Alina G. Bridges

Postoperative pyoderma gangrenosum (PG): The Mayo Clinic experience of 20 years from 1994 through 2014

BACKGROUND Postoperative pyoderma gangrenosum (PG) is a neutrophilic dermatosis characterized by the development of PG-type lesions within surgical sites. OBJECTIVE We sought to characterize postoperative PG as a distinct subtype of PG for earlier recognition and prevention of improper therapy. METHODS We conducted a retrospective chart review of patients with nonperistomal postoperative PG at Mayo Clinic from 1994 to 2014.x RESULTS Eighteen patients had postoperative PG with an average age of 58 years. Fifteen (83%) were female. Among patients with postoperative PG, 4 (22%) had an associated systemic disease traditionally associated with PG. Sites of postoperative PG included 7 breast (38%), 7 abdomen (38%), 1 back, 1 shoulder, 1 ankle, and 1 scrotum, witxxh breast reconstruction being the most common surgery. The average time to symptoms was 11 days. No patients had a fever. Eight (44%) had documented anemia and 5 (27%) had leukocytosis. Antibiotics and systemic corticosteroids were initiated in 10 (56%) and 14 (83%), respectively. Debridement was done in 11 (61%) patients. LIMITATIONS Small sample size and retrospective study are limitations. CONCLUSION Postoperative PG is a rare surgical complication with predilection for the breast and abdomen of females and has less association with systemic disease than idiopathic PG. Early recognition may prevent unnecessary debridements and morbidity.

Patch granuloma annulare : Clinicopathologic study of 6 patients

BACKGROUND Granuloma annulare is a common skin disorder that usually presents with smooth papules arranged as annular plaques. Variants, such as disseminated, subcutaneous, and perforating granuloma annulare, have been described. OBJECTIVE The purpose of this study is to describe the clinical and histologic features of a distinct patch form of granuloma annulare. METHODS The clinical and histologic features of 6 patients with patch granuloma annulare were evaluated. RESULTS Six women 27 to 72 years of age had patches on the extremities. Two patients also had a lesion on the trunk. Only one patient had annular patches. Histologic examination showed an interstitial infiltrate of lymphocytes and histiocytes with diffuse necrobiosis. CONCLUSION Patch granuloma annulare is a distinct variant with rather subtle clinical and histologic features. A high index of suspicion both clinically and histologically aids in making the diagnosis.

Pediatric hospital dermatology: Experience with inpatient and consult services at the mayo clinic

Data describing the management of pediatric patients admitted to a hospital under the care of a dermatologist and dermatology hospital consults for pediatric inpatients are limited. We aim to describe the role of an inpatient hospital service jointly run by dermatology and pediatrics and the activities of a pediatric dermatology hospital consult service. We retrospectively identified pediatric (age < 18 yrs) dermatology inpatients and hospital consult patients from January 1, 2009, through December 31, 2010. We examined patient demographics, indications for admission, length of stay, treatment provided, consult‐requesting service, and consult diagnosis. One hundred eight admissions were by a dermatologist. The mean age was 5.8 years; the median length of stay was 3 days. Indications for admission included atopic dermatitis (86.1%), psoriasis (3.7%), and eczema herpeticum (2.8%). The main treatment provided was wet dressings (97.2%). Eighty‐three dermatology hospital consults were requested. The mean age was 7.4 years. The main indications for dermatology consultation included drug rash (12.1%), cutaneous infections (12.1%), contact dermatitis (9.6%), psoriasis (8.4%), atopic dermatitis (6.0%), and hemangiomas (6.0%). This study describes the utility of the hospital pediatric dermatology inpatient and consult services in treating patients with severe skin disease.

Thioguanine Nucleotides and Thiopurine Methyltransferase in Immunobullous Diseases Optimal Levels as Adjunctive Tools for Azathioprine Monitoring

OBJECTIVE To prospectively determine optimal levels of 6-thioguanine nucleotide for disease remission in patients with immunobullous disease treated with azathioprine. DESIGN Prospective, longitudinal study. Laboratory tests and clinical evaluations were performed monthly for 6 months and then every 2 to 3 months (median follow-up, 13.4 months). SETTING Tertiary care medical center. PATIENTS Twenty-seven patients with immunobullous disease treated with azathioprine were enrolled during a 2-year period. Twelve met the criteria for evaluation of optimal levels of 6-thioguanine nucleotide. MAIN OUTCOME MEASURES Blood levels of 6-thioguanine nucleotide, 6-methylmercaptopurine, and thiopurine methyltransferase by polymerase chain reaction and enzyme activity were measured longitudinally during treatment. RESULTS The range of 6-thioguanine nucleotide was 48 to 457 pmol/8 x 10(8) red blood cells (RBCs), with an average optimal level of 190.7 pmol/8 x 10(8) RBCs for all patients. The mean optimal levels were 179.4 and 205.6 pmol/8 x 10(8) RBCs for pemphigus and pemphigoid, respectively. Limited disease required less 6-thioguanine, with a mean of 145.3 pmol/8 x 10(8) RBCs. Longitudinal induction of thiopurine methyltransferase activity was observed during treatment. Patients with recalcitrant disease showed higher induction of enzyme activity (with an increase of 9.1 to 23.6 U/mL of RBCs above baseline) than did those with responsive disease. CONCLUSIONS Optimal levels of 6-thioguanine nucleotide metabolites for disease remission in dermatology patients are 150 to 300 pmol/8 x 10(8) RBCs. High levels of the inactive metabolite 6-methylmercaptopurine and induction of thiopurine methyltransferase are associated with recalcitrant disease.

Acute generalized exanthematous pustulosis: clinical characteristics, etiologic associations, treatments, and outcomes in a series of 28 patients at Mayo Clinic, 1996–2013

Acute generalized exanthematous pustulosis (AGEP) is a rare skin condition typically caused by medications. The objective of this study was to examine the clinical features, causes, and outcomes of AGEP at a sole tertiary care center.

Cutaneous microemboli from hydrophilic polymer after endovascular procedures

BACKGROUND Multiple devices and coatings assist with endovascular insertion of sheaths, catheters, and guide wires. Hydrophilic polymer coatings, a common component of endovascular surgical devices, reportedly cause microvascular obstruction and embolization, with various sequelae in organs and soft tissue. OBJECTIVE We sought to describe clinical and histopathologic features of cutaneous manifestations of hydrophilic polymer gel emboli. METHODS We evaluated the clinical and histopathologic characteristics of 8 patients with cutaneous complications of hydrophilic polymer gel emboli who presented in May 2013 through February 2015. RESULTS Sudden onset of lower extremity livedo racemosa, purpuric patches, or both, occurred hours to days after endovascular procedures involving the aorta. Histopathologic evaluation showed basophilic lamellated material, consistent with hydrophilic polymer gel emboli, within small dermal vessels. LIMITATIONS This was a retrospective study with small sample size and not controlled for all similar procedures in this population. CONCLUSION Hydrophilic polymer gel coatings in endovascular devices can embolize to skin and cause microvascular occlusion, presenting as livedo racemosa, purpura, or both. Given the number of patients observed over a short period, this phenomenon may be underappreciated. Hydrophilic polymer gel emboli should be considered in differential diagnosis of livedo racemosa and purpura after endovascular procedure.

Diffuse dermal angiomatosis of the breast: Clinicopathologic study of 5 patients

BACKGROUND Diffuse dermal angiomatosis (DDA) is a rare skin condition considered to be a type of reactive angioendotheliomatosis. Histologic features are quite characteristic. It has been reported in association with vaso-occlusive disease, trauma, or underlying hypercoagulability. In the past, it was thought to be most common on the lower extremities. OBJECTIVE The purpose of this study was to describe the clinical and histologic features of 5 patients with DDA. METHODS The clinical and histologic features of 5 patients with DDA were evaluated. RESULTS Five women (47-58 years old) had DDA of the breast. Histologic examination showed a diffuse proliferation of benign endothelial cells between the collagen bundles throughout the dermis. LIMITATIONS The main limitation of our study is the limited number of patients. CONCLUSION Involvement of the breast is much more common than previously reported. Smoking seems to be a strong risk factor for the disease. Revascularization, oral corticosteroids, and oral anticoagulation have all been reported to be somewhat successful in the treatment of DDA of the breast.

Clinicopathologic features and BRAFV600E mutation analysis in cutaneous metastases from well‐differentiated thyroid carcinomas

Cutaneous metastases from well‐differentiated thyroid carcinomas are rare and are usually identified in patients with widely disseminated disease. Occasionally, thyroid carcinomas can present as cutaneous metastases for which the primary site needs to be determined. Papillary thyroid carcinomas (PTCs) commonly have BRAFV600E mutation. A series of 16 cutaneous metastases were analyzed from well‐differentiated thyroid carcinomas to learn more about the clinicopathologic features and BRAFV600E mutation status.

Experience with the dermatology inpatient hospital service for adults: Mayo Clinic, 2000–2010

Background  There is a paucity of medical literature describing the role of dermatology inpatient hospital services for patients with severe dermatologic disease. A diminishing number of US hospitals have a dedicated dermatology inpatient service run by dermatologists.

Interleukin-3—induced urticaria-like eruption

We describe an interleukin-3 (IL-3)-induced urticaria-like reaction in a patient with mesothelioma. IL-3 or multi-colony-stimulating factor (CSF) is a hematopoietic growth factor derived from T lymphocytes. 1 It is a member of the broad class of non-immunoglobulin polypeptide cytokines that includes hematopoietic growth factors, interferons, tumor necrosis factor, and interleukins. 1,2 IL-3 promotes the survival, proliferation, and differentiation of multipotential hematopoietic stem cells and committed progenitor cells of megakaryocyte, granulocyte-macrophage, erythroid, eosinophil, basophil, and mast cell lineages. 1-4 A cytokine with IL-3-like activity has been isolated from human keratinocytes 5 and recombinant human IL-3 (rhIL-3) is currently undergoing clinical trials in patients with advanced malignancies, myelodysplastic syndromes, aplastic anemia, and bone marrow failure. 3,4,6-8 Treatment with rhIL-3 may reduce the complications of chemotherapy, radiation therapy, and diseases associated with pancytopenia by stimulation of leukopoiesis, erythropoiesis, and thrombopoiesis. 1-4,6-8