Claudia Morales

Inflammatory Diseases of the Skin

This chapter reviews common inflammatory diseases of the skin that may undergo sonography. Fluid collections and fistulae, lipodermatosclerosis, panniculitis, psoriasis, morphea, warts, and hidradenitis suppurativa are among the several conditions that are covered in this chapter. A correlation of the clinical and sonographic findings is described and well illustrated using selected cases.

Sonographic Anatomy of the Skin, Appendages, and Adjacent Structures

Recognition of normal sonographic anatomy is of utmost importance when performing imaging examinations. The ultrasound morphology of the skin layers, appendages, and adjacent structures in correlation with the histological findings is provided. Common anatomical variants are also discussed

Skin Cancer: The Primary Tumors

Skin cancer is the most frequent form of cancer in human beings and the sonographic imaging support of the primary lesion can provide relevant anatomical data that can improve the prognosis of patients and decrease recurrences. The most frequent types of skin cancer are discussed and include basal cell carcinoma, squamous cell carcinoma, and melanoma. Information on the sonographic morphology, contrast-enhanced ultrasound, and sonoelastography of skin cancer is provided. Other types of malignant skin tumors such as dermatofibrosarcoma protuberans, Merkel cell carcinoma, and cutaneous lymphomas are also covered.

Postnatal 2- and 3-Dimensional Sonography of the Skin and Nail in Congenital Autosomal Recessive Ichthyosis Correlated With Cutaneous Histologic Findings

The ichthyoses are a heterogeneous group of cornification disorders characterized by generalized hyperkeratosis or scaling of the skin. There are both inherited and acquired forms.1 The most infrequent form of presentation of the ichthyoses is lamellar or congenital autosomal recessive ichthyosis, which presents at birth and implies a mutation in at least 3 loci of the chromosomes.2 This condition is usually nonlethal and presents a normal life expectancy. Nevertheless, congenital autosomal recessive ichthyosis shows anatomic changes that may elicit numerous problems. Clinically, these infants are born with a membrane that appears as an extra layer of the skin with an erythrodermic base, also called a “collodion membrane.” The skin of these infants had a more rigid structure, which commonly causes other clinical problems such as eversion of the eyelids (ectropion) and lips (eclabion). Also, abnormal thickening of the skin of the palms and soles (palmoplantar keratoderma) and ungual dystrophies may be detected, among other changes. Congenital autosomal recessive ichthyosis differs from another type of congenital ichthyosis called the “harlequin type.” The latter form is the most severe presentation among the spectrum of congenital ichthyoses and is usually lethal. To date, the reports about the use of sonography for congenital ichthyosis available in the literature are mostly related to the harlequin type,3–5 which also has clinical findings similar to the ones already described for congenital autosomal recessive ichthyosis; however, additionally, the infants with harlequin ichthyosis commonly have severe cranial and limb deformities. Thus, the harlequin name was originated because of both the infant’s apparent facial expression and the diamond shape of the scales of the skin (Arlecchino’s costume), which are caused by severe hyperkeratosis. Uneven skin is among the changes already reported in prenatal sonography of infants with harlequin ichthyosis; in addition are some reports in the literature have described the use of prenatal 3and 4dimensional sonography to study these infants.6–8 On the other hand, as far as we know, there are no reports in the literature about the postnatal sonographic changes in the skin and nails that can be detected in children that have the less severe form of congenital ichthyosis. Furthermore, because of the rarity and diffuse involvement of this disorder, it may pose diagnostic and management challenges for physicians. The aim of this letter is to assess the potential of sonography to determine the cutaneous and ungual anatomic changes in congenital autosomal recessive ichthyosis in correlation with skin histologic findings. The case is a 5-month-old child that was born from nonconsanguineous parents and by cesarean delivery. No medications or drugs were reported as used or prescribed during pregnancy, and there was no family history of ichthyosis. This infant was the third child of the family and after birth had extensive scaling of the skin with an erythematous base, thick crusts in the scalp, and rigid skin. The patient also had ectropion, eclabion, and hypoplasia of the nasal and auricular cartilages and ungual dystrophy in all nails (Figure 1A). Color Doppler sonography of the skin and nails was requested to evaluate the anatomic changes. The examination was performed according to a technique previously reported for studying the skin and nails,9,10 using a multichannel machine with a compact linear probe ranging from 7 to 15 MHz (HDI 5000; Philips Healthcare, Bothell, WA). The child was sedated with chloral hydrate (50 mg/kg) before the test and after the informed consent was signed by the parents. The examination was performed according to the Helsinki principles of medical ethics. The Institutional Review Board waived provision of additional informed consent for the purpose of this report. A copious amount of gel was applied over the skin and nail surface, and the child stayed in the Department of Radiology and was medically supervised (using a modified Aldrete score). The sonographic examination showed whole-body diffuse thickening and hyperechogenicity of the epidermal layer and also diffuse thickening of the nail plates in all fingernails and toenails, in comparison with the previously reported normal sonographic appearances of the skin layers and nails.9,11 In addition, the interplate space (the hypoechoic space between the ventral and dorsal ungual plates) was absent in all nails. Furthermore, the plantar epidermis on both feet showed mostly a single thick hyper echoic layer instead of the normal bilaminar hyperechoic pattern described in healthy children.12 No signs of hypervascularity were detected within the cutaneous layers. Three-dimensional reconstructions (5to 8-second sweep) of the skin and nails using the software provided in the equipment were performed to highlight the findings (Figure 1, B–E). Histologic examination showed compact hyperkeratosis and slight hyperplasia of the epidermis. The granular layer of the epidermis was unremarkable, and there were no signs of inflammation (Figure 1F).

Perineurioma of the Nail on Sonography

Received April 12, 2010, from the Department ofRadiology, Clinica Servet, and Faculty of Medicine,Universidad de Chile, Santiago, Chile (X.W.);Department of Dermatology (D.M., V.C.) andDepartment of Pathology, Dermopathology Section(C.M.), Hospital Clinico Universidad de Chile,Santiago, Chile; and Nail Disease Center, Cannes,France (R.B.). Revision requested May 5, 2010.Revised manuscript accepted for publication May11, 2010.Address correspondence to Ximena Wortsman,MD, Department of Radiology, Clinica Servet,Almirante Pastene 150, Providencia, Santiago, Chile.E-mail: xwo@tie.cl

Cystic Lesions in Autoimmune Pancreatitis.

Autoimmune pancreatitis (AIP) can be chronic or recurrent, but frequently completely reversible after steroid treatment. A cystic lesion in AIP is a rare finding, and it can mimic a pancreatic cystic neoplasm. Difficulties in an exact diagnosis interfere with treatment, and surgery cannot be avoided in some cases. We report the history of a 63-year-old male presenting with jaundice and pruritus. AIP was confirmed by imaging and elevated IgG4 blood levels, and the patient completely recovered after corticosteroid therapy. One year later, he presented with a recurrent episode of AIP with elevated IgG4 levels, accompanied by the appearance of multiple intrapancreatic cystic lesions. All but 1 of these cysts disappeared after steroid treatment, but the remaining cyst in the pancreatic head was even somewhat larger 1 year later. Pancreatoduodenectomy was finally performed. Histology showed the wall of the cystic lesion to be fibrotic; the surrounding pancreatic tissue presented fibrosis, atrophy and lymphoplasmacytic infiltration by IgG4-positive cells, without malignant elements. Our case illustrates the rare possibility that cystic lesions can be part of AIP. These pseudocysts appear in the pancreatic segments involved in the autoimmune disease and can be a consequence of the local inflammation or related to ductal strictures. Steroid treatment should be initiated, after which these cysts can completely disappear with recovery from AIP. Surgical intervention may be necessary in some exceptional cases.

Cutaneous Vascular Tumors

Vascular tumors comprise a wide spectrum of lesions. Sonography can support the diagnosis and provide anatomical data on their location, thickness, and degree of vascularity, among other features. Benign and malignant vascular entities are reviewed in this chapter and include: angiokeratomas, kaposiform hemangioendothelioma, glomus tumor, pyogenic granuloma, epithelioid hemangioma, cutaneous angiomyxoma, cutaneous angiosarcomas, and Kaposi’s sarcoma, besides other conditions.

Sonographic Comparison of Morphologic Characteristics Between Pilonidal Cysts and Hidradenitis Suppurativa

To compare the sonographic characteristics of pilonidal cysts and hidradenitis suppurativa.

Enfermedad de Ménétrier con compromiso gástrico difuso y duodenal: Caso clínico

Background: Menetrier disease is a rare disorder of the stomach, characterized by giant hypertrophic folds that usually involve the gastric body and fundus, associated to hypoalbuminemia due to serum protein loss across the gastric mucosa. We report a 55-years-old male presenting with abdominal pain, vomiting, weight loss and hypoalbuminemia. Diffuse hypertrophic gastric folds, elevated ulcerated sessile lesions and focal duodenal involvement were seen at endoscopy. Biopsies showed foveolar hyperplasia and glandular atrophy with cystic dilatation. A total gastrectomy was performed with a good outcome.

Lentiginous eruption in resolving psoriasis plaques during treatment with ixekizumab: a case report and review of the literature

We report the case of a 56-year old male with severe plaque psoriasis that was successfully treated with ixekizumab, a new anti interleukin (IL)-17 monoclonal antibody. During the first months of treatment he developed a lentiginous eruption in the sites of rapidly resolving plaques. Biopsy and immunohistochemistry reports showed elements of both lentigo and post-inflammatory hyper pigmentation. These findings, which have been increasingly described in anti-tumor necrosis factor alpha (TNF α ) and anti IL-12/IL-23 therapy, may be explained by the down regulating effect of TNF α and IL-17 on pigmentation genes, which is very rapidly suppressed by ixekizumab, resulting in hyper pigmentation, and by the alteration of mesenchymal-epidermal interaction via keratinocyte growth factor during the inflammatory period, which results in the development of histopathological elements of lentigo.