Edward Heilman

Widespread flat warts associated with human papillomavirus type 5: a cutaneous manifestation of human immunodeficiency virus infection.

Numerous flat and tinea versicolor-like warts developed on the face, trunk, and upper extremities of a 10-year-old boy with human immunodeficiency virus infection. Nucleic acid analysis of involved skin revealed human papillomavirus type 5, which has sometimes been associated with epidermodysplasia verruciformis. This human papillomavirus type has also been described in patients with common variable immunodeficiency and dyskeratosis congenita and in renal allograft recipients. Human immunodeficiency virus infection should be added to the list of immune-related disorders that predispose to widespread flat warts.

The “dysplastic” nevus

Dysplastic nevi have become an increasing focus clinically, with evidence that they are associated with a higher risk of developing melanoma. However, there still is contention regarding the significance of dysplastic nevi. This contribution provides an overview of the history, epidemiology, genetics, clinical and histologic features, and procedures for clinical management of dysplastic nevi. Since dysplastic nevi were described originally in 1978, a great deal of research has examined the epidemiology of these lesions and the genetic factors related to the development of dysplastic nevi. However, there is disagreement regarding the clinical management of dysplastic nevi and the histologic definition of dysplastic nevi. Current recommendations include preventative measures, such as sun protection and careful surveillance and biopsies of suspicious lesions as needed. The advent of new technologies, such as computer-vision systems, have the potential to significantly change treatment of dysplastic nevi in the future.

Volume of malignant melanoma is superior to thickness as a prognostic indicator : preliminary observation

There are many clinical and histologic factors that are known to be valuable in predicting survival rates for patients with cutaneous malignant melanomas. Breslow thickness is considered to be the most reliable prognostic factor; however, thickness is a unidimensional measurement. A more accurate mensuration to predict biologic behavior might be one that takes into account the three-dimensional volume of the neoplasm. In a study of 35 primary malignant melanomas, the volumes of the dermal components of the tumors were calculated. Those patients with tumor volumes of 200 mm3 or less had a 91.4% 5-year disease-free survival rate, compared with survival rate of only 16.7% for those patients whose lesions had tumor volumes exceeding 200 mm3. On multivariate analysis, tumor volume exceeded thickness as a prognostic indicator. Thus, measurement of tumor volume proved to be of greater significance than thickness in predicting the outcome for patients with malignant melanomas.

The pathology of malignant melanoma.

It is clear that much of what has been taught over the years concerning the pathology of melanoma may have little validity. Melanoma is viewed simply as a malignant neoplasm comprised initially of a proliferation of atypical melanocytes within the surface epithelium (epidermis). It has many features in common, regardless of anatomic site. It spreads within the epidermis first for months, possibly years or even for decades. At this stage (melanoma in situ) it is wholly curable if completely surgically excised. What determines how long a given melanoma remains in situ is not clear. It is probably a combination of factors, including host response to the neoplasm; physical barriers to growth and metastasis (perhaps solar damage); chemical or humoral growth factors or inhibitors (perhaps genetically determined); and other as yet undiscovered factors. Once a given neoplasm penetrates into the subjacent dermis, there are whole ranges of ill-defined events that act on its ability to continue to grow and develop the competence for metastasis (growth factors and inhibitors, neoangiogenesis factors and inhibitors, host immune responses, and so forth). Let us throw out all of our prejudices that may have developed or nurtured over the years. There is much to learn about the pathobiology of melanoma. Clinicians should keep their minds open to new concepts and try to separate what makes sense from that which does not.

Eccrine syringofibroadenoma surrounding a squamous cell carcinoma: A case report

A 91‐year‐old man presented with a 9.0 × 7.0 cm exophytic mass on the dorsum of the right foot, surrounded by a scaling hyperkeratotic plaque‐like lesion that had been present for many years. He had similar long‐standing hyperkeratotic plaque‐like lesions on both legs. Histopathologic examination of the exophytic mass revealed a well‐differentiated squamous cell carcinoma surrounded by an eccrine syringofibroadenoma (ESFA). Histochemistry, immunohistochemistry and electron microscopy support this diagnosis. To our knowledge, this is the only reported case of ESFA being intimately associated with a malignant neoplasm.

Spitz nevi in black children

Four black children with Spitz nevi are presented. The initial clinical diagnosis was pyogenic granuloma for three patients. One child had two Spitz nevi. Histologic examination revealed melanocytic dendritic hyperplasia in all cases.

Periumbilical perforating pseudoxanthoma elasticum

primary manufacturer of DINP), there are no severe hazardous side effects from DINP unless it is burned. In this case, it releases toxic fumes. The greatest hazards from contact are mild eye and skin irritation. The Federal Department of Transportation does not consider DINP hazardous (Aristech Chemical Co., personalcommunication, June 1991). The Consumer Protection Agency had no reports of problems relating to DINP or Sqwish Balls. The other possible irritant to which the patient was exposed is the cleanser. The manufacturer of Soft Scrub informed us that the primary ingredient is calcium carbonate and that there have been few reports of dermatitis from its use (personal communication, August 1991). Because of the detergent Journal of the American Academy of Dermatology

Secondary syphilis presenting as a palisading granuloma

A diagnosis of secondary syphilis was made in a 37-year-old man who presented with a papular eruption and a penile ulceration. Skin biopsy revealed a palisading granuloma similar to that seen in granuloma annulare. This represents a histologic finding that has not been described for early secondary syphilis.

Modulation of Delayed-Type Hypersensitivity Responses in Hairless Guinea Pigs by Peptides Derived from Enkephalin

Although opioid peptides such as methionine (met)-enkephalin have been previously shown to enhance or suppress immune responses, few studies in animal models have addressed the immunomodulatory activity of their metabolic derivatives. Hairless (IAF/HA-HO) guinea pigs immunized with Freund’s complete adjuvant containing Mycobacterium tuberculosis and repeatedly skin tested with purified protein derivative of tuberculin (PPD) display high levels of stable delayed-type hypersensitivity (DTH) to PPD. Met-enkephalin (YGGFM) and two of its metabolites (YGG, YG) enhanced and accelerated PPD-elicited DTH inflammatory reactions when injected together with elicitor in these animals. At 24 h, 5 × 10–3 pmol met-enkephalin significantly enhanced DTH responses by 30% over PPD alone, while 5 × 10–5 pmol of YGG and 5 × 10–9 pmol of YG significantly enhanced these responses by 62 and 32%, respectively. At much higher doses (5 × 103 pmol), met-enkephalin and its metabolites significantly suppressed DTH reactions by 25–32%. Tyrosine and glycine had no effect on PPD-elicited DTH. All DTH reactions (control, enhanced, suppressed) displayed typical perivascular mononuclear cell infiltrates. We conclude that the immunoactivity of met-enkephalin resides in its first two amino acids and suggest that cleavage of enkephalin molecules to YG occurs in serum and/or on the cell surface.

Pruritic Pustular Eruption in an Infant

A 13-month-old Hispanic girl had recurrent crops of pruritic papulopustules on the scalp, trunk, and extremities since birth. The lesions were recalcitrant to treatment with oral erythromycin, dicloxacillin, trimethoprim-sulfamethoxazole, and topical permethrio. They waxed and waned spontaneously. The child had approximately four lesion-free intervals since birth, each lasting three to four weeks. Her birth and developmental history were normal. On examination approximately 20 white to yellow pustules, 2 to 3 mm, each on an erythematous base, were clustered on the vertex of the scalp (Fig. I). Some of the lesions were crusted. Five similar pustules, as well as a number of 3to 4-mm hyperpigmented macules, were scattered over the trunk and extremities. Laboratory investigations revealed a white blood cell count of 13,000 with 39% neutrophils, 33% lymphocytes, 5% monocytes, and 23% eosinophils. Serum immunoglobin levels (IgA, IgG, IgM). T4:T8 ratio, C3, C4, and G-6PD were within normal limits. A skin biopsy specimen was obtained from a scalp lesion, and the histopathology is shown in Figures 2, 3, and 4.