Kaare Weismann

Acute HTLV III infection associated with exanthema, diagnosed by seroconversion

We report three homosexual men who developed malaise, fever and a roseola‐like exanthema which disappeared over 2 weeks. During 3 months follow‐up, all three patients felt well and had no symptoms. HTLV III seroconversion was detected several weeks after the acute HTLV III infection. In two of the three cases the Western blot technique was able to detect HTLV III antibodies before they were detectable by the ELISA technique.

The dermatoscopic ABCD rule does not improve diagnostic accuracy of malignant melanoma

The dermatoscopic ABCD rule has been suggested to improve diagnostic performance regarding cutaneous malignant melanoma. Using this rule, a total dermatoscopy score is calculated from the presence of various dermatoscopic elements. A total dermatoscopy score above 4.75 signifies possible and 5.45 probable melanoma. We compared the diagnostic accuracy of dermatoscopy with and without the use of the ABCD rule. Furthermore, receiver operating characteristic analysis was performed for the ABCD rule. The area under the receiver operating characteristic curve was 0.854 (range 0.777-0.906) demonstrating that in 85.4% of the cases, cutaneous malignant melanomas were rated higher than the non-melanoma skin lesions. Sensitivity for the melanoma diagnosis was higher for simple dermatoscopy than when the ABCD rule was used (p<0.05). There was no difference in specificity when a total dermatoscopy score of 4.75 was used as cut-off point, but specificity was lower for simple dermatoscopy than when the total dermatoscopy score of 5.45 was used. Diagnostic accuracy was higher for simple dermatoscopy than for the ABCD rule (p<0.01). In conclusion, the dermatoscopic ABCD rule was not superior to simple dermatoscopy, and fewer malignant melanomas were identified with this rule.

Pernio of the hips in young girls wearing tight-fitting jeans with a low waistband

Sir, In 1980 Beacham et al. (1) described equestrian cold panniculitis in overweight young women wearing tightfitting uninsulated riding trousers. They developed reddish tender plaques on the thighs due to prolonged cold exposure during equestrian activities in the winter. Cold panniculitis and pernio (chilblains), which is a relatively mild form of cold injury, has also been described in children wearing cold wet shoes or boots (2) and in mountaineers after wading across rivers (3). It is especially the fat-rich hip and lateral thigh regions of young women that are affected. The recent fashion among young women for tight jeans with a low waistband, exposing the upper part of the hip region to cold may result in hip pernio, as described in the following cases.

Incidence, clinical presentation and treatment of neurosyphilis in Denmark 1980-1997.

Neurosyphilis is now a rare disease in the developed countries. In Denmark 92 cases of neurosyphilis were identified in the period 1980-1997. We obtained the hospital records for 77 of these patients and studied the clinical presentation, treatment and result of the treatment. Most patients were treated with penicillin by the intramuscular or intravenous route, but the amounts and duration of the antibiotic treatment varied a lot among the patients. All patients treated with intravenous penicillin were cured.

Neutrophil dermatosis of the dorsal hands

Neutrophil dermatosis of the dorsal hands (NDDH) is a recently described skin manifestation regarded as a subset of acute febrile neutrophilic dermatotis (Sweet syndrome). We describe 5 cases with pustular and ulcerative plaques and/or bullae and vesicles of the dorsal hands. Three of the patients also had skin changes at sides other than the hands. Associated conditions were found in two patients, one patient treated with hemo‐dialysis for chronic glomerulonephritis, and one patient had suffered from a streptococcal tonsillitis prior to the eruption. Two of the patients had fever, two had neutrophil leucocytosis in peripheral blood and two had elevated sedimentation rates. Histological findings showed signs of vasculitis in biopsies from two of the patients. NDDH is discussed on the basis of prior case reports concerning the subject, and it is concluded that Neutrophil dermatosis of the dorsal hands should be regarded as a localized variety of Sweet syndrome.

Dermatoscopic prediction of melanoma thickness using latent trait analysis and likelihood ratios

Breslow thickness and Clark level can be used to determine surgical procedures for cutaneous malignant melanoma and patient eligibility for experimental adjuvant therapy. Efforts to predict the thickness of melanomas using dermatoscopy have focused on differences between single dermatoscopic findings. The aim of this study was to develop a method for preoperative identification of melanomas of > or = 1 mm Breslow thickness using the entire range of dermatoscopic findings. Sixty-five melanomas were assessed for the presence of 22 dermatoscopic features. Ten dermatoscopic features showed differences in thick and thin melanomas and were selected for further analysis. A latent trait analysis construct implied that a progression in dermatoscopic features was associated with advancement of melanomas. Early melanomas are characterized by a light brown colour, a pigment network and irregularity or heterogeneity. Gray-blue areas, white scar-like areas and an atypical vascular pattern gradually displace these features. Likelihood ratios were determined for these 6 dermatoscopic findings and an algorithm for calculating the probability of thick malignant melanoma was established.

Dystrophic epidermolysis bullosa treated unsuccessfully with oral zinc.

Recently, we described a 5-year-old girl with severe zinc deficiency who developed acute, bullous acrodermatitis on her hands and feet during total parenteral nutrition [6]. Electron microscopy revealed extracellular oedema in the epidermis and cleavage at the level of the basal cells. Several basal cells were partly or completely separated from the basal lamina and showed multiple vacuoles and signs of degeneration. In epidermolysis bullosa (EB) of the non-scarring types, the split formation goes through the basal-cell layer above the basal-cell membrane [2, 3]. In the dominant Weber-Cockayne type, there is epidermal cleavage in the mid-squamous area; in junctional EB, the separation is situated lower, i.e. at the junction of the dermis and epidermis above the basement membrane. In the scarring types of EB, the dermolYtic blisters are formed beneath the basal lamina [2, 3]. Both clinically and pathologically, the changes observed in EB mimic bullous acrodermatitis. Therefore, it can be speculated that zinc therapy might have beneficial effects on EB diseases, but apparently, no attempts have been made to study this possibility. Bauer et al. [1] introduced phenytoin therapy in the treatment of recessive dystrophic EB and observed a positive effect using this therapy. A prerequisite is the maintainance of a serum-phenytoin concentration of above 8 ~tg/ml. It is believed that phenytoin interferes with collagen breakdown in the dermis by decreasing the high activity of collagenase in EB [1, 3]. Zinc is chelated by phenytoin, and the drug has been shown to increase the absorption of orally ingested zinc, as demonstrated experimentally on rats using the wholebody counting technique and 6 SZn as the radionuclide [5]. Mammalian collagenase is a zinc metalloenzyme [4], and hypothetically, phenytoin could work in EB either by trapping the collagenase-bound zinc or by raising the zinc concentration and thereby changing the enzyme activity. A 17-year-old female suffering from recessive dystrophic EB underwent a therapeutical trial with oral zinc therapy. The patient had been treated with phenytoin (200 mg daily) for 2 years, but due to complaints of dizziness, the daily dose had been reduced to 50-100 mg phenytoin. When receiving the high dosage, she experienced a moderate improvement of her erosive skin lesions on the fingers, feet and genitals. With lower doses of phenytoin, the effect was reduced; therefore, we decided to stop this treatment and tentatively initiated zinc sulphate therapy (0,2 g three times daily). During the following 2 months, her serum zinc level rose from 14 to 33 gmol/1 (normal range 10-19 gmol/1). Her skin condition gradually deteriorated, and after 2 months, the zinc therapy was discontinued, and phenytoin (50 mg daily) was readministered. Her serum alkaline-phosphatase activity remained practically unaltered, indicating that a zinc deficiency was not involved. The zinc treatment had no side-effects, and as reflected by the highly increased serum zinc level, her zinc absorption was intact. The present trial with a single patient does not allow any definite conclusions to be drawn about zinc therapy and EB, but the total lack of response suggests that dystrophic EB is not a target for this modality of treatment.

A case of penile pilus migrans: a sexually transmitted condition?

men’s barbae can cause interdigital sinuses in barbers (1, 2). Similar lesions have been described in hairdressers (3), and long, curved hairs imbedded in the feet (4) remind one of cutaneous larva migrans. To our knowledge, fragments of the hair imbedded in the mucous membrane have not been reported previously. In this case a man is presented with a fragment of hair located on the glans penis, probably transmitted during sexual activity.

Phlebotomy combined with erythropoietin therapy for porphyria cutanea tarda

To the Editor: Porphyria cutanea tarda (PCT) is caused by a disordered heme synthesis due to hepatic deficiency of uroporphyrinogen decarboxylase. The defect results in accumulation of uroporphyrinogen in the organism [1]. The mechanism of uroporphyrinogen decarboxyiase deficiency is at present uncertain, but it appears to be iron-dependent, and PCT patients often have increased body stores of iron [1]. Phlebotomy remains the therapy of choice for PCT [1] but one limitation of repeated phlebotomies is that patients may develop anaemia. Erythropoietin (EPT) is a kidney-produced hormone which stimulates erythropoiesis [2] and can prevent the development of anaemia following phlebotomies. It has been recognised that EPT can mobi-