Akimasa Saito

Giant Lipoma with Fat Necrosis of the Back Mimicking Atypical Lipomatous Tumor in MRI Findings

Background: Although fat necrosis can be observed in several inflammatory adipose diseases, the occurrence of fat necrosis in lipomas is reported to be rare. Method: A case report of fat necrosis in a lipoma mimicking atypical lipomatous tumor in MRI findings. Result: A 63-year-old man presented with a 2-year history of a subcutaneous nodule in his back. MRI showed that a 20 × 15 cm well-circumscribed tumor was located beneath the latissimus dorsi muscle with high signal intensities on both T1- and T2- weighted images and signal attenuation on fat suppression sequences. Inside the tumor, there were multiple thickened septa with gadolinium enhancement, which was consistent with atypical lipomatous tumor. However, we diagnosed this case as a lipoma with fat necrosis from the findings of an incisional biopsy and enucleation of the tumor was performed. Conclusion: A lipoma with fat necrosis may show similar imaging findings to atypical lipomatous tumor. Therefore, it is important to confirm the diagnosis histologically, when we encounter a lipomatous tumor that imaging findings indicate to be atypical lipomatous tumor. Also, we should plan to take samples of not just the adipose lesion, because the differential diagnosis may be difficult if only lipomatous regions are biopsied.

Cutaneous infection due to Mycobacterium szulgai in a patient with myelodysplastic syndrome

was done and numerous whitish colonies were observed after 1 week (Fig. 1f). For identification of the mycobacterial species, we performed polymerase chain reaction hybridization and erythromycin ribosome methyltransferase gene polymerase chain reaction (PCR). As a result, it was identified as M. massiliense. In addition, we took an ultrasound-guided lymph node needle biopsy in the left inguinal area. Histopathological findings showed reactive hyperplasia with granulomatous histiocytic infiltration but negative results in Gram, PAS, AFB staining and culture(Fig. 1e). As drug sensitivity tests revealed sensitivity to clarithromycin, oral clarithromycin 500 mg/day was administrated for 5 months and incision and drainage was performed intermittently. The lesions had decreased in size and recurrence was not observed after discontinuation of medication (Fig. 1c). Mycobacterium massiliense was first described as a new species from the M. abscessus and M. chelonae group by Adekambi et al. Clinically, cutaneous M. massiliense infections manifest as disseminated subcutaneous nodules in immunocompromised patient and skin nodules, ulcer and abscess at traumatic sites in immunocompetent individuals. There are less than 10 reported cases of cutaneous M. massiliense worldwide. Among these, just three cases were not preceded by a previous event. This infection is usually assumed to have originated from an environmental source but it may occur in immunocompetent patients without antecedent event. It is usually difficult to diagnose non-tuberculous mycobacterium (NTM) because of its various clinical manifestations and lower sensitivity of culture results. However, it is important to find out the causative microorganism at the species level to manage infection. To diagnose NTM infection, real-time PCR assay is a very useful tool because of its accuracy and rapidness. Previously, combination therapy including clarithromycin with other antibiotics has been used empirically for the treatment against M. massiliense. At present, we treat our patient with clarithromycin alone and with good improvement. Long-term medication is recommended to prevent recurrence.

High-grade mucoepidermoid carcinoma of the columella successfully reconstructed using bilateral nasolabial flaps set up in a sandwich shape and an auricular cartilage graft after surgical resection

Mucoepidermoid carcinoma (MEC) usually originates from the salivary glands. However, there has been no report on mucoepidermoid carcinoma of the columella. In this study, we report the case of a high‐grade MEC of the columella that was successfully reconstructed after surgical resection with bilateral nasolabial flaps set up in a sandwich shape and an auricular cartilage graft. A 66‐year‐old man presented with a nodule on the columella. Histological findings were suggestive of a high‐grade mucoepidermoid carcinoma. Wide excision was performed, and the defects of the columella and the nasal floor were reconstructed with bilateral nasolabial flaps set up in a sandwich shape and an auricular cartilage graft. The postoperative cosmetic result was good with excellent tissue texture. The reconstructed columella had an appropriate, not bulky, width as well as satisfactory height and depth. This reconstructive technique is particularly useful for correcting the large defect of the columella with nasal septum and/or nasal floor defects.

Diffuse erythema with ‘angel wings’ sign in Japanese patients with anti-small ubiquitin-like modifier activating enzyme antibody-associated dermatomyositis

Myositis-specific autoantibodies (MSAs) are closely associated with distinct clinical subsets of dermatomyositis (DM). In 2007, a novel MSA-reacting small ubiquitin-like modifier activating enzyme (SAE) was identified in some patients with DM characterised by extensive rash and dysphagia1 . Owing to the low proportion of patients with DM having the anti-SAE antibody (1.5%-3% in Asia2-4 and 6.7%-8.4% in Europe5-7 among all patients with DM), their clinical features have not been sufficiently analysed. This article is protected by copyright. All rights reserved.

Case of facial lupus erythematosus profundus with intractable ulceration successfully treated with dapsone

Dear Editor, Lupus erythematosus profundus (LEP) is an uncommon clinical subtype of cutaneous LE, which affects subcutaneous adipose tissue. LEP has a chronic and recurrent clinical course. Antimalarial drugs are used to treat LEP worldwide, however, its use was prohibited in Japan until recently. Here we report a case of LEP with intractable ulceration on the face treated with dapsone. A 66-year-old woman presented with a 7-month history of indurative erythema with ulceration on her right cheek, which did not respond to oral prednisolone at 30 mg daily. Physical examination revealed an ulcer 10 cm 9 7 cm in diameter covered with a thick yellowish crust and surrounded by erythema (Fig. 1a). She did not have any systemic symptoms. Laboratory investigations revealed normal blood cell counts, normal results on blood coagulation tests including activated partial thromboplastin time, and negative antinuclear antibody. A skin biopsy from the edge of the ulcer demonstrated lobular panniculitis with infiltration of lymphocytes and scattered plasma cells, which was also dense in perivascular and periadnexal sites in

Immunoglobulin A vasculitis associated with HIV infection.

1 Bardazzi F, Odorici G, Virdi A et al. Autoantibodies in psoriatic patients treated with anti-TNF-a therapy. J Dtsch Dermatol Ges 2014; 12: 401–406. 2 Poulalhon N, Begon E, Lebbe C et al. A follow-up study in 28 patients treated with infliximab for severe recalcitrant psoriasis: evidence for efficacy and high incidence of biological autoimmunity. Br J Dermatol 2007; 156: 329–336. 3 Hoffmann JH, Hartmann M, Enk AH et al. Autoantibodies in psoriasis as predictors for loss of response and anti-infliximab antibody induction. Br J Dermatol 2011; 165: 1355–1358. 4 Pink AE, Fonia A, Allen MH et al. Antinuclear antibodies associate with loss of response to antitumour necrosis factor-a therapy in psoriasis: a retrospective, observational study. Br J Dermatol 2010; 162: 780–785. 5 Saraceno R, Specchio F, Torres T et al. The role of antinuclear autoantibodies in patients with psoriasis treated with anti-tumor necrosis factor-a agents: a retrospective long-term study. J Am Acad Dermatol 2012; 66: e180–e182.

Angiosarcoma of the scalp in a patient with systemic sclerosis

osa. A year after the first visit, severe edema occurred on the right leg (Fig. 1d). Contrast-enhanced computed tomography of both legs revealed DVT in the right femoral vein (Fig. 1e). He had also suffered recurrent oral aphthae and genital ulceration. In addition, iritis and positive human leukocyte antigen-B51 were found. From these findings, we made the final diagnosis of BD. We started administration of heparin at 12 000 U/L, then switched to oral warfarin at 6 mg/day and oral NSAIDs. The edema on the right leg soon improved, and there have been no signs of clinical deterioration at 1 year after therapy. In these cases, DVT was the key clinical feature suggesting the diagnosis of BD. Venous thrombosis is the major complication of BD. Superficial venous thrombophlebitis is the most common vascular symptom of BD. In contrast, DVT has not been regarded to be a major complication of BD, and very few cases have been reported in the dermatological published work. In previous reports, the prevalence of DVT in BD patients was found to range 4–38.9%, which is much higher than expected. Therefore, 6.8% cases of BD had vascular involvement at or before BD diagnosis, which is commonly observed in men around the age 30 years. DVT can cause pulmonary embolism, which is the third leading cause of cardiovascular-associated death. In addition, DVT can develop sporadically, as well as in relation with other diseases, including BD. Therefore, clinicians should keep in mind that acute edema and swelling of the legs are key features suggesting DVT associated with BD.