Anna Jucglà

Treponema pallidum distribution patterns in mucocutaneous lesions of primary and secondary syphilis: an immunohistochemical and ultrastructural study

To study the different patterns of Treponema pallidum distribution in primary and secondary syphilis, 34 biopsy specimens of 8 patients with primary and 26 with secondary syphilis were assessed. Histopathological features, silver stain, and immunohistochemical T pallidum polyclonal antibody expression were investigated. The number and distribution of spirochetes were evaluated, and ultrastructural studies were performed. Spirochetes were identified with Warthin-Starry stain in 17 specimens (4/8 primary and 13/26 secondary syphilis), whereas immunohistochemical analysis disclosed spirochetes in 29 (8/8 primary and 21/26 secondary syphilis). In secondary syphilis, an epitheliotropic pattern characterized by abundant spirochetes in the lower mucosa/epidermis in an intercellular distribution was observed. In contrast, primary syphilis exhibited a mixed epitheliotropic and vasculotropic pattern further manifested by treponemes surrounding the vascular walls. These differences were statistically significant. Ultrastructural examination confirmed these results. Immunohistochemistry shows greater sensitivity when compared with Warthin-Starry staining. The immunohistochemical pattern of T pallidum distribution may permit the diagnostic differentiation of primary from secondary syphilis.

Epithelial to mesenchymal transition markers are associated with an increased metastatic risk in primary cutaneous squamous cell carcinomas but are attenuated in lymph node metastases

BACKGROUND Cutaneous squamous cell carcinoma (cSCC) is the second most common malignancy in humans and approximately 5% metastasize, usually to regional lymph nodes. Epithelial to mesenchymal transition (EMT) is a process involving loss of intercellular adhesion, acquisition of a mesenchymal phenotype and enhanced migratory potential; epithelial markers, such as E-cadherin, are down-regulated and mesenchymal proteins (Vimentin), increased. OBJECTIVE To investigate the expression of EMT markers in metastatic SCC (MSCC) and their corresponding metastases, and to correlate them with clinico-pathological factors associated with an increased risk of metastasis. METHODS We performed a retrospective study that included 146 cSCC samples (51 primary non-metastatic, 56 primary metastatic, 39 lymphatic metastases). Immunohistochemistry for E-cadherin, Vimentin, Snail, beta-catenin, Twist, Zeb1 and Podoplanin was performed. RESULTS Loss of membranous E-cadherin was observed in 77% cSCCs, with no differences between MSCC and non-MSCC. Among the transcriptional factors controlling EMT, no significant Snail1 expression was detected. Twist, Zeb1, Vimentin, beta-catenin and Podoplanin were significantly overexpressed in MSCCs. Twist ectopic expression in SCC13 cells induced Zeb1, Vimentin and Podoplanin expression and E-cadherin delocalization. These changes resulted in a scattered migration pattern in vitro. Expression of EMT markers was decreased in the metastases when compared with the corresponding primary tumors. CONCLUSION These results suggest that a partial EMT, characterized by the expression of Twist but without a total E-cadherin depletion, is involved in the acquisition of invasive traits by cSCC, but the process is downregulated in lymph node metastases.

Dermatomyositis and metastatic malignant melanoma, with complete regression of the primary lesion.

6 days after stopping calcipdtriol was within the normal range (2-S4mmul/n. and remained normal (2-44mmol/l) al 12 days post-therapy. As the response to treatment had been good, caicipotriol was reintroduced 15 days after it had initially been discontinued, with the intention of using HOg/ week. After S days of treatment {M)g of ointment) serum adjusted ealcium had risen to 2-7mmol/l. Caicipotriol was discontinued, and 5 days later the serum adjusted calcium was within normal limits (2-51 mmol/l}. and thereafter has remained normal.

Calcinosis cutis following liver transplantation: a complication of intravenous calcium administration

Calcinosis cutis may be a complication of administration of intravenous calcium solutions. We report four patients who developed calcinosis cutis following orthotopic liver transplantation, all of whom had received calcium chloride solutions intravenously during surgery. There was no evidence of extravasation of the solutions. A gradual improvement of the lesions was seen in the subsequent months.

D2-40 immunohistochemical overexpression in cutaneous squamous cell carcinomas: A marker of metastatic risk

BACKGROUND Approximately 4% of cutaneous squamous cell carcinomas (cSCCs) develop lymphatic metastases. The value of lymphatic endothelial markers to enhance the detection of lymphatic tumor invasion in cSCC has not been assessed previously. OBJECTIVE We sought to evaluate the use of the antibody D2-40, a podoplanin immunohistochemical marker, to identify tumor lymph vessel invasion in cSCC and to assess its expression in tumor cells. METHODS This was a retrospective case-control study. A series of 101 cSCC, including 51 cases that developed lymphatic metastatic spread (metastasizing cSCC [MSCC]) and 50 cases that resolved definitely after surgical excision (non-MSCC) were included in the study. Lymph vessel invasion using D2-40 was evaluated on all primary biopsy specimens. The percentage of tumor cells showing D2-40 positivity and intensity scoring were recorded. All the immunohistochemical findings were correlated with the clinicopathological features. RESULTS Lymph vessel invasion was observed in 8% of non-MSCCs and in 25.5% of MSCCs (P = .031). D2-40 expression was significantly increased, both in intensity (odds ratio 4.42 for intensity ++/+++) and in area (odds ratio 2.29 for area >10%), in MSCC when compared with non-MSCC. Interestingly, almost half (49%) of the MSCC had moderate to intense D2-40 positivity compared with 16% of non-MSCC. D2-40 immunohistochemical expression was increased in tumors with an infiltrative pattern of extension. In the multivariate analysis, histologically poorly differentiated tumors, recurrent lesions, and cSCC showing D2-40 overexpression (in intensity) were significantly associated with lymphatic metastases development (odds ratios 15.67, 14.72, and 6.07, respectively). LIMITATIONS This was a retrospective study. CONCLUSION The expression of podoplanin associates with high metastatic risk in cSCC.

Rheumatoid neutrophilic dermatitis associated with pyoderma gangrenosum

Sir, Langerhans cell histiocytosis (LCH) includes a spectrum of disorders with overlapping clinical features, i.e. Letterer±Siwe disease, Hand±SchuÈ ller±Christian syndrome, eosinophilic granuloma and congenital self-healing reticulohistiocytosis. The typical cutaneous findings comprise seborrhoeic dermatitis-like lesions, reddish-brown purpuric papules and nodules, oozing erosions, and ulcerations. A child with LCH is described, who presented with an uncommon pattern of pustular lesions on the forehead, hands, feet and genital region, following an atypical clinical course. One week after birth, a 14-month-old girl developed multiple, sharply demarcated itchy pustules on the forehead, together with red papules, and pustules partly covered with haemorrhagic crusts, which were predominantly on the soles of the feet (Fig. 1a). Some pustules occurred on the hands and in the genital and gluteal region. No lymphadenopathy was detectable. During topical treatment with lotio zinci (lotion with zinc oxide, talcum, glycerol and distilled water) the cutaneous lesions regressed slowly, but new lesions developed during the following months. After 5 months, an ulcer developed in the maxillary region. There was no specific family history of skin diseases. A skin biopsy of a pustule from the gluteal region revealed a dense upper dermal infiltrate of large histiocytes with a reniform nucleus, and intraepidermal collections of histiocytic cells (Fig. 1b). Immunohistochemical stains were positive for CD1 and for S-100 antigen. Electron microscopy revealed intracytoplasmic Birbeck granules within the histiocytic cells, thus confirming the diagnosis of LCH. Bacteriological and mycological examinations from skin lesions were negative. Full blood count, liver and kidney function were normal. Scintiscanning and radiography showed distinct involvement of the maxilla. Abdominal sonography was normal. Based on the occurrence of new cutaneous lesions and the subsequent involvement of the osseous part of the maxilla, chemotherapy was initiated with oral prednisolone 40 mg m daily for 4 weeks; then reduction of dose, vinblastine 0 ́2 mg kg once weekly for 6 weeks, then once monthly; and 6-mercaptopurine 50 mg m daily. Cutaneous lesions on the scalp, hands and feet, and the osseous lesion of the maxilla healed during the chemotherapy, which was performed for 1 years. In 1955, Lichtenstein summarized the three entities Letterer±Siwe disease, Hand±SchuÈ ller±Christian disease and eosinophilic granuloma under the term histiocytosis X. The cause of histiocytosis X (LCH) is unknown, but it is believed to be a proliferative process of Langerhans cells. Lesional histiocytes in the child described here were positive for S-100 antigen and CD1, as well as for intracytoplasmic Birbeck granules. The skin lesions did not clear completely

Orofacial granulomatosis: clinical study of 20 patients.

OBJECTIVES The objective of this study was to analyze the clinical features of a series of patients with orofacial granulomatosis (OFG). STUDY DESIGN Twenty patients diagnosed with OFG at Bellvitge Hospital (Barcelona, Spain) from 1985 to 2010 were included in the study. RESULTS All of our patients (9 men and 11 women, median age 48.1 years) presented with labial swelling. Six patients presented with recurrent orofacial swelling, 12 with permanent swelling, and 2 with progressive swelling. Fissured tongue was observed in 9 cases, and 2 patients presented with recurrent episodes of peripheral facial paralysis. The median follow-up time was 65.1 months, ranging from 4 to 300 months. None of our patients developed sarcoidosis or Crohn disease. CONCLUSIONS In the south of Europe, OFG does not appear to be as frequently associated with Crohn disease as in northern Europe. Although several treatments may achieve transient control of the orofacial swelling, there is no curative treatment for OFG and some patients may develop embarrassing lesions.

Tuberculous lymphadenitis presenting with cutaneous leucocytoclastic vasculitis

Cutaneous leucocytoclastic vasculitis is an inflammatory vascular disorder due to deposition of immune complexes in dermal vessels. A direct or indirect rule of infectious agents in the pathogenesis of such vasculitis has been postulated. We describe a patient with cervical lymphadenitis due to Mycobacterium tuberculosis infection who developed cutaneous vasculitis. The vasculitis resolved with standard antituberculous therapy. The association between leucocytoclastic vasculitis and tuberculous infection has only rarely been reported.

A papular eruption secondary to infection with Corynebacterium jeikeium, with histopathological features mimicking botryomycosis

Summary Corynebacterium jeikeium has been increasingly recognized as a pathogen, particularly in immuno‐compromised patients and in those with a prosthetic heart valve. Although cutaneous manifestations of C. jeikeium infection have been described, we have only found two case reports that give an histological description of the lesions. We present three patients with haematological malignancies who developed infection with C. jeikeium and a papular eruption. Skin biopsy disclosed similar histological features in all three patients, namely numerous Gram‐positive bacteria enclosed in an eosinophilic matrix, with a minimal inflammatory response. C. jeikeium was cultured from cutaneous lesions in two cases.

Images in clinical medicine. Geographic tongue.

n engl j med 361;20 nejm.org november 12, 2009 e44 A 61-year-old man was referred for treatment of painless white lesions on his tongue that had appeared 1 month earlier. He had been treated with topical and systemic antifungal drugs for presumed oral candidiasis, but the lesions remained unchanged. The patient reported that a similar episode 1 year earlier had resolved spontaneously. Lingual examination revealed multiple erythematous patches with an annular, welldemarcated white border. A diagnosis of geographic tongue was made. Geographic tongue (benign migratory glossitis) is a benign inflammatory condition that affects approximately 2% of the world’s population. The classic manifestation is a maplike distribution of erythema caused by atrophy of the filiform papillae of the tongue, surrounded by a white hyperkeratotic rim. The lesions typically resolve spontaneously without sequelae but can develop quickly in other areas of the tongue.