Cristina Guerriero

Usefulness of ultrasound imaging in detecting psoriatic arthritis of fingers and toes in patients with psoriasis.

Background. Given that clinical evaluation may underestimate the joint damage and that early treatment can slow down psoriatic arthritis (PsA) progression, screening psoriasis patients with imaging tools that can depict early PsA changes would entail clear benefits. Objective. To compare the ability of X-ray and ultrasound (US) examination in detecting morphological abnormalities consistent with early PsA in patients with psoriasis, using rheumatological evaluation as the gold standard for diagnosis. Methods. Patients with chronic plaque psoriasis and no previous PsA diagnosis attending our outpatient dermatology clinic and reporting finger/toe joint and/or tendon pain underwent X-ray and US evaluation; they were subsequently referred to a rheumatologist for clinical examination and review of imaging findings. Results. Abnormal US and/or X-ray findings involving at least one finger and/or toe (joints and/or tendons) were seen in 36/52 patients: 11 had one or more X-ray abnormalities, including erosion, joint space narrowing, new bone formation, periarticular soft tissue swelling, and periarticular osteoporosis; 36 had suspicious changes on US. Conclusion. US proved valuable in detecting joint and/or tendon abnormalities in the fingers and toes of patients with suspicious changes. The dermatologist should consider US to obtain an accurate assessment of suspicious findings.

Achilles tendinitis in psoriasis: clinical and sonographic findings

BACKGROUND Involvement of the Achilles tendon is frequent in psoriatic arthritis, but it is easily missed at clinical examination. OBJECTIVE To seek evidence of Achilles tendon abnormalities by means of sonography in psoriatic patients and to correlate sonographic findings with clinical symptoms (tendon and soft-tissue swelling, pain, and difficulty in walking). METHODS Fifty-nine patients with plaque-type psoriasis (Psoriasis Area and Severity Index score, 3.7-34.7) and 50 healthy, aged-matched volunteers underwent clinical and sonographic evaluation of Achilles tendons and peritendinous structures. RESULTS Eighteen (30.5%) of the 59 patients had clinical symptoms of Achilles tendinitis. Thirty-five (59.3%) of the patients had sonographic abnormalities. Of these, 13 patients had clinically symptomatic abnormalities, and 11 had psoriatic arthritis. Degenerative tendinitis was the most frequent sonographic finding (76.9%) among patients with symptomatic conditions. Five patients with symptoms did not have sonographic alterations. None of the controls had clinical or sonographic changes. CONCLUSIONS In psoriatic patients Achilles tendon abnormalities cannot be excluded even when they are clinically absent.

High prevalence of celiac disease in psoriasis

the bacterial overgrowth. Although superficially it might seem that this study argues against bacterial overgrowth in IBS, the data actually support the notion. Even if Simren et al. are correct and only 12% of IBS subjects have upper gut bacterial overgrowth, this warrants attention. There is more attention to ruling out celiac disease in IBS sufferers, with a reported prevalence of only 4.6% (14). Given their single location sampling for bacteria, it is also likely that if more of the small bowel were cultured more cases would have been detected. Furthermore, the low eradication rate with antibiotics was identical to our study (2), and the group confirmed our recent finding that the lack of phase III might play a role in these IBS cases (15). With all the difficulties mentioned above, whether bacterial overgrowth or some enteric bacterial aberration is contributing to IBS symptoms is likely to be debated for some time. However, in the examination of IBS and the possible role of enteric bacteria, the clinical response and dependence on the lactulose breath test after antibiotic treatment needs to be the focus. With the lack of better tests or even a reliable gold standard, no test can be accurately trusted, only the clinical response. What Dr. Parisi fails to explain is the 75% clinical improvement seen in IBS subjects with normalization of lactulose breath test after antibiotics in a controlled, published, peer-reviewed study (2). Dr. Parisi and colleagues might want to consider a follow-up study with adequate controls. Subsequently, they should submit any new data as an original research submission for peer review and publication rather than in a letter in which the methodologic details leading to their results and conclusions cannot be evaluated.

Huriez syndrome: case report with a detailed analysis of skin dendritic cells

We report a 60‐year‐old man with familial scleroatrophic syndrome of Huriez who developed squamous cell carcinomas on the affected skin of the right palm. Immunohistochemical analysis showed a marked reduction in the number of CD1a+, Lag+ and S100+ epidermal Langerhans cells, but not of CD1b+ and factor XIIIa+ dermal dendritic cells, limited to palmoplantar skin. The Langerhans cell depletion was not associated with an abnormal skin content of mRNA for factors involved in Langerhans cell development or recruitment in the epidermis, including granulocyte/macrophage colony‐stimulating factor, transforming growth factor‐β1 and macrophage inflammatory protein‐3α. The results indicate that other as yet unknown mechanisms may account for the reduced number of Langerhans cells in the affected skin of such patients.

Malabsorption in psoriatic patients: cause or consequence?

Objective. The aetiopathogenesis of psoriasis is still unclear. Associations between gut and skin diseases are well known, since psoriatic patients show a high prevalence of coeliac disease. Small-bowel abnormalities can cause clinical or, more frequently, laboratory alterations that give rise to malabsorption. The aim of the study was to evaluate the prevalence of malabsorption in psoriatic patients. Material and methods. Fifty-five (29 M, 26 F, mean age 51±8 years) psoriatic patients in the Dermatology Centre of our hospital and 65 healthy controls (36 M, 29 F, mean age 47±9 years) were screened for malabsorption using a D-xylose test. Psoriatic subjects who resulted positive were further investigated in order to reach a better characterization of the malabsorption using serum antigliadin, antiendomysium and anti-transglutaminase antibodies, H2 lactulose breath test, the parasitological faecal test and colonoscopy with retrograde ileoscopy. Results. Altered D-xylose absorption was found in 60% (33/55) of psoriatic patients and in 3% (2/65) of controls. Of the former, 6% had coeliac disease, 21% had bacterial overgrowth, 3% had parasitic infections and 1 patient presented eosinophilic gastroenteritis. Conclusions. Malabsorption was more prevalent among psoriatic patients than among controls. Coeliac disease, bacterial overgrowth, parasitic infestations and eosinophilic gastroenteritis could be possible causes of malabsorption in these patients. Further studies are needed to clarify the pathogenesis and possible causative associations between gut and skin diseases.

Squamous cell carcinoma arising in a venous ulcer as a complication of the Klippel–Trenaunay syndrome

Summary Klippel–Trenaunay (KT) syndrome is a vascular malformation characterized by a port‐wine stain, varicose veins and hypertrophy of the affected limb. Ulceration is considered an uncommon complication of KT syndrome and occurrence of skin cancer has been previously reported only in one case. We observed a case of KT syndrome in a 48‐year‐old woman who developed a large ulcer and a squamous cell carcinoma on the affected leg.

Erythema nodosum induced by kerion celsi of the scalp in a child: a case report and mini-review of literature

A 9‐year‐old girl, presented with a 4‐week history of an inflammatory suppurative plaque, 8 cm in diameter, localised in the occipital area of the scalp. Mycological direct examination showed ectoendothrix invasion of the hair and Trichophyton mentagrophytes was isolated. Oral therapy with griseofulvin 25 mg kg−1 day−1 was prescribed, but after 2 weeks of treatment appeared multiple erythematous subcutaneous nodules localised in the legs. Erythema nodosum (EN) was confirmed by histological examination of a nodule and then we combined therapy with 1 mg Kg−1 day−1 of prednisone. At the remission of the panniculitis, which occurred in about 10 days, the steroid therapy was suspended, while the orally administered griseofulvin continued for 6 weeks until full recovery. EN is the most frequent clinical form of acute nodular panniculitis and it is considered an epiphenomenon relative to various infectious and non‐infectious stimuli. The association of EN with dermatophytosis of the scalp is infrequent, with only 15 cases reported in the Literature.

Merkel cell carcinoma metastatic to the stomach.

Merkel cell carcinoma (MCC) is an uncommon, highly aggressive cutaneous neoplasm of neuroendocrine origin, associated with a newly discovered Merkel cell polyomavirus. In the majority of cases, the presentation is that of a flesh-coloured, red or blue, firm, non-tender intracutaneous mass that grows rapidly over a few weeks to months and that may ulcerate. It is estimated that 470 cases occur in the USA each year. Survival is reported to be poor, with a 3-year rate of only 55%. Most patients (70–80%) with MCC present with localized disease. Tumour usually develops in sun-exposed areas, most commonly the head and the neck region, followed by the extremity and the trunk. Rare occurrences in sun-protected areas, such as the oral mucosa, the vulva and the penis, are reported. Distant metastasis is present in 1–4% of patients, the common metastatic sites being the skin (28%), lymph nodes (27%), liver (13%), lung (10%) and brain (6%). Metastatic involvement of the gastrointestinal tract by MCC is exceedingly rare; there have been only three previous reports of gastric metastasis of MCC in the literature. In all cases, tumour presented with a severe gastrointestinal bleeding, and in all patients, but the present, the follow-up was extremely poor. A 72-year-old woman was admitted to our unit with a 1-month history of light-headedness, epigastric abdominal pain, haematemesis and loss of weight. The patient’s past medical history was remarkable for a cutaneous MCC presenting as a right-sided groin mass. The tumour was treated with surgery, chemotherapy (carboplatin and etoposide) and radiotherapy (50.4 Gy). When the patient presented to our attention 2 years later, on physical examination a voluminous epigastric mass was palpable, and laboratory values were notable for a decreased haemoglobin level of 6.3 g/dL and an increased level of neuronspecific enolase (103.1 ng/mL). The patient was stabilized with blood transfusion and subsequently underwent an esophagogastroduodenoscopy, which showed a voluminous irregular mass with a 1-cm ulcer along the greater curvature of the stomach. Multiple cold forceps biopsies were taken. Computed tomography scan (Fig. 1) showed a circumferential thickening of the gastric body, ‘linitis plastica’-like. Histopathologic evaluation of biopsy specimens disclosed homogenous and uniform round cells infiltrating the lamina propria (Fig. 2). Immunohistochemical analysis revealed intense staining for chromogranin, synaptophysin and Anti-Cytokeratin (CAM 5.2), consistent with the diagnosis of metastatic MCC. At laparotomy (Fig. 3), a grossly apparently exophytic lesion involving the greater curvature of the stomach was found. The patient was operated on, and a Billroth II resection was performed. Definitive histological findings confirmed a metastatic MCC of the stomach. The patient received other two cycles of adjuvant chemotherapy, and is still alive with no clinical and radiological evidence of recurrence within 24 months of follow-up. Gastric metastasis is an extremely rare complication in the evolution of cancers and is associated with a very bad short-term prognosis. The most common tumours that metastasize to the stomach are melanoma, lung and breast cancers. According to autoptic studies, the incidence of gastric metastasis in neoplastic patients is very low (0.2–1.7%).

Extragenital lichen sclerosus and atrophicus treated with topical steroids and retinoids in a child with vitiligo.

Lichen sclerosus and atrophicus (LSA) most commonly affects the anogenital region. Extragenital involvement is rare, and women are reported to be affected 6 to 10 times more often than men. The aetiology of LSA is unclear, but genetic, physiological and environmental factors are thought to be involved. Several lines of evidence support the hypothesis of an autoimmune basis for LSA; an increased incidence of tissue-specific antibodies and an association with autoimmune disorders such as vitiligo, alopecia areata, thyroid disease and pernicious anaemia have been reported. We describe a paediatric patient with extragenital LSA associated with vitiligo who was successfully treated with topical steroids and retinoids.

Subcutaneous abscess as a side-effect of cetuximab therapy

ejd.2010.1231 Auteur(s) : Cristina GUERRIERO1, Francesco RICCI1, Andrea PARADISI1, Barbara FOSSATI1, Vincenzo VALENTINI2, Fabio PACELLI3, Rodolfo CAPIZZI1 fraric1984@libero.it 1 Department of Dermatology, 2 Department of Radiotherapy, 3 Department of Digestive Surgery, Catholic University of the Sacred Heart, L.go A Gemelli 8 - 00168 Rome, Italy Cetuximab, a chimeric monoclonal antibody against epidermal growth factor receptor (EGFR), is used to treat colorectal cancer and head and neck squamous-cell [...]