Jacqueline Schönlebe

Mycological and histological investigations in humans with middle ear infections.

Summary The aim of our investigations was to characterize fungal colonization of the ear in immunocompetent patients. From 1993 to 2000, 128 patients supposed to suffer from otomycosis were included. Mycological examination conducted by direct microscopy and fungal cultures was performed on 139 specimens. Among these, 115 patients suffered from chronic otitis media with persisting tympanum perforation and otorrhea. A further 13 patients had clinical signs of an otitis externa only. Out of 139 samples, fungi were identified in the auditory canal (n = 54), on the tympanic membrane (n = 5), and in the middle ear (n = 5). Two‐thirds were as moulds and one‐third yeasts. The dominating species were Aspergillus niger and Candida parapsilosis. Samples from 15 patients supposed to have mastoiditis or cholesteatoma were examined histologically. Fungal hyphae were observed in the middle ear cavity and/or between horny lamellae of cholesteatoma in four patients. In the middle ear of immunocompetent patients chronic‐hyperplastic (polypoid) inflammation was detected with increased production of mucus, which probably promotes colonization by pathogenic fungi in the middle ear as well as in the auditory canal. In vasive fungal growth into the subepithelial connective tissue was not observed.

Tumescent suction curettage versus minimal skin resection with subcutaneous curettage of sweat glands in axillary hyperhidrosis.

BACKGROUND Axillary hyperhidrosis is a common problem with a strong negative impact on professional and social life. Various types of surgical procedures have been developed for its treatment. OBJECTIVE We want to compare efficacy and risk–benefit ratio of two local surgical procedures, i.e., the minimal skin excision with subcutaneous curettage (Method A) and tumescent liposuction curettage (Method B). METHODS A total of 163 patients with primary axillary hyperhidrosis as assessed by positive iodine-starch test were included. The age range of patients was 16 to 61 years (mean 28 years), including 33 males and 129 females. A total of 125 underwent Method A, and 37 were treated by Method B. Both procedures were performed in tumescent anesthesia. The mean follow-up was 21 months (Method A) and 48 months (Method B). The outcome was evaluated by patients global assessment and by Minors starch test. Patient satisfaction was scored as “satisfied,”“partially satisfied,” or “dissatisfied.” Adverse effects, complications, hospitalization time, and time to return to work were recorded and compared for both methods. In patients who underwent Method A, scar formation was assessed only for the first axilla (n=99). RESULTS In Method A, the rate of residual sweating was 12.0%. The relapse rate was 1.0% of patients or 2% of axillae. In Method B, the relapse rate was 16.2% of patients or 14.5% of axillae within 12 months. If we consider both the relapses and the residual sweating, this modified relapse rate per axilla was 12.8% for Method A and 14.5% for Method B. Patients who underwent Method B had significantly less pain, no atrophic or hypertrophic scars, and no complications such as wound infections, bleeding (with the need of a second operation), or delayed healing. Using Method A, the stay in hospital was on average 5.8 days per patient or 3.2 days per axilla. Mean time to return to work was 8.8±3.5 days. For Method B, the procedure was performed in an outpatient setting. The mean time to return to professional work was 1.3±0.8 days. The total satisfaction rate was 97% for Method A and 89.2% for Method B, respectively. CONCLUSIONS As shown by this study, minor skin resection with subcutaneous curettage of axillary sweat glands (Method A) is somewhat more effective in permanent reduction of hyperhidrosis than suction curettage. The minimal invasiveness of suction curettage and the minimal scarring, however, are significant advantages over excisional surgery. Downtime after surgery is significantly shorter for suction curettage. Therefore, suction curettage might be the surgical treatment of choice for axillary hyperhidrosis.

Successful treatment of relapsing disseminated coccidioidomycosis with cutaneous involvement with posaconazole.

A 52‐year‐old woman with pulmonary sarcoidosis on immunosuppressive therapy developed pulmonary infiltrates and cutaneous granulomatous abscesses after a trip to the USA in April 2005. A hyphomycete was identified, further characterized by a gene probe as Coccidioides spp. and then definitively identified as Coccidioides posadasii by polymerase chain reaction and sequencing. Antibodies towards Coccidioides spp. were detected. The infection was successfully treated with posaconazole (Noxafil®), 2 x 400 mg/d.

Leg ulcers are a diagnostic and therapeutic challenge.

Leg ulcers are common. They cause a substantial burden to the patient and society. However, there is no need for therapeutic nihilism. The target of leg ulcer therapy is the individual patient. To be treated in a rational and successful way, exact diagnosis of the underlying cause(s) and associated diseases is necessary. This can be done in the most effective way with an interdisciplinary approach. The collection of cases demonstrates the need for careful clinical investigation substantiated and supported by vascular, histopathologic, and microbiologic techniques whenever needed. It is difficult to heal every ulcer completely, but improvement of the medical situation as well as the quality of life of the patient is possible in most cases.

Histologische Untersuchungen bei Otomykosen

Zusammenfassung. Pilzerkrankungen des Ohres werden am häufigsten als Gehörgangsmykose beschrieben. Ziel unserer Untersuchungen war die Frage nach der Art der Besiedlung im Ohr bei immunkompetenten Patienten. Von 1993 bis 2000 wurden 128 Patienten mit Verdacht auf Otomykose untersucht. 115 Patienten litten an chronischer Otitis media bei persistierender Trommelfellperforation und Ohrsekretion. 13 weitere Patienten hatten klinische Zeichen einer Otitis externa. Bei 59 Patienten wurde eine Gehörgangsmykose diagnostiziert, bei fünf auch eine Pilzinfektion des Mittelohres. Von 139 Proben wurden im Gehörgang 54‐mal, am Trommelfell fünfmal und im Mittelohr fünfmal Pilze nachgewiesen. Zu 2/3 wurden Schimmelpilze und zu 1/3 Hefen isoliert. Dabei dominierten Aspergillus niger und Candida parapsilosis. Bei Mastoiditis oder Cholesteatomverdacht wurden Proben von 15 Patienten entnommen und histologisch nach Pilzfärbung untersucht. Bei vier Patienten wurden Pilzelemente neben der Kultur auch in histologischen Präparaten vom Mittelohr nachgewiesen. Die Pilzhyphen fanden sich in den Hohlräumen des Mittelohres oder zwischen den Hornlamellen des Cholesteatoms. Im Mittelohr immunkompetenter Patienten fand sich eine chronisch‐hyperplastische (polypöse) Entzündung mit starker Sekretion, was wahrscheinlich Ansiedlung und saprophytäres Wachstum der Pilze sowohl im Mittelohr als auch im Gehörgang fördert. Invasives Pilzwachstum in das subepitheliale Bindegewebe hinein wurde nicht beobachtet.

Merkel cell carcinoma of the lower leg with retroperitoneal GIST: a very rare association

SummaryMerkel cell carcinoma (MCC) is a rare neuroendocrine tumor of the skin. Although its association with other malignancies is well known, an association with gastrointestinal stromal tumor (GIST) has yet not been described.We report about a 65-year-old female patient who presented with a hypervascularized subcutaneous tumor mass of her left calf. Resection of the primary tumor and histopathological investigations confirmed the diagnosis of MCC. The patient was treated by delayed Mohs surgery, and tumor-free margins were obtained. Sentinel lymph node biopsy was negative for metastatic spread. Primary tumor and lymph node basin were treated by adjuvant radiotherapy. During staging of the patient, a second malignancy—a GIST—was detected. Neoadjuvant treatment with multikinase inhibitor imatinib induced a partial response of GIST that was eventually removed by surgery. However, 8 months later, the patient developed subcutaneous regional metastases of MCC, which were surgically removed. Adjuvant therapy was planned by oncologists.To the best of our knowledge, the occurrence of MCC and GIST in the same patient has yet not been reported. In contrast to GIST, MCC did not respond to imatinib, although c-kit mutations are common in MCC.ZusammenfassungDas Merkelzellkarzinom (MCC) ist ein seltener neuroendokriner Tumor der Haut. Obwohl bekannt ist, dass es mit anderen Malignomen gemeinsam vorkommen kann, wurde die Assoziation zum gastrointestinalen Stromatumor (GIST) bislang noch nicht beschrieben.Wir berichten über eine 65-jährige Patientin, die sich mit einem hypervaskularisierten Tumor der rechten Wade vorstellte. Die Resektion des Tumors erfolgte, und die histologische Aufarbeitung ergab die Diagnose eines MCC. Es wurde die Komplettresektion des Tumors mittels verzögerter Mohs-Chirurgie eingeleitet, und tumor-freie Schnittränder wurden erzielt. Die Sentinellymphonodektomie zeigte keine Hinweise auf metastatische Absiedlungen. Das Gebiet des Primärtumors und die regionalen Lymphknoten wurden adjuvant bestrahlt. Im Rahmen des Tumorstagings wurde ein Zweittumor – hier ein GIST – entdeckt. Die neoadjuvante Behandlung mit dem Multikinaseinhibitor Imatinib induzierte eine partielle Response des GIST, eine chirurgische Entfernung schloss sich an. Acht Monate später mussten subkutane regionale Metastasen des MCC operativ entfernt werden. Eine adjuvante onkologische Therapie ist geplant.Das gemeinsame Auftreten von MCC und GIST ist unseres Wissens noch nicht beschrieben worden. Imatinib konnte in unserem Fall den GIST verkleinern, hatte jedoch auf das MCC keinen therapeutischen Einfluss gezeigt.

Reed’s syndrome: segmental piloleimyomas type 1 and uterus myomatosus

BACKGROUND Cutaneous mosaicism is a possible cause of segmental skin diseases. Cutaneous leiomyomatosis represent a spectrum of conditions ranging from single lesions to disseminated wide distribution. Reeds syndrome, is an autosomal dominant disorder characterized by multiple cutaneous and uterine leiomyomas. MAIN OBSERVATION We observed a segmental cutaneous piloleimyomatosis type 1 in a 55-year old female who had an uterus extirpation because of uterine leiomyomas. The cutaneous lesions were moderately painful and localized on her left upper trunk. They presented as firm nodules and small plaques in a linear arrangement. Renal cancer was excluded. CONCLUSION In patients with multiple cutaneous (pilo)leiomyomas a search for underlying systemic diseases is necessary in order to not miss benign or malignant tumors of internal organs.

Pressure ulcer-like presacral gummata in a patient with tertiary syphilis

Pressure ulcers are common among elderly patients. Here, we describe a case of tertiary syphilis with ulcerated gummata, appearing as a possible pressure ulcer. In such a case, wound management has to be accompanied by specific antibiosis to achieve healing.

Disseminated specific cutaneous infiltrates of B‐cell chronic lymphocytic leukemia – Wolf's isotopic response following herpes zoster infection

Herpes zoster is caused by the varicella zoster virus (VZV). The lifetime risk of contracting a herpes zoster infection is 30 % [1, 2]. Clinically, it is typically characterized by painful vesicular dermatitis arranged in a segmental pattern. Blisters and necroses may occasionally develop from these vesicles. Disseminated herpes zoster is not confined to a single dermatome, but rather leads to generalized dissemination of multiple vesicles without predilection sites, which also occasionally become necrotic. Usually, such widespread and atypical forms are associated with various conditions of immunosuppression [1]. Dreaded complications of herpes zoster infections include postherpetic neuralgia, herpes zoster ophthalmicus, herpes zoster encephalitis, and carditis [2]. A 66-year-old patient showing pronounced herpes zoster lesions on the left side of the face presented (as a consult) with disseminated hyperpigmented papulovesicular skin lesions that had developed five days after the onset of aberrant zoster vesicles. While the vesicular herpes zoster lesions were initially translucent, their clinical appearance subsequently changed, assuming an apparently hemorrhagic tinge and a livid-red color. The patient had a history of B-cell chronic lymphocytic leukemia (B-CLL). Treatment for herpes zoster with acyclovir had already been initiated. The left side of the face showed mostly papular lesions, partly covered with scabs and arranged in a herpetiform patClinical Letter

Idiopathic Scrotal Calcinosis – A Case Report

Idiopathic scrotal calcinosis is a rare disorder presenting with firm and painless nodules on the scrotal skin. The most common site is the frontal aspect of the scrotum whereas the dorsal aspect with the transition to the perineum is rarely involved. Surgery is the gold standard of treatment.