Enrique S. Miralles

Pityriasis rubra pilaris and human immunodeficiency virus infection

Recently, the occurrence of pityriasis rubra pilaris (PRP) has been reported in patients with HIV infection. It presents different clinical features, and has a poorer prognosis, than the classical adult type of PRP. We report the occurrence of severe PRP in an HlV‐infected patient, and review the previously reported cases of this association. We propose the designation of a new category of PRP (type 6), characterized by the presence of HIV infection, usually without immunosuppression, a poor prognosis and response to treatment, and the development of nodulocystic and lichen spinulosus lesions.

Mucocutaneous Leishmaniasis and HIV

Mucocutaneous leishmaniasis is a rare disease in Europe. Relapses after treatment are more frequent than in visceral leishmaniasis. HIV patients infected by Leishmania have frequently visceral involvement, and responses to treatment are poor. Mucocutaneous leishmaniasis in HIV-infected patients has rarely been reported. A patient with centrofacial granuloma was diagnosed as having mucocutaneous leishmaniasis; simultaneously HIV infection was detected. To our knowledge this is the first case acquired in Europe. Intravenous meglumine antimonate 20 mg/kg/day for 28 days was proven to be useful.

Concurrent Cytomegalovirus, M. Tuberculosis and M. Avium‐Intracellulare Cutaneous Infection in an HIV Patient

We report a 25‐year‐old HIV‐positive man with a past medical history of disseminated cytomegalovirus (CMV) infection, who developed cutaneous lesions during a disseminated mycobacterium infection. The histological changes of CMV and acid‐fast bacilli were seen on histopathology of the lesions. Cultures were positive for M. tuberculosis and M. avium‐intracellulare (MAI). CMV is frequently isolated from HIV patients, but skin involvement is rare. The association of CMV and mycobacteria can occur in cutaneous lesions of AIDS patients, but concurrent cutaneous involvement of CMV, M. tuberculosis, and MAI is unusual. These findings emphasize the polymorphous presentation of infectious disorders in AIDS patients and the need for multiple biopsies and for special stains in such patients.

Appearance of Oral Erosive Lichen Planus during Interferon Alfa-2a Therapy for Chronic Active Hepatitis C

To the Editor: A relationship between lichen planus and hepatitis C virus (HCV) has been recently reported (l). Low dose interferon alfa treatment has shown to be an effective therapy for chronic active hepatitis C. Appearance or exacerbation of lichen planus during interferon alfa-2a therapy for chronic active hepatitis C has been communicated (2-5). We report a patient with chronic active hepatitis C who experienced the appearance of an oral erosive lichen planus a short time after beginning interferon alfa-2a therapy. Case Report: In March of 1993, a 45-year-old woman was diagnosed with chronic active hepatitis C, based upon a liver biopsy and anti-hepatitis-C virus antibody positive ELISA. Antinuclear, antimitochrondia, and anti-smooth muscle antibody tests were negative. In November of 1993, treatment with interferon alfa (Roferon) was started at a dose of 3 million units subcutaneously three times a week for 6 months. The patient had no other regular medication. Two weeks after she initiated interferon treatment, oral erosive lesions involving the tongue and inner aspects of the cheeks appeared. A biopsy specimen was consistent with lichen planus. Four weeks later, the mucosal lesions had progressed and limited normal alimentation. Otherwise, she tolerated the interferon therapy well, and the hepatopathy improved. Because interferon was presumed to be responsible for the appearance of the oral lesions, therapy was discontinued. The oral mucosa returned to normal in 3 weeks. When the lichen planus changes cleared, we again administered interferon alfa. The oral lesions recurred 18 days after the reinitiation of interferon treatment. 461

PRIMARY ANETODERMA AND ORBITAL PSEUDOTUMOR

A 31-year-old healthy woman with a 6-month history of swelling, erythema, and pain of her superior right eyelid was referred to the department of ophthalmology. She had no complaints of decreased vision or diplopia. The general examination was normal. On ophthalmologic examination, the lacrimal glands of both eyes were enlarged. Visual acuity, color vision, pupillary examination, applanation tonometry, slit lamp examination, and fundoscopy were normal. There was limitation of internal superior and lateral gazes and ptosis in both eyes. Basal tear secretion was diminished. Blood chemistry profile, complete blood cell count, tuberculin test, rheumatoid factor, serum and urine calcium, and urinalysis were normal or negative. Antinuclear antibody test was positive at 1:80 and plasma immunoglobulins were increased. Abdominal and chest x-ray, gallium gammagraphy, and a pulmonary diffusion test were also normal. A computerized tomogram of the orbits showed an enlargement of both lacrimal glands without involvement of adjacent muscles and bone (Fig. 1). A fine needle aspiration biopsy showed a cellular pattern of nonspecific orbital inflammation.

Minocycline hydrochloride hyperpigmentation complicating treatment of pyoderma gangrenosum.

Minocycline‐associated hyperpigmentation is an uncommon side effect We report the case of a patient with pyoderma gangrenosum successfully treated with oral minocycline but complicated by marked hyperpigmentation in his pyoderma gangrenosum and acne scars. One of the clinical forms of minocycline hyperpigmentation includes dark‐blue or black macules in depressed acne scars or other sites of skin inflammation; this pattern seems to be independent of the total cumulative dose and the skin process.

Bilateral Basal Cell Carcinoma of the Breasts in a Woman

Basal cell carcinomas (BCC) on covered sites of the body are rare (1). A case of a young woman with superficial basal cell carcinoma of both breasts is described. No history of sun bathing, X‐ray, or arsenical exposure was reported. Simple excision of both lesions was performed without recurrence.

Carbon dioxide laser treatment for the tuberous component of port-wine stains

Background and Objectives The flashlamp-pumped pulsed-dye laser is the treatment of choice for port-wine stains (PWS) but the tuberous component of PWS responds poorly to this treatment. This study evaluated the efficacy of vaporizing this component with a continuous carbon dioxide (CO2) laser.Materials and Methods The PWS tuberous components of 30 patients unresponsive to dye laser were treated with a continuous CO2 laser. In 15 patients no anaesthesia was used.Results All the lesions disappeared. A texture change was detected in 37% of the patients and one patient developed hypertrophic scarring. Patient satisfaction was excellent in all cases. Pain was noted in only four of those patients who underwent treatment without anaesthesia.CONCLUSION CO2 laser vaporization of the tuberous lesions of PWS is an excellent option complementary to treatment with the pulsed-dye laser.

Unilateral Localized Failure of Beard Growth

Abstract: Hair may be classified by type as vellus or terminal. The transformation of vellus follicies into terminal follicles is induced by androgens in androgen‐dependent areas by promoting the genetic program existing within individual follicies. Patients with normal androgen plasma levels and absent hair growth in certain areas under androgenic control have been described. One explanation of this condition may be abnormal target tissue sensitivity. We report a 17‐year‐old man whose only complaint was inability to grow a beard on the left side of his face.

Transformed cutaneous T cell lymphoma and biclonal gammopathy.

A 57-year-old man with a 18-year history of mycosis fungoides (MF), first in the plaque stage and 8 years later in the tumor stage, was referred to our hospital in January 1993. He had received different treatment regimens with little or only transient benefit (topical corticosteroids, PUVA, etretinate, methotrexate, and prednisone, radiation therapy, and interferon alfa). In the last reevaluatlon study in 1991, axillary adenopathy with inflammatory changes on histologic examination was detected, but the bone marrow biopsy was normal (T3 NI MO BO). On clinical examination the patient showed four large, irregular ulcers with elevated and necrotic borders in the left lower extremity; there were also some infiltrated plaques spread over the trunk and upper extremities. In the left inguinal fold, a 3 X 3 cm, mobile, hard, nontender lymph node was detected. Hemoglobin level and erythrocyte count were normal, the leukocyte count was 7,400 cells per mm^ with 5.8% lymphocytes and 23% eosinophils (1700 cells per mm^); the erythrocyte sedimentation rate was 75 mm in 1 hour. Sezary cells were not noted on peripheral blood smears. Serum protein concentration and electrophoresis showed a low total protein level (5.5 g per dL) without a gamma spike. Immunoglobulin levels were normal, but the IgE level was elevated (568 IU per mL, normal < 85). Serum immunoelectrophoresis showed an IgG kappa monoclonal protein. There was no proteinuria and the immunoelectrophoresis of the urine was normal. A cutaneous biopsy revealed characteristic features of a cutaneous T cell lymphoma (CTCL) and the lymphocytes stained for T cell markers CD4, CD2, CD3, CD5. Histologic examination of the inguinal lymph gland showed large cells with large oval nuclei, prominent nucleoli, and abundant amphophilic cytoplasm, consistent with a high-grade T cell lymphoma (Fig. 1) that stained positive for CD2, CD3, CD4, but not for CD5, and with a proliferation rate of 20% and positivity to CD25 marker. The bone marrow biopsy specimen was normal with 20% eosinophils. An extension study was negative. The DNA was extracted from a frozen lymph gland. Amplification for the immunoglobulin heavy chain (IHC) was performed by