Kiran Preet Malhotra

Combined Squamomelanocytic Tumor of the Plantar Surface of the Foot: Histogenetic Insights.

To the Editor: A 70-year-old farmer presented with a blackish nodule on the plantar aspect of the right foot for a duration of 2 months. The lesion was not preceded by a mole, and there was no evidence of any other similar lesions. An excision biopsy was done. The excised lesion was a rounded blackish firm mass of 1 cm in diameter. Microscopic evaluation revealed an unremarkable epidermis. The superficial and deep dermis was infiltrated by islands of atypical cells (Fig. 1A). Some of these islands showed atypical cells with abundant eosinophilic cytoplasm and intercellular desmosomal bridges. Intimately admixed with these were nests of cells with pleomorphic polygonal nuclei, prominent inclusionlike nucleoli, and brown pigmented cytoplasm (Fig. 1B, C). Thorough sampling of the lesion did not reveal any in situ radial growth phase melanoma or adjacent invasive lentiginous melanoma component. Immunohistochemistry revealed positivity for cytokeratin 5/6 antibody in the epithelioid cells suggestive of squamous differentiation and melan A positivity in the pigmented cells suggestive of melanocytic differentiation (Fig. 2). The lesion was diagnosed as a combined type of squamomelanocytic tumor. Squamomelanocytic tumors have been reported hitherto in 17 cases in the English literature. These have been reported twice as frequently in males as in females and have commonly affected elderly patients with an average age of 68 years. We report the first case from the Indian subcontinent. The commonest sites of occurrence have been the head and neck area, followed by the trunk and extremities. This case is the first report of this lesion occurring on the plantar aspect of the foot. A differential diagnosis of pigmented squamous cell carcinoma is ruled out in such cases by the noticeable atypia in both the cell populations and a lack of singly infiltrating melanocytes with dendritic cell processes. An intimate admixture of the cellular components and a lack of history of either lesion preceding the other excludes the possibility of collision tumors and tumor-to-tumor metastasis. Biphenotypic tumors that arise from a common precursor and differentiate to produce 2 phenotypically varied cell populations are also on record. These exhibit coexpression of immunohistochemical markers in both the tumor components, which is at variance with the antigenic expression in combined squamomelanocytic tumors. Rare existence of “colonized tumors” with a carcinoma (usually of basal cell type), which gets populated by nondendritic malignant melanocytes has been reported. However, these melanocytes

Nerve biopsy in Indian patients with mononeuropathy multiplex of undetermined etiology

A diagnosis of mononeuropathy multiplex (MM) requires detailed evaluation to determine etiology. We performed nerve biopsy on patients with MM in whom the etiology could not be established via other investigations. Methods: Sixty‐eight patients with MM seen between January 2013 and June 2014 underwent detailed diagnostic evaluation. Those in whom the investigations failed to establish an etiology underwent nerve biopsy. Results: A diagnosis of leprosy was confirmed in 14 patients and was highly probable in 17 others. Eleven patients had vasculitic neuropathy, and in 1 patient there were amyloid deposits on nerve biopsy. Conclusions: In 43 of 68 Indian patients (63%) with MM, nerve biopsy identified a definite (26 patients) or probable (17 patients) etiology. Nerve biopsy is a valuable investigation in MM that frequently results in a diagnosis of leprosy in India. Muscle Nerve, 2016 Muscle Nerve 55: 23–27, 2017

A case of antiepiligrin cicatricial pemphigoid with extensive cutaneous erosions mimicking pemphigus vulgaris

Cicatricial pemphigoid (CP) is a chronic, autoimmune, subepidermal blistering disease with predominant mucosal involvement. In this article, we report a young patient with mucosal and extensive cutaneous involvement in the form of large erosions mimicking those of pemphigus vulgaris thus leading to diagnostic dilemma. We were unable to find any other previous reports with such extensive cutaneous erosions mimicking those of pemphigus vulgaris. Laminin 5 was the antigen found on knockout substrate testing. Antiepiligrin CP is a distinct subtype of CP with antibodies against laminin 5. This subtype is mostly associated with malignancy but no underlying malignancy was found in our case. Present report also highlights the importance of knockout substrate testing when immunoblot is not available.

Isolated thickened greater auricular nerve due to leprosy

Leprosy is caused by Mycobacterium leprae bacillus and despite recommendation of multidrug therapy by World Health Organisation in 1981 and eradication programme in various countries; disease prevails and new cases added annually. Variable clinical presentation ranges from limited tuberculoid to widespread lepromatous leprosy. The neuritic presentation varies from mononeuropathy to mononeuropathy multiplex. The disease commonly affects the ulnar, radial in upper and common peroneal, posterior tibial in lower extremity. The neuritic leprosy is easily suspected when there is hypoanesthetic skin lesion with thickened and tender nerve. Involvement of uncommon nerve and pure neuritic presentation, a rare form of leprosy in which skin is spared often leads to diagnostic challenge. Biopsy is not needed to initiate treatment but sometimes required to rule our other diseases. We report a rare case of isolated thickening of greater auricular nerve and diagnostic dilemma encountered in the era of evidence-based medicine.

ENL developing 10 years after leprosy treatment masquerading as atypical-mycobacterial infection

### Learning point for cliniciansnnType II lepra reactions can occur after a long interval post therapy, which may span a decade as in this case. Skin lesions and lymphadenopathy can be the presenting features and would need careful exclusion of atypical mycobacterial infections. Modified Ziehl-Neelson stain is helpful in staining both these bacilli.nnA 35-years-old gentleman presented with continuous, moderate grade fever for 7 days preceded by multiple erythematous, papulonodular lesions on the thighs, face and trunk, along with enlarged, discrete, and tender, cervical and inguinal lymph nodes. (Figure 1a) The symptoms persisted despite intake of antihistaminics. There were no thickened nerves or hypoesthetic skin lesions. nnnnFigure 1. n(a) Clinical photograph showing papular lesions over right arm. (b) Aspirate smear showing abundant polymorphs and foamy histiocytes (May Grunwald Giemsa stain, ×400). Inset shows numerous rod-shaped lepra bacilli in clusters and lying singly (arrow) (Modified ZN stain, …

Isolated superficial peroneal neuropathy: a rare presentation of Hansen's disease (Leprosy)

### Learning Point for CliniciansnnLeprosy should be kept as one of the treatable common neuropathy even when there is involvement of uncommon nerve and absence of classical features of neuritic leprosy. In such cases nerve biopsy may help to make a definitive diagnosis, rule out other causes of nerve thickening and early initiation of treatment to prevent neurodeficits.nnA 43-year-old female presented with a 6-month history of gradually progressive loss of sensation over the dorsum of right foot with tingling sensation on wearing footwear. On sensory examination, there was sensory loss for pinprick, touch and temperature on the dorsolateral aspect of right foot with thickened, non-tender superficial peroneal nerve (Figure 1a). There was no demonstrable weakness with normal deep tendon reflexes. Her haematological parameters, blood sugars, serum creatinine, thyroid and …

Primary breast lymphoma with progression to the scalp

Primary lymphomas developing in the breast constitute a rare entity. A 50-year-old female presented with a breast lump for duration of 2 months. She also had a scalp swelling since 2 days. No lymph nodal involvement was present. Histopathological examination and immunohistochemistry performed on a core needle biopsy of the breast lump revealed a diffuse large B-cell non-Hodgkins lymphoma, an aspirate of the scalp swelling revealed progression from the primary breast lymphoma (PBL). We review the relevant literature and discuss the diagnostic aspects of extranodal lymphomas arising in the breast. Disease progression to the scalp from PBL has not been reported until date. We hereby report the first case of progression to the scalp in a case of PBL.

Inflammatory myofibroblastic tumor of inguinal lymph nodes, simulating lymphoma

Multiple enlarged lymph nodes in an elderly female patient can have varied etiologies as well as histologic pictures. We are presenting the case of a 53-year-old female who presented with inguinal lymphadenopathy with fever, which was clinically misconstrued as lymphoma. Cytology could not exclude a lymphoma. Histology led to the unusual diagnosis of inflammatory myofibroblastic tumor of lymph node in this case. Inflammatory myofibroblastic tumor of the lymph node is a rare, distinctive reactive proliferative pattern in the lymph node which involves proliferation of the connective tissue elements of the lymph node, admixed with lymphocytes, plasma cells, eosinophils, and histiocytes. Multiple etiologic agents have been suggested in existing literature. Despite extensive search, no definite attributable cause could be sought. It is now widely accepted that inflammatory pseudotumor of the lymph node is a non-neoplastic proliferation which has a benign clinical course and excellent prognosis after surgical resection.

Fatal fungal nephropathy in an immunocompetent host: an interesting case

Isolated renal mucormycosis is rarely encountered in immunocompetent individuals. Mucor affects the kidney producing extensive necrosis and vascular thrombosis. Aggressive antifungal therapy is generally attempted in such cases, but the kidney is seldom salvageable and fatality is high. We report a unique case of fatal renal rupture and infarction presenting in an immunocompetent host who presented with fever of unknown cause.nnA 50-year-old patient without diabetes presented to the emergency department in a state of shock. This was preceded by low-grade fever and malaise for 10u2005days, with …

Centchroman: Is unsupervised long-term use warranted? Case report

ABSTRACT Objectives Centchroman (Ormeloxifene) is a synthetic non-steroidal compound used as an oral and a post-coital contraceptive. It is currently under trial for treatment of breast cancer and postmenopausal osteoporosis. Centchroman has been reported to induce only minimal side effects and no hormonal imbalance. Case A young woman who used centchroman for a long time in an unsupervised fashion presented with menorrhagia, which was controlled with norethisterone. Her massively enlarged uterus showed extensive decidual changes in a hyperplastic endometrium, and diffuse microglandular cervical hyperplasia. Conclusions The case suggests a prominent oestrogenic effect of centchroman on the uterus. This could be a significant adverse effect related to prolonged therapy. Lengthy intake of centchroman requires medical surveillance and long-term studies are needed.