Jami L. Miller

Remission of severe epidermolysis bullosa acquisita induced by extracorporeal photochemotherapy

We report a patient with severe epidermolysis bullosa acquisita (EBA) whose disease was refractory to conventional treatments. New bullae continued to develop over greater than 50% of his body surface area despite therapy. His course was complicated by hyperglyeaemia, sepsis, hypoxia caused by pulmonary Aspergillus infection and an idiopathic cardiomyopathy. His EBA resolved after treatment with extracorporeal photochemotherapy (ECP). Hence, ECP may be effective in the treatment of severe EBA which has failed to respond to standard treatment regimens.

Illicit drugs: What dermatologists need to know

We review the most common systemic and cutaneous signs of heroin, cocaine, methamphetamine, Ecstasy, and marijuana use. We also provide an overview of the skin and soft-tissue infections frequently found in intravenous drug users and the effects of the adulterants added to the drugs.

Herpes simplex virus-induced plasmacytic atypia.

The clinical and histopathological features of cutaneous herpes simplex virus (HSV) infection have been well described. Genital herpetic infections are largely induced by HSV type 2, but 30% of cases can be caused by HSV type 1. Immunocompromised patients are known to exhibit atypical patterns of clinical presentation with variable lesion morphology and anatomic location. A subset of patients may show morphology such as nodules or verrucous lesions. Analogously, some biopsy specimens may show unusual microscopical features, such as a lack of keratinocyte cytopathology, lymphocyte infiltration or vasculopathic changes that are expected irrespective of the patients immune status. We present the case of a patient carrying a previous diagnosis of pemphigus vulgaris, status posttreatment with methotrexate and prednisone, who developed a perineal ulcer exhibiting significant numbers of plasma cells, many of which were cytologically atypical. This morphology was suggestive of a hematopoietic malignancy. Immunoperoxidase staining for HSV decorated a focal collection of keratinocytes that lacked appreciable viral changes expected of HSV infection.

Occurrence of Acute Cerebellar Syndrome After Topical Application of Fluorouracil

Case Report | A man in his 60s was treated for extensive scalp actinic keratoses with fluorouracil cream applied twice daily, massaging this onto the skin in the morning after showering and onto dry skin each evening. Only minimal scalp tenderness occurred after 2.5 weeks. After 3.5 weeks, the patient experienced severe headaches and awoke in the morning with marked unsteadiness on his feet, altered coordination in gait, and dizziness. No other neurological findings were noted. Diagnostic testing was deferred, and fluorouracil treatment was stopped. All signs and symptoms resolved within 8 hours of treatment cessation without any intervention other than acetaminophen. At last follow-up, 23 months later, he had experienced no recurrence. Dihydropyrimidine dehydrogenase (DPD) deficiency, a known risk factor for fluoropyrimidine toxic effects, was ruled out by DPYD targeted and whole gene sequencing.