J. Pec

Kaposi's sarcoma – still an enigma

Kaposis sarcoma (KS) is an unusual neoplasm that has proved to be an enigma in many ways since its original description in 1872. KS, a vascular tumour that is otherwise rare, is at present the most common neoplasm in patients with AIDS. The lesions contain spindle cells that share features with endothelial cells and smooth muscle cells and are in all likelihood primitive mesenchymal cells that can form vascular channels. These cells are monoclonal in origin indicating therefore that KS is a neoplasm. The presence of a novel type of human herpes virus, KS herpesvirus (KSHV) also called human herpesvirus type 8 (HHV8) in KS lesions support a viral ethiology. KS may be mistaken in the skin for an inflammatory or other lesion, thus skin biopsy is important for correct diagnosis, with the use of immunohistochemistry or molecular biology if needed. Radiation or interferon alpha dominate in the therapeutic approaches.

Cough sensitivity in atopic dermatitis

The aim of study was to investigate the cough sensitivity (C2) to capsaicin (CAPS) in patients with atopic dermatitis without clinical respiratory symptoms. Cough sensitivity (C2) is defined as the lowest CAPS concentration, which evokes two or more coughs. Forty eight dermatological patients (21 M, 27 F; mean age 44 yr) and 24 healthy volunteers (14 M, 10 F; mean age 37 yr) inhaled deep breath (2 l) of CAPS aerosol in doubled concentrations (from 0.02 to 200 micromol/l) (Pari Provokationstest I, PARI WERK; mass median diameter 1.2 microm). Cough sensitivity (C2) expressed as geometric mean (95% CI) of CAPS concentration was 0.13 micromol/l (0.06-0.31) in 26 patients with atopic dermatitis (10 M, 16 F; mean age 41 yr), 5.51 micromol/l (1.33-22.90) in 22 patients with psoriasis (11 M, 11 F; mean age 46 yr) and 4.29 micromol/l (2.54-7.26) in 24 controls. There is significant difference of cough sensitivity (C2) between patients with atopic dermatitis and healthy volunteers (p<0.001) and also between patients with atopic dermatitis and psoriasis (p<0.001). Cough sensitivity (C2) in atopic dermatitis patients without clinical respiratory symptoms is significantly increased. In patients with psoriasis cough sensitivity (C2) is not significantly changed.

Phaeohyphomycosis caused by Alternaria species and Phaeosclera dematioides Sigler, Tsuneda and Carmichael

A case of phaeohyphomycosis caused by strains of both Alternaria spp. and Phaeosclera dematioides is presented. First clinical signs of mycosis appeared on the patients face, after an injury with a straw stalk during the wheat harvest in Germany in 1942. Further signs developed in 1955 at one forearm, and again in 1968 in the mouth, leading to perforation of the palate. After treatment with amphotericin B (1973–75) she went into a 13‐year‐long, clinically asymptomatic remission. She relapsed in 1988, when eight foci of the disease developed, mostly on both forearms. Diabetes mellitus and asthma developed at this time. After pulse therapy with itraconazole the patient remains in a good clinical condition.

Linear focal elastosis: what's new?

Midand lower dermal elastosis was a prominent feature on histopathology. Only 20 cases of LFE have since been described in the literature, although this is an underestimation of the real occurrence of the disease. The originally reported cases suggested that LFE occurs predominantly in elderly men. Analysis of the reports currently available confirm this male predominance, with only four female patients reported among 20 published cases. 2–5 The age preference is less clear because six out of 20 patients were less than 20 years old, and the youngest patient was aged 7 at the time of disease onset. 6 Nine out of 20 patients were of Asian descent, two reported men were black. 7,8 Analysis of the available case reports does not necessarily reflect the true epidemiological and demographic proportions of the disease. A distinct clinical picture of the affection is marked by the occurrence of several asymptomatic, yellow, palpable, irregularly indurated, striae-like bands or lines extending horizontally across the middle and lower back. In a few cases, the location was noted outside this area, on the legs only in two cases, 4,5 and on the shoulders besides a typical location on the back in another two; 8,9 in one case the lesion migrated from the lumbar to shoulder area. 10 The lesions may first impress like striae distensae, but they are palpable rather than depressed, and yellow in colour, making them different from purplish striae rubrae distensae. No concomitant morbidity or significant associated findings with putative relevance to LFE were noted in any reported case. Moiin and Hashimoto reported the case of a 29year-old black man with LFE onset in early childhood whose father had had similar lesions since childhood, which raised the suspicion of a genetically conditioned abnormality. 7

Phaeohyphomycosis due to Alternaria spp. and Phaeosclera dematioides: a histopathological study

Summary. A case of phaeohyphomycosis caused by strains of both Alternaria spp. and Phaeosclera dematioides is presented. The biopsy material was studied using histological, immunohistochemical and transmission electron microscopy techniques. The agents dematiaceous mycelia are composed of thick‐walled hyphae, branched and unbranched, with terminal vesicular formations. All the described structures occur alone or in chains within multinuclear giant foreign body‐type cells or invading an abscess. Also present are budding forms. Immunostaining of histiocytic inflammatory cells in either diffuse or granulomatous infiltrates revealed cytoplasmic positivity for lysozyme and Ki‐M1P antibody. The lymphocytic infiltrates of the upper corium show predominantly small T lymphocytes (CD3 and CD45RO positive) and absence of CD20‐positive B cells. Plasma cells occurring within the infiltrates of the deeper parts show polyclonal expression of both Ig light chains.

Generalized melanosis with malignant melanoma metastasizing to skin—a pathological study with S-100 protein and HMB-45

A patient with primary malignant melanoma localized to the right gluteal region is described. Four years later and alter intercurrent influenza, disseminated metastases of malignant melanoma to the skin occurred. After a further 6 months melanodermia developed and lasted until the death of the patient (6 months later). Autopsy revealed melanosis of the visceral organs. Histology taken from internal organs using S‐100 protein and HMB‐45 melanoma methods confirmed metastases of malignant melanoma to the skin, oral cavity, palatal tonsils, nasal and nasopharyngeal mucosae, lungs, myocardium and brain. The authors discuss the mechanism of melanosis—a rare sign in patients with metastasizing malignant melanoma.

Isolation of Neisseria gonorrhoeae from urine obtained by suprapubic puncture of bladders of men with gonococcal urethritis.

The authors examined three urine specimens from each of 24 men with acute gonococcal urethritis. Gonococcal concentrations in urine were 7 X 10(3)/ml to 9 X 10(8)/ml in first samples, 1 X 10(2)/ml to 5 X 10(6)/ml in midstream samples, and, in the terminal samples from only 22 men, 8 X 10(4)/ml. A further 17 men with symptomless gonococcal urethritis were examined. Seven of them yielded 1 X 10(2)/ml to 2.5 X 10(5)/ml in first samples and 5 X 10(5)/ml in midstream samples, and only two yielded 5 X 10(1)/ml in final samples. All 24 men with acute gonococcal urethritis, and seven of the men with symptomless gonococcal urethritis who had yielded N gonorrhoeae in midstream urine samples, were examined by suprapubic puncture before morning voiding. Four of the 24 men with acute gonococcal urethritis were found to have infection that had ascended into the bladder.

Human papilloma virus infection in the oral cavity‐a source of infection

tion at that site [1,2]. Beard and colleagues, stressing the clinical and histological similarities between CIAE and graft-versus-host disease (GVHD), suggested that chemotherapeutic drugs, by changing cell surface receptors, are able to induce hostversus-altered host changes [6]. Nielsen described a palmar-plantar erythema in a patient with a myeloproliferative disease who had received neither antineoplastic drugs nor a blood transfusion, but only ampicillin and gentamicin, underlining the fact that myelodisplastic disease may itself have a role in the pathogenesis of CIAE [7]. Troussard and colleagues described three patients who underwent allogenic bone marrow transplantation, after a conditioning regimen including AraC or etoposide, that developed CIAE followed by acute GVHD [8]. The histopathologic pictures of CIAE are characterized by mild basal vacuolization, isolated dyskeratotic cells and a mild superficial mononuclear infiltrate similar to those seen in erythema multiforme and acute GVHD [ 1,6]. Our case is of interest because the complete necrolysis of the epidermis with no signs of dermal vasculitis, similar to those seen in toxic epidermal necrolysis, has never before been histologically documented. These findings indicate that CIAE may be considered as being part of the interface dermatitis group, in which the cytotoxic effects are prevalent over the immunologic ones.

A case of systemic mastocytosis--an ultrastructural and immunohistochemical study of the dermal mast cells in relation to activation of the epidermal melanin unit.

To the Editor: Mastocytosis is a disease characterized by an abnormal increase in mast cells and their abnormal accumulation in tissues [1,2]; it has been associated with haematologic and lymphoprolipherative disorders [3-61. We present a rare case of systemic mastocytosis with ‘atypical dermal mast cells’ infiltrates and activation of the epidermal melanin unit. A 1-month-old boy with disseminated yellowbronze confluent skin lesions, small papules with vesiculation and erythematous rash was presented (Fig. 1). The patient had noteworthy systemic intermittent flushing and fever, diarrhea and attacks of bronchospasmus with hepatosplenomegaly, generalized (also mesentheric) lymphadenopathy diagnosed by abdominal ultrasonography . Routine laboratory evaluation revealed anaemia, mild macrocytosis, anisocytosis with multiple spherocyte cells, anisochromia, polychromasia, reticulocytosis, lymphocytosis and thrombocytopenia, with some pathological values of haematologic coagglutinating factors (Table 1). Other haematologic parameters included absolute eosinophil count and haematologic coagglutinating factors. Bone marrow (sternal puncture) was slightly hypercellular, with M E ratio (myelopoietiderythropoietic cells) of 1-3.4:l-1.5; 26% of the mast cell findings were in confluent clusters within the marrow aspirates. As a result of clemastine treatment (0.4 mg/day) in combination with ketotifen (1 .O mg/day), antagonists of H2 receptors and with diet were without therapeutic effect, prednisone treatment (1.5 mg/kg of body weight) was started. After 1 year of consistent treatFig. 1 . A month-old boy with systemic mastocytosis, multiple confluent vesiculation.

Female paraurethral ducts and glands as the sites of agents of sexually transmitted diseases.

1 Van de Laar MJW, Pickering J, van den Hoek JAR, van Griensven GJP, Coutinho RA, van de Water HPA. Declining gonorrhoea rates in The Netherlands, 1976-88: consequences for the AIDS epidemic. Genitourin Med 1990;66:148-55. 2 Le Faou A, Guy I, Riou J-Y. Auxotypes et sensibilite a 6 antibiotiques des souches de Neisseria gonorrhoeae isolees a Strasbourg en 1977-1978. Ann Dermatol Venereol (Paris) 1979, 106:267-72. 3 Sivakumar K, Basu Roy R. Falling prevalence of Chlamydia trachomatis infection among female patients attending the Department of Genitourinary Medicine, Bournemouth. Genitourin Med 1990;66:400. 4 Shanmugaratnam K, Pattman RS. Declining incidence of Chlamydia trachomatis in women attending a provincial genitourinary medicine clinic. Genitourin Med 1990;66:400.