Alina Jankowska-Konsur

A 5-year survey of dermatomycoses in southwest Poland, years 2003–2007

The study was performed to analyse the spectrum of dermatomycoses in southwest Poland during the period 2003–2007. A total of 10 486 patients were investigated for fungal skin infections by means of native specimen and cultivating procedures. Skin scrapings, plucked hairs and nail clippings were examined and identified by direct microscopy and culture. From 2468 patients, 2753 fungi were identified including dermatophytes, yeast and moulds. Among the dermatophytes, the most common pathogen isolated was Trichophyton rubrum (59.4%), followed in descending order by: Trichophyton mentagrophytes var. interdigitale (16.6%), Trichophyton mentagrophytes var. mentagrophytes (9.0%), Trichophyton tonsurans (6.8%), Microsporum canis (5.1%) and Epidermophyton floccosum (2.7%). Among the yeast‐like fungi, a marked predominance of Candida species was observed (86.3%). Scopulariopsis brevicaulis was the most commonly isolated mould (25.2%). The most frequently affected body sites were the toenails (53.9%), followed by the fingernails (19.0%). In children under 15 years of age, glabrous skin was the most commonly affected body site with M. canis as the most frequent causative agent.

Tinea capitis in southwest Poland

Tinea capitis in southwest Poland is mainly caused by zoophilic dermatophytes. Microsporum canis is the main pathogen, which was demonstrated in all analysed periods between 1977 and 2006 (50.5%–63.2%). Recently (2002–2006), a significant (P < 0.05) increase of Trichophyton tonsurans isolates was observed, which may be due to increasing migration of Polish population in this period. To sum up, the data on the prevalence of tinea capitis in southwest Poland resemble the epidemiological situation in Poland and bordering countries at large.

Expression of CXCR4 and CXCL12 and their correlations to the cell proliferation and angiogenesis in mycosis fungoides

Introduction Chemokines play an important role in tumor growth, invasion and metastasis. The CXCR4/CXCL12 axis has been implicated in development of both solid tumors and hematological malignancies and is also relevant in the pathogenesis of the most common primary cutaneous T-cell lymphoma, mycosis fungoides (MF). Aim To evaluate the expression of CXCR4 and CXCL12 in MF and to examine their associations with cell proliferation and angiogenesis. Material and methods The material for the study consisted of skin samples obtained from 56 patients with MF and 20 healthy volunteers. The expression of CXCR4 and CXCL12 was assessed by immunohistochemistry on the paraffin blocks and compared to the expression of angiogenesis marker (CD34) and proliferation indicators (Ki-67, AgNORs). Results The expression of chemokine CXCL12 and its receptor CXCR4 was significantly higher in MF than in the healthy skin (p < 0.001). There was no significant difference between early and advanced stages of MF. Similarly, there was no statistically important correlation between the expression of CXCR4/CXCL12 and angiogenesis and proliferation markers, however a significant correlation between CD34 and AgNORs expression was found (p < 0.001). Conclusions The CXCR4/CXCL12 axis seems to play an important role in MF development in the early as well as in the advanced stages of the disease. Therefore, the CXCR4/CXCL12 axis seems to be an interesting potential target for the future strategies of new drug development, giving hope for more efficacious therapies for mycosis fungoides.

Altered expression of Bcl-2, c-Myc, H-Ras, K-Ras, and N-Ras does not influence the course of mycosis fungoides.

Introduction Data about genetic alterations in mycosis fungoides (MF) are limited and their significance not fully elucidated. The aim of the study was to explore the expression of various oncogenes in MF and to assess their influence on the disease course. Material and methods Skin biopsies from 27 MF patients (14 with early MF and 13 with advanced disease) and 8 healthy volunteers were analyzed by real-time polymerase chain reaction (PCR) to detect Bcl-2, c-Myc, H-Ras, K-Ras and N-Ras expression. All PCR reactions were performed using an Applied Biosystems 7900HT Fast Real-Time PCR System and interpreted using Sequence Detection Systems software which utilizes the comparative delta Ct method. The level of mRNA was normalized to GAPDH expression. All data were analyzed statistically. Results All evaluated oncogenes were found to be expressed in the skin from healthy controls and MF patients. Bcl-2 (–4.2 ±2.2 vs. –2.2 ±1.1; p = 0.01), H-Ras (–3.0 ±3.3 vs. 0.6 ±2.6; p = 0.01) and N-Ras (–3.6 ±2.0 vs. –1.1 ±2.4; p = 0.03) were expressed at significantly lower levels in MF. No relationships between oncogene expression and disease stage, presence of distant metastases and survival were observed (p > 0.05 for all comparisons). Conclusions The pathogenic role and prognostic significance of analyzed oncogenes in MF seem to be limited and further studies are needed to establish better prognostic factors for patients suffering from MF.

Confluent brownish papules and plaques on the neck, upper chest and back: a quiz. Confluent and reticulated papillomatosis of Gougerot and Carteaud.

A 20-year-old woman presented with multiple confluent, brownish lesions, which had developed gradually over the previous year, on the upper trunk and neck. She had been treated for pityriasis versicolor with oral ketokonazole 200 mg daily for one week and topical antifungal (clotrimazole) creams with no improvement, and applied topical 1% hydrocortisone cream for more than one month with no effect. Dermatological examination revealed brownish, scaling plaques and papules distributed in a confluent and reticulated pattern on the lateral parts of the neck, the nape, upper back, intermammary area and caudal region (Fig. 1). Potassium hydroxide examination was negative for Malassezia spp. and examination with a Wood’s lamp showed no fluorescence in the lesional areas. Histopathological examination of a punch biopsy obtained from the lesional skin revealed hyperkeratosis, acanthosis and papillomatosis, with scant perivascular lymphocytic infiltration (Fig. 2). Periodic acid-Schiff staining demonstrated no fungal cells. Blood tests excluded diabetes mellitus and thyroid dysfunction. The patient was otherwise healthy.

Multiple disseminated keratoacanthoma-like nodules: a rare form of distant metastases to the skin

Cutaneous metastases are found in approximately 0.7–10.4% of internal malignancies and they may rarely be the first symptom of the underlying neoplasm [1]. Typically, cutaneous secondaries present as a single, erythematous nodule, occasionally ulcerated, however, other presentations, including erysipelas carcinomatosa, alopecia neoplastica or carcinoma en cuirasse in the course of the breast cancer, or angiomatous tumors in the course of renal carcinoma may be occasionally observed. The metastases assimilating keratoacanthomas are extremely rare [2, 3]. Herein, we present a 72-year-old man, cigarette smoker, who was referred to our department with disseminated skin tumors of unknown etiology. On admission, domeshaped, inflamed tumors, some of them with central, keratin-filled craters, clinically mimicking keratoacanthomas were observed on the scalp, forehead, nose, neck and trunk (back and left shoulder) (Figures 1, 2). All the

Hirudotherapy – a rare cause of pseudolymphoma

225 Cutaneous pseudolymphoma (C-PSL) represents a heterogeneous group of cutaneous reactions characterized by polyclonal T and/or B cell proliferation [1, 2]. The disease can be either idiopathic or triggered by various stimuli including infections, primarily Borrelia burgdorferi and drugs [3, 4]. Several lines of evidence indicate minor traumas such as tattoos, acupuncture, insect bites and vaccination as C-PSL inducers [3, 4]. Herein, we present a rare case of a C-PSL provoked by hirudotherapy. A 38-year-old woman was admitted to the Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, for diagnosis and treatment of skin lesions that appeared 7 months before hospitalization. On admission, physical examination revealed 10 well-defined, firm and pruritic nodules, red in color, ranging from 6 to 10 mm in diameter in her pubic area (Figures 1 A, B). The skin changes appeared soon after the patient underwent hirudotherapy that had been recommended by her friend as a successful treatment for uterine myoma. The pruritic cutaneous lesions appeared after the first procedure, however the patient decided to apply the second therapy after 3 weeks. Each time 5 leeches were used. For the apparent skin lesions the patient was given oral antihistamines and moderate potent topical glucocorticosteroids with no improvement. The patient did not take any other medicines, except for ulipristal acetate 5 mg/day, orally, administered by a gynecologist for the uterine myoma. Laboratory tests (morphology, urinalysis, lipids, liver function, renal function and inflammation markers) were within normal ranges. Histological examination of the skin biopsy revealed irregular acanthosis and mixedcell infiltration, composed of lymphocytes, histiocytes, plasma cells and eosinophils in the dermis. An evident exocytosis with focal spongiosis and intraepidermal inflammatory infiltration were observed. In the immunohistochemical study, the lymphocyte population consisted of a mixed population of T and B lymphocytes with T cell predomination. The T lymphoid cells were positive for CD3, CD43, CD45RO, CD4, CD8, CD30, CD20, CD79a, CD138. The numerous epithelioid histiocytes were CD68 positive. The proliferative rate measured by Ki-67 expression was low (labeling index = 7%). Based on the histological, immunohistochemical results and clinical observations the diagnosis of C-PSL was made. Initially, the skin changes were treated with 100 mg hydrocortisone intralesionally and topical glucocorticosteroid ointment (clobetasol propionate) applied twice a day. Cryotherapy was used in the case of one nodule, however the results were unsatisfactory as the nodule became discolored. After 4 weeks of topical treatment, nodules became smaller and less red but remained firm. We modified the previous therapy by adding methylprednisolone acetate intramuscularly 40 mg every 4 weeks. We chose intramuscular instead of intralesional drug administration because the patient had a bad experience with previous mesotherapies and preferred systemic treatment (one injection) instead of a series of injections. The patient continued treatment for 20 weeks with a slow regression of skin lesions. Cutaneous pseudolymphomas are not a rare dermatological problem, however, due to the overlapping histopathological and clinical features they may create a diagnostic and therapeutic challenge even for experienced dermatologists [5, 6]. To diagnose C-PSL, histological and clinical criteria must be fulfilled [5, 6]. Clinical criteria include typical location and morphology of the skin changes as well as characteristic clinical course of the disease. Typically, skin changes appear on the face, which is the most common localization of the lesions, on the chest and upper extremities. They are usually single and localized nodules or plaques, red to purple in color and tend to be self-regressing or disappear when the causative factor is removed [3]. Histological features of C-PSL include polyclonal lymphocyte infiltration in the upper layers of the skin. According to the predominant Letter to the Editor

Diffuse melanosis cutis related to dermal micrometastases as the first clinical symptom of distant metastatic malignant melanoma: Case report

Rationale: Diffuse melanosis cutis (DMC) is a very rare sign of malignant melanoma progression. The condition usually develops after approximately one year from melanoma diagnosis in a patient with metastatic tumors and after anticancer treatment with cytostatic medications. Patient concerns: A 72-year old Caucasian man was admitted to the Department of Dermatology with DMC for 4 months and the history of two melanomas treated surgically 30 years and 9 months before present hospitalization. Diagnosis: Histological and immunohistochemical examinations of DMC biopsy indicated melanoma metastatic cells as well as free deposits of melanin and melanophage presence in the dermis. Interventions: The patient refused to the treatment. Outcomes: The patient died eight months after DMC appeared. Lessons: DMC is a rare presentation of advanced MM and is a bad prognostic factor. The pathomechanisms of the discoloration of the skin are not fully explained. The role of micrometastases, as well as melanin precursors, released during lysis of MM metastases, and growth factors may play a role in the development of the symptom.

Extensive chronic Tuberculosis luposa treated incorrectly with long-term course of isoniazid monotherapy.

© 2013 The Authors. doi: 10.2340/00015555-1419 Journal Compilation