Keiko Nakashima

Trichophyton rubrum infection histologically identical to eosinophilic pustular folliculitis

We describe a case of Trichophyton rubrum infection on the face histologically identical to eosinophilic pustular folliculitis. A 39-year-old Japanese woman was referred to our hospital with a 3-month history of erythema with pustules on the left cheek. Topical steroid ointment and oral administration of antibiotics had no effect on the lesion. On physical examination, a pruritic erythematous plaque 35 · 30 mm in size, with pustules arranged on its periphery, was found on the left cheek (Fig. 1). Scrapings were taken from the lesion; microscopical examination found no evidence of fungus. A biopsy was taken from the lesion, and histological examination showed dense infiltration of eosinophils and neutrophils around hair follicles and intrafollicular, in particular, intrainfundibular, eosinophilic micropustules (Fig. 2a). Although the histological features were consistent with eosinophilic pustular folliculitis, Grocott and periodic-acid– Schiff (PAS) stains showed fungal organisms in the infundibulum of the hair follicle (Fig. 2b). In addition, T. rubrum was identified by culture of the biopsy specimen (Fig. 3). Treatment with antifungal ointment resulted in complete clearance of the lesion.

Solitary sclerotic fibroma of the skin : morphological characterization of the 'plywood-like pattern'

Sclerotic fibroma is an uncommon skin tumor. Rapini and Golitz reported 11 cases of solitary sclerotic fibromas in patients without Cowden’s disease in 1989. We report a case of sclerotic fibroma that presented as an asymptomatic nodule in a 34‐year‐old Japanese man. Histopathological examination revealed typical features of sclerotic fibroma of the skin. Ultrastructural examination showed that spindle cells with myoid features had proliferated around the vasculature. They had segregated from the perivascular area by leaving the surrounding basal lamina, resulting in their phenotypical change to produce collagen accumulating in a concentrically lamellar fashion. We suggest a possible role of abnormal blood vessels and surrounding specific cells in the development of sclerotic fibroma.

Solitary sclerotic neurofibroma of the skin.

Solitary neurofibroma of the skin is a benign soft tissue tumor. Clinically, it is a flesh-colored, slow-growing, soft tumor and sometimes shows diverse histological patterns. We present here a case of nontender, hard neurofibroma with sclerotic change. By transmission electron microscopic observation, some mast cells in close contact with fibroblasts and abundant collagen fibers were seen in the lesion. Our findings suggest that mast cells may have played a role in the formation of the sclerotic regions of the current tumor.

Primary Cutaneous Aspergillosis

© 2010 The Authors. doi: 10.2340/00015555-0865 Journal Compilation

Multiorgan involvement in Sweet's syndrome.

A 59-year-old man who had been hospitalized for endoscopic excision of untreated early gastric cancer (stage 1A) presented with a 1-week history of high fever and indurated painful erythemas on the nape of the neck and the right ear. The gastric cancer had been diagnosed 4 months before, and the patient was hospitalized for endoscopic excision. At the time the eruption first appeared, a diagnosis of myelodysplastic syndrome had been made by a haematologist. The erythemas had gradually appeared on the patient s face, the dorsa of both hands and the left ear during the course of 1 week. Physical examination revealed indurated erythemas with superficial pustules on the patient s face (Fig. 1) and his dorsal hand and finger appeared gangrenous. There were a few reddish nodules on both conjunctiva and swelling on the lower jaw. Laboratory investigations showed pancytopenia, with a red blood cell count of 2.26 · 10 ⁄ L (normal range 1.5– 6.5 · 10 ⁄ L), haemoglobin 79 g ⁄ L (13.0–18.0), white blood cell count of 2.8 · 10 ⁄ L with 66% polymorphonuclear leucocytes (4–11 · 10 ⁄ L and 40–60%) and platelet count of 105 · 10 ⁄ L (150–400 · 10 ⁄ L). Serum granulocyte colony-stimulating factor (G-CSF) was raised at 122 pg ⁄ mL (normal, < 10 pg ⁄ mL). Skin biopsies taken from the lesions on the patient s face and hands revealed a high level of neutrophil infiltration with marked dermal oedema but without any signs of vasculitis (Fig. 2). No microorganisms grew on cultures. These findings led to the diagnosis of Sweet s syndrome (SS). Chest X-ray and computed tomography scan revealed right lower pulmonary infiltrates. Sonography of the lower jaw revealed swelling of the submandibular gland. As there were no signs of another disease (e.g. sarcoidosis, tuberculosis), the pulmonary infiltrates and swelling of the submandibular gland were likely to be related to SS. The patient was started on oral prednisolone 40 mg ⁄ day and sulfamethoxazole–trimethoprim 1 g ⁄ day. The skin lesions gradually improved, but the treatment had no effect on the pulmonary infiltrates or the swelling of the lower jaw. The patient was then given pulse treatment with methylprednisolone (1000 mg ⁄ day), and the symptoms were dramatically improved. After the pulse treatment, the dosage of oral prednisolone was gradually tapered from 60 mg ⁄ day, but when it reached 35 mg ⁄ day, the patient developed a high fever and reduced consciousness. Although the symptoms indicated involvement of the meninges, infectious brain meningitis (due to infection with viruses, tuberculosis or other bacteria) was excluded by the results of cerebrospinal fluid investigations and

Necrotizing Soft-Tissue Infection Caused by Both Candida glabrata and Streptococcus agalactiae

dronate and zoledronic acid. No established guidelines exist for dosing of zoledronic acid in children. Our patient’s severe symptomatic hypocalcemia may have been dose related and/or related to his severe osteopenia. He received 4 mg (0.1 mg/kg) of zoledronic acid, which has been safely used in multiple patients with osteopenia treated by one of us (J.E.H.). Two recent case series of zoledronic acid therapy used to treat a small number of children with osteoporosis or localized bone disease and evidence of active resorption have used initial doses of 0.0125 to 0.025 mg/kg. Owing to the risk for osteopenia and osteoporosis, patients with RDEB should be screened for bone mineral density with dual-energy x-ray absorptiometry. Low serum calcium and 25-hydroxyvitamin D levels should be treated with vigorous supplementation and exercise programs to prevent development of osteopenia. Caution should be used when choosing a zoledronic acid dose: an initial low dose (0.025-0.05 mg/kg) should be considered for patients with severe osteopenia to prevent hypocalcemia, and treatment should be repeated every 3 to 6 months. Further studies of the safest and most effective oral and/or intravenous doses of bisphosphonates in children are needed.

Difficulty to Identify Sentinel Lymph Nodes with Computed Tomography-lymphography in Patients with Cutaneous Melanoma

Since the report on the sentinel lymph node (SLN) concept by Morton et al. (1), SLN biopsy has become a standard method for assessing occult métastases in regional lymph nodes in various cancers, including cutaneous malignant melanoma, head and neck squamous cell carcinoma, and breast cancer (1-3). The combined use of vital blue dye and radioactive tracer with a hand-held gamma probe in addition to preoperative lymphoscintigraphy is a reliable method to search for SLNs (4). The single-photon-emission computed tomography/computed tomography (SPECT/CT) system is also useful for determining the anatomical location of SLNs, though the specialized equipment is expensive (5, 6). Another method using CT-lymphography with a non-ionic contrast medium for identification of SLNs has been reported to be useful in many institutions in Japan that do not have the necessary facilities for radioisotopes (7-9). The aim of this study was therefore to evaluate the efficacy of CT-lymphography compared with that of the ordinary method for identification of SLNs in patients with cutaneous melanoma.