Hyang-Joon Park

Ecthyma gangrenosum without bacteraemia in a leukaemic patient

Ecthyma gangrenosum is a well recognized cutaneous manifestation of Pseudomonas aeruginosa infections in immunocompromised patients. Most cases of ecthyma gangrenosum have been associated with concomitant septicaemia. However, ecthyma gangrenosum rarely develops due to Ps. aeruginosa in the absence of bacteraemia. We report a rare case of a nonsepticaemic form of ecthyma gangrenosum presenting as a large solitary necrotic ulcer in a patient with acute myelogenous leukaemia. A culture from the lesion revealed the presence of Ps. aeruginosa, but the results of repeated blood cultures were negative. Histological examination revealed numerous tiny eosinophilic bacilli in the dermis and panniculus with Grams stain.

Benign glandular schwannoma

Glandular schwannoma is a rare variant of schwannoma characterized by the presence of glands in an otherwise typical schwannoma. We report a patient with benign glandular schwannoma occurring on the scalp, a site not previously reported. Histologically, a well‐defined, encapsulated oval nodule was observed in the subcutaneous tissue. The nodule was composed of a spindle cell component and glandular structures. The spindle cell component stained positively for S‐100 protein. All of the glandular epithelium stained with CAM 5.2 and epithelial membrane antigen but not with S‐100 protein. The glandular epithelium was focally positive for carcinoembryonic antigen. The histogenesis of the glandular elements in these tumours is still debated. The variable size of the glandular structures in our case was evidence against an entrapped normal sweat gland origin. The glandular epithelium did not stain with S‐100 protein at all, but stained with CAM 5.2, which did not support a direct metaplastic origin of the epithelial elements from the schwannian component. A few scattered CAM 5.2‐positive cells and microglandular structures in our case may be the initial differentiating epithelial elements possibly derived from pluripotential neural crest cells.

A case of primary cutaneous mucinous carcinoma with neuroendocrine differentiation.

Primary cutaneous mucinous carcinoma is a rare malignant tumor that originates from the deepest portion of the eccrine sweat duct. Common sites of involvement are the face and scalp. Biopsy shows dermal epithelial cell islands embedded in mucin pools separated by fibrous septae. It is difficult to differentiate this tumor histologically from metastatic adenocarcinoma. Recurrence after excision is common but metastases are rare. We report a primary cutaneous mucinous carcinoma with neuroendocrine differentiation on the right cheek of a 63-year-old man.

Granulomatous pyoderma gangrenosum: two unusual cases showing necrotizing granulomatous inflammation

We present two cases of pyoderma gangrenosum (PG) with unusual histopathological findings. The main histopathological feature of PG is usually massive neutrophilic infiltration; the neutrophil is thus the cytologic hallmark of PG. The occurrence of vasculitis is controversial. In our patients, in contrast, biopsy specimens revealed extensive granulomatous inflammation with massive tissue necrosis throughout the entire dermis and subcutaneous tissue and vascular involvement simulating many other granulomatous diseases. However, there was no evidence of systemic disease. Our cases may therefore represent a histopathologically distinct subset of PG.

A case of accessory tragus on the nasal vestibule.

We present a case of accessory tragus (AT) which developed at an unusual site, the nasal vestibule, of a 1-day-old girl. To our knowledge, this is the first report of an accessory tragus that appears on the nasal vestibule.

Recalcitrant Oral Pyoderma Gangrenosum in a Child Responsive to Cyclosporine

We report a case of recalcitrant pyoderma gangrenosum which developed on the tongue of an 8‐year‐old, previously healthy boy without any systemic associated disease. The lesion was confined to the tongue and was not responsive to conventional treatment with prednisolone and sulfa drug, but it showed dramatic improvement with oral cyclosporine therapy. In addition, the histopathology of the lesion included many eosinophils, which caused difficulties in diagnosis to differentiate this condition from other oral ulcerative diseases showing tissue eosinophilia including eosinophilic ulcer of the tongue.

The Accuracy of Ultrasonography on the Location of Lipomas in the Forehead.

BACKGROUND Preoperative recognition of tumor plane is important to avoid surgical complications in surgeries involving the scalp. Ultrasonography is a useful diagnostic tool to detect the depth of tumor noninvasively. However, some findings are not always in accordance with the actual locations of lipomas, especially in the forehead. OBJECTS To evaluate the accuracy of preoperative ultrasonographic findings for the location of lipomas in the forehead. MATERIALS AND METHODS The study included 14 patients with lipomas in the forehead who all underwent preoperative ultrasonography and surgical excision of the lesions. The authors compared the diagnostic location of tumors by ultrasonography with the actual location in the surgical field. RESULTS On ultrasonography, 10 of 14 cases were diagnosed as frontalis-associated lipomas. However, 13 cases were confirmed as frontalis-associated lipomas intraoperatively, and only 1 case as superficial lipoma, which did not correspond with the ultrasonographic finding. The ultrasonographic findings were accurate in 9 of 14 cases (64.3%). CONCLUSION The accuracy of ultrasonography on the location of lipomas in the forehead is not as high as expected. Therefore, the surgeon must consider the possibility of deep lipoma even if a forehead lipoma is superficial in location on ultrasonography.

Blue Toe Syndrome as an Early Sign of Disseminated Intravascular Coagulation.

Dear Editor: Blue toe syndrome (BTS) is often described as painful digits with blue or purple discoloration without direct trauma1. Also it can lead to the amputation of toes and feet and be life threatening. Atheromatous embolism caused by vascular wall injuries from invasive percutaneous procedures or from anticoagulant or fibrinolytic therapy is reported as a common cause of BTS2. However, other causes of decreased blood flow are thrombosis, vasoconstrictive disorders, infectious and noninfectious inflammation, and other vascular obstruction2. The conditions which lead to thrombotic state such as disseminated intravascular coagulation (DIC) can also give rise to BTS. Herein, we report a rare case of BTS that occurred as an early sign of DIC. In our institute, a 69-year-old male complained of non-palpable bluish discoloration on both feet after he was admitted to the ICU ward due to pneumonia (Fig. 1). The physical examination demonstrates symmetric color change with petechiae that had lasted 1 month. The toes felt cold, and the sensation of toes was uncheckable because of his semi-coma status. Also the patient has been treated for pneumonia with history of diabetes mellitus, hypertension, and cerebral infarct. On histological examination from his foot, ischemic necrosis of epidermis and tons of red blood cell extravasation were found (Fig. 2A, B). Also, there were eosinophilic fibrinoid thrombi in the medium- sized vessels and leukocytoclasis (Fig. 2C). The laboratory results were as follows: white blood cell 28,470/mm3, hemoglobin 9.4 g/dl, platelet 37,000/mm3, prothrombin time/activated partial thromboplastin time 18.4/91.7 s, fibrinogen 71 mg/dl, D-dimer 3.75 mg/L. Hence, we could confirm that the causative disease might be DIC. After then, we obtained the result of multi drug resistant acinetobacter baumannii bacteremia from the blood culture. Gram stain and bacterial culture of the skin tissue were not conducted. We concluded that DIC resulted from severe infectious bacteremia. Henceforward, the patient was treated with vancomycin and conservative care for DIC. However, the patient died after 1 month. The possibility of purpura fulminans was ruled out because the patients lesion was limited to the toes. Fig. 1 Blue to purple discoloration with petechiae on the right foot. Fig. 2 (A) Scanning view (H&E, ×40). (B) Ischemic necrosis of epidermis, and red blood cell extravasation (H&E, ×200)

Auricular composite chondrocutaneous grafts in the repair of nasal alar rim defects.

Dear Editor: An 82-year-old man presented with a grayish-black papule on the right ala of the nose that had been there for 3 to 4 years, and which bled occasionally. Physical examination revealed that the size of the papule was 0.5×0.5 cm. The patient had no family history of skin cancer; he had a history of heavy cigarette smoking. We suspected basal cell carcinoma and performed a 2-mm punch biopsy. The results of the pathologic examination of the specimen confirmed the diagnosis of basal cell carcinoma. Before the surgery, we ensured that he stopped cigarette smoking to allow better survival of the graft. The tumor was widely excised with a 2-mm surgical margin, resulting in a 0.9×0.8 cm full-thickness defect (Fig. 1A). The defect was reconstructed by using a composite chondrocutaneous graft harvested from the antitragus of the right ear (Fig. 1B). The graft was prepared in such a way that it was approximately 20% larger than the defect in order to compensate for the natural contraction of the graft. The donor site was closed primarily, and after hemostasis of the recipient bed, the defect was repaired with the composite skin graft (Fig. 1C). To lower the metabolic demand, an ice pack was applied to the recipient site postoperatively for surface cooling. At a 5-month postoperative follow-up, desirable aesthetic and functional results were observed (Fig. 2). The patient agreed publication of his case. Fig. 1 (A) Full-thickness defect of the nasal ala after tumor excision. (B) Composite graft designed over the donor site

Late-onset bulky naevocytoma of the perineum masquerading as a malignant melanoma.

Bulky naevocytoma of the perineum is a very rare variant of giant congenital melanocytic naevus (GCMN). It presents as a bulky naevocytic tumour in the perineal region with characteristic histological findings, such as extensive areas with a neural appearance called ‘lames foliacees’, formation of a pseudofollicular structure and extension of naevus cells between collagen bundles in a row called ‘Indian‐file’ pattern. We report a case of late‐onset bulky naevocytoma of the perineum in a 13‐year‐old girl. The patient presented with two bulky, pedunculated, heavily pigmented masses in the vulvar area that developed in a pre‐existing GCMN lesion, which began around puberty and caused severe gait disturbance. Given the possibility of malignant transformation, we conducted staged reduction surgery of the tumour masses, which were found to be intradermal naevi without evidence of malignancy. The patients gait disturbance improved markedly after surgery.