid, a fleshy, non-tender, ovoid, pedunculated mass was found attached to the palpebral conjunctiva of the right, nasal, upper tarsus. Surgical excision was performed in the office and pathologic examination of the lesion was consistent with pyogenic granuloma. CONCLUSIONS. Unilateral hemolacria should raise clinical suspicion for a hidden conjunctival lesion such as pyogenic granuloma, although other more sinister causes of hemolacria must also be considered. Thorough evaluation including eyelid eversion is critical in identifying and managing occult conjunctival lesions

Squamous Cell Carcinoma (Marjolin’s Ulcer) Arising in a Sacral Decubitus Ulcer Resulting in Humoral Hypercalcemia of Malignancy

Long-standing burns, fissures, and ulcers that undergo malignant transformation into a variety of malignancies, including squamous cell carcinoma, is commonly referred to as a Marjolin’s ulcer. It is well recognized that squamous cell carcinomas of the lung and esophagus can cause humoral hypercalcemia of malignancy secondary to paraneoplastic secretion of parathyroid hormone-related peptide. However, it is extremely rare for a squamous cell carcinoma developing in a sacral decubitus ulcer to cause humoral hypercalcemia of malignancy. We describe the first case of a patient found to have elevated serum levels of parathyroid hormone related peptide related to his Marjolin’s ulcer. A 45-year-old African American man with T6 paraplegia and a sacral decubitus ulcer present for 20 years was admitted for hypercalcemia of unclear etiology. He was subsequently found to have elevated parathyroid hormone related peptide and an excisional biopsy from the ulcer showed invasive squamous cell carcinoma suggestive of humoral hypercalcemia of malignancy. The patient ultimately succumbed to sepsis while receiving chemotherapy for his metastatic squamous cell carcinoma. Humoral hypercalcemia of malignancy is a rare and likely underrecognized complication that can occur in a Marjolin’s ulcer

Squamous Cell Carcinoma (Marjolin’s Ulcer) Arising in a Sacral Decubitus Ulcer Resulting in Humoral Hypercalcemia of Malignancy

Long-standing burns, fissures, and ulcers that undergo malignant transformation into a variety of malignancies, including squamous cell carcinoma, is commonly referred to as a Marjolin’s ulcer. It is well recognized that squamous cell carcinomas of the lung and esophagus can cause humoral hypercalcemia of malignancy secondary to paraneoplastic secretion of parathyroid hormone-related peptide. However, it is extremely rare for a squamous cell carcinoma developing in a sacral decubitus ulcer to cause humoral hypercalcemia of malignancy. We describe the first case of a patient found to have elevated serum levels of parathyroid hormone related peptide related to his Marjolin’s ulcer. A 45-year-old African American man with T6 paraplegia and a sacral decubitus ulcer present for 20 years was admitted for hypercalcemia of unclear etiology. He was subsequently found to have elevated parathyroid hormone related peptide and an excisional biopsy from the ulcer showed invasive squamous cell carcinoma suggestive of humoral hypercalcemia of malignancy. The patient ultimately succumbed to sepsis while receiving chemotherapy for his metastatic squamous cell carcinoma. Humoral hypercalcemia of malignancy is a rare and likely underrecognized complication that can occur in a Marjolin’s ulcer

Case Report: Crying Blood.

SignificanceHemolacria (bloody tears) is a rare clinical presentation with varied underlying etiologies. Thorough clinical evaluation is essential to diagnosis and management.PurposeThis study aimed to report unilateral hemolacria in a known contact lens wearer with an occult, palpebral, conjunctival pyogenic granuloma and review the literature.Case reportA 21-year-old female contact lens wearer presented to the clinic after three episodes of sudden painless bloody tears from the right eye. She was referred to the oculoplastic clinic for evaluation. On everting her right upper lid, a fleshy, nontender, ovoid, pedunculated mass was found attached to the palpebral conjunctiva of the right, nasal, upper tarsus. Surgical excision was performed in the office, and pathological examination of the lesion was consistent with pyogenic granuloma.ConclusionsUnilateral hemolacria should raise clinical suspicion for a hidden conjunctival lesion such as pyogenic granuloma, although other more sinister causes of hemolacria must also be considered. Thorough evaluation including eyelid eversion is critical in identifying and managing occult conjunctival lesions

Extragenital lichen sclerosus et atrophicus-morphea overlap as an initial presentation of genital lichen sclerosus

Lichen sclerosus et atrophicus (LSA) is a chronic inflammatory disorder, most often characterized by atrophic skin plaques located on female genitalia. Infrequently, LSA may present extragenitally; however, much is unknown about the temporal relationship between genital and extragenital LSA. Morphea, also known as localized scleroderma, is a rare inflammatory skin condition characterized by sclerotic plaques. Investigators debate whether LSA and morphea exist on the same spectrum of disease, with LSA representing a superficial variant of morphea involving genitalia, or if they are distinct but coincidental entities. Although researchers have described LSA and morphea occurring in different locations on the same patient, few reports describe LSA and morphea occurring in the same lesion and in the inguinal folds. Herein, we report a case of a 62-year-old woman with extragenital LSA-morphea overlap in the inguinal folds, who three months later developed genital LSA. Extragenital LSA-morphea in the same plaque, with no signs of genital lesions on initial exam, with later development of genital LSA, is especially uncommon. The temporal progression of extragenital LSA-morphea overlap to genital LSA over a three-month period is an important contribution to the literature, as the temporal relationship between extragenital and genital LSA is not previously discussed