Kerith E. Spicknall

Repetitive transcranial magnetic stimulation to SMA worsens complex movements in Parkinson's disease

OBJECTIVES To evaluate the therapeutic potential of repetitive transcranial magnetic stimulation (rTMS) for Parkinsons disease (PD) by delivering stimulation at higher intensity and frequency over longer time than in previous research. Promising beneficial effects on movement during or after rTMS have been reported. METHODS Ten patients with idiopathic PD were enrolled in a randomized crossover study comparing active versus sham rTMS to the supplementary motor area (SMA). Assessments included reaction and movement times (RT/MT), quantitative spiral analysis, timed motor performance tests, United Parkinsons Disease Rating Scale (UPDRS), patient self-report and guess as to stimulation condition. RESULTS Two of 10 patients could not tolerate the protocol. Thirty to 45 min following stimulation, active rTMS as compared with sham stimulation worsened spiral drawing (P=0.001) and prolonged RT in the most affected limb (P=0.030). No other significant differences were detected. CONCLUSIONS We sought clinically promising improvement in PD but found subclinical worsening of complex and preparatory movement following rTMS to SMA. These results raise safety concerns regarding the persistence of dysfunction induced by rTMS while supporting the value of rTMS as a research tool. Studies aimed at understanding basic mechanisms and timing of rTMS effects are needed.

Determinants of seizure threshold in ECT: Benzodiazepine use, anesthetic dosage, and other factors

The electrical dosage of the ECT stimulus impacts on efficacy and cognitive side effects, yet seizure threshold (ST) may vary as much as 50-fold across patients. It would be desirable to predict ST on the basis of patient and treatment characteristics. In particular, concerns have been raised that benzodiazepine use and higher dosage of barbiturate anesthetics elevate ST. In a three-site study, ST was quantified at the first ECT session using an identical empirical titration procedure in 294 patients who met RDC and DSM-IIIR criteria for a major depressive episode. ST varied over a 35-fold range across patients treated with right unilateral (RUL) (n = 267) and bilateral (BL) (n = 27) ECT. Higher ST was associated with BL electrode placement (p = 0.001). Among patients treated with RUL ECT, univariate analyses indicated that higher ST was associated with advanced age (p < 0.001), male gender (p < 0.001), greater burden of medical illness (p < 0.001), weight (p < 0.01), duration of mood disorder (p < 0.01), and history of previous ECT (p < 0.05). Average lorazepam dose in the 48 hours prior to ECT was not associated with ST, but was associated with decreased seizure duration (p < 0.01). Absolute, but not weight-adjusted, methohexital dose was associated with ST (p < 0.01). Multivariate analyses in patients treated with unilateral ECT showed that only 27.6% of the variance in ST (p < 0.0001) could be predicted. In the multivariate analyses, only age (p = 0.0001), gender (p = 0.01), and methohexital dose (p = 0.0001) were independently related to ST. Low dosage of lorazepam and methohexital dosage below 1 mg/kg are unlikely to impact on ST. Given the limited capacity to predict ST, empirical titration remains the only accurate method to determine electrical dosage in RUL ECT.

Azathioprine-induced EBV-positive mucocutaneous ulcer

Epstein‐Barr virus (EBV)‐positive mucocutaneous ulcer was recently described as a clinicopathologic entity occurring secondary to iatrogenic or age‐related immune suppression. The histopathology of EBV‐positive mucocutaneous ulcer reveals a polymorphous infiltrate including atypical large B‐cells and Reed‐Sternberg‐like cells which are CD20‐positive, CD30‐positive and EBV‐positive. The disorder follows an indolent and self‐limited course. We report a case of EBV‐positive mucocutaneous ulcer secondary to prolonged use of azathioprine for the treatment of pemphigoid and highlight the need for recognition of this disorder by dermatopathologists and dermatologists.

Wong-type dermatomyositis: a mimic of many dermatoses.

Wong‐type dermatomyositis (DM) is a rare variant characterized by keratotic follicular papules that may mimic pityriasis rubra pilaris. Histopathologic examination shows follicular and non‐follicular epidermal invaginations filled with keratin. The diagnosis is often delayed. Twenty‐four cases of Wong‐type DM have been reported thus far in the literature. Herein, we report the clinical and histopathologic findings of three additional cases in order to raise awareness of the disorder.

Histologic findings following use of hydrophilic polymer with potassium ferrate for hemostasis

Hydrophilic polymer with potassium salt is a hemostatic agent marketed for use by healthcare professionals and as an over‐the‐counter product available to healthcare consumers. In particular, dermatologic surgeons may use hydrophilic polymer for hemostasis in wounds left to heal by secondary intention. Foreign body reaction to hydrophilic polymer was recently reported. The microscopic findings in four additional patients treated with hydrophilic polymer are presented. The wounds of three patients were treated with hydrophilic polymer following a dermatologic surgical procedure while one patient used over‐the‐counter hydrophilic polymer on an abrasion. Three patients developed a foreign body reaction. Histopathologic examination revealed angulated fragments of deep purple material representing hydrophylic polymer admixed with round orange‐red bodies and yellow‐brown granules representing potassium ferrate. The components were found both free in the dermis and within multinucleated giant cells. Hydrophilic polymer must be differentiated from other materials observed in re‐excision specimens, including ferric subsulfate, aluminum chloride and Gelfoam® (Pharmacia and Upjohn Co., New York, NY, USA).

Localized toxic erythema of chemotherapy during treatment with paclitaxel.

to replace the term ‘‘baboon syndrome’’ with the acronym SDRIFE. This condition is characterized by five clinical findings, and the case reported here had all five findings. First, the patient was exposed to celecoxib. Second, the patient presented with sharply demarcated erythema of the gluteal area and V-shaped erythema of the perigenital area. Third, there was involvement of the axillae. Fourth, the lesions were symmetrically distributed. Fifth, there were no systemic symptoms or signs. Thus, the clinical diagnosis of SDRIFE was made. SDRIFE is an adverse cutaneous drug reaction without any known history of previous cutaneous sensitization. According to previous reports, the most common causative agents were antibacterials such as aminopenicillins and b-lactams and chemotherapeutic agents such as mitomycin. Previously reported causes of symmetrical flexural eruption using the term SDRIFE include: penicillin, valacyclovir, telmisartan hydrochlorothiazide, ethyl loflazepate, rivastigmine, risperidone, and iodinated radiocontrast media. This is the first case report of SDRIFE related to celecoxib. Thus, it should be added to the growing list of drugs causing SDRIFE. Patch test is only positive in up to one-half of patients probably because of reduced absorption of drugs to skin, and oral provocation test is found positive in most patients with SDRIFE. This case illustrates an uncommon presentation of a skin-related drug reaction to celecoxib that was confirmed by a provocation test.

Multiple lymphatic-type, atypical vascular lesions of the breast following radiation therapy.

The development of angiosarcoma is a rare but known complication of radiation treatment for breast carcinoma. The atypical vascular lesion (AVL) is another vascular proliferative entity that may develop following such therapy. First defined by Fineberg and Rosen as a focal proliferation of dilated vascular spaces lined with a single layer of plump endothelial cells, AVL most commonly presents as a small solitary lesion in irradiated skin 1–20 years following treatment.