Lukas Kofler

Histamine 50-Skin-Prick Test: A Tool to Diagnose Histamine Intolerance

Background. Histamine intolerance results from an imbalance between histamine intake and degradation. In healthy persons, dietary histamine can be sufficiently metabolized by amine oxidases, whereas persons with low amine oxidase activity are at risk of histamine toxicity. Diamine oxidase (DAO) is the key enzyme in degradation. Histamine elicits a wide range of effects. Histamine intolerance displays symptoms, such as rhinitis, headache, gastrointestinal symptoms, palpitations, urticaria and pruritus. Objective. Diagnosis of histamine intolerance until now is based on case history; neither a validated questionnaire nor a routine test is available. It was the aim of this trial to evaluate the usefullness of a prick-test for the diagnosis of histamine intolerance. Methods. Prick-testing with 1% histamine solution and wheal size-measurement to assess the relation between the wheal in prick-test, read after 20 to 50 minutes, as sign of slowed histamine degradation as well as history and symptoms of histamine intolerance. Results. Besides a pretest with 17 patients with HIT we investigated 156 persons (81 with HIT, 75 controls): 64 out of 81 with histamine intolerance(HIT), but only 14 out of 75 persons from the control-group presented with a histamine wheal ≥3 mm after 50 minutes (P < .0001). Conclusion and Clinical Relevance. Histamine-50 skin-prickt-test offers a simple tool with relevance.

Surgical treatment of rhinophyma: experience from a German cohort of 70 patients

BackgroundRhinophyma is a deforming soft tissue hyperplasia of the nose and surgical removal represents the treatment of choice. Comprehensive data on surgical therapy and the impact of rhinophyma on patient quality of life are lacking.ObjectivesPatients who received surgery for rhinophyma between 2006 and 2015 were retrospectively evaluated for postoperative complications, clinical outcome, recurrence of rhinophyma, and the impact of rhinophyma on daily life.Materials & MethodsA total of 143 patients were treated with superficial tumour decortication by scalpel under tumescent anaesthesia. Outcomes were determined by clinical review, clinical files, and a patient questionnaire.ResultsOf 143 patients, 70 answered the questionnaire and were included in this study with a mean follow-up time of 54 months. Cosmetic results were evaluated as very good or good in 77% of patients. The majority of patients (87%) were very satisfied or satisfied with the postoperative result. Surgical treatment of rhinophyma improved patients’ quality of life in 67% of patients. Recurrence of rhinophyma was detected in 38% of patients.ConclusionSurgery is an effective therapy for rhinophyma with excellent outcome.

Type 1 diabetes mellitus caused by treatment with low-dose interferon-α in a melanoma patient

Interferon-α (INF-α) is used as an adjuvant treatment for high-risk cutaneous melanoma. It has a large variety of potentially severe and irreversible side effects and can contribute toward the development of autoimmune disease. We report a case of a 59-year-old woman who developed type 1 diabetes following the use of low-dose IFN-α for the adjuvant treatment of stage IIB melanoma. Fifteen months after initiating IFN-α, she presented with blood glucose of 1126 mg/dl, hyponatremia, and microalbuminuria. Antibodies to glutamic acid decarboxylase and islet antigen-2 were negative and C-peptide was markedly reduced. There was no personal or family history of any autoimmune conditions. Reinforced insulin treatment and volume substitution with saline and glucose as a counter-regulation was started. To the best of our knowledge, this is the first reported case of low-dose IFN-α-induced type 1 diabetes. Clinicians should closely evaluate the pros and cons of IFN-α treatment in an adjuvant setting and remain mindful of the possibility of drug-induced autoimmune disease.

Lymph node dissection for melanoma using tumescence local anaesthesia: an observational study

BackgroundThe possibility that tumescence local anaesthesia (TLA) may lead to dissemination of tumour cells in lymph nodes is presently unclear.ObjectivesTo evaluate whether infiltration by TLA influences metastatic spread and survival probability, compared to general anaesthesia (GA), based on lymph node dissection in melanoma patients.Patients & methodsIn total, 281 patients (GA: 162; TLA: 119) with cutaneous melanoma and clinically or histologically-confirmed metastases in regional lymph nodes were included. All patients underwent complete lymph node dissection.ResultsMedian follow-up was 70 months. The rate of lymph node recurrence at the dissection site was 25.3% in the GA group and 17.6% in the TLA group (p = 0.082). No significant difference was found concerning 10-year melanoma-specific survival (GA: 56.2%, TLA: 67.4%; p = 0.09), disease-free survival (GA: 72.8 %, TLA: 81.1%; p = 0.095), or lymph node-free survival (GA: 72.8%, TLA: 81.1%; p = 0.095). Distant metastases-free survival appeared to be slightly reduced in the TLA group (GA: 49.9%, TLA: 64.0%; p = 0.025).ConclusionsNo differences were identified between the GA and TLA groups regarding prognostic outcome for overall survival or disease-free survival.

Multiple nodular papules and tumors of the head and face

Multiple tumors on the scalp, the temples, and in the preauricular region were removed by en-bloc resections and sent for histopathological evaluation. One of the tumors located in the nasolabial fold showed follicular differentiation and islets of small basaloid, palisading basophilic cells and multiple small keratin pearls at the center of the lesion. A second tumor (from the preauricular region) was made up of multiple basophilic nodules – surrounded by a fi brous capsule – of slightly basophilic cells with large nuclei at the center as well as smaller peripheral cells with hyperchromatic nuclei (Figure 2 a). Multiple nodular papules and tumors of the head and face Case for Diagnosis

Recurrent vulvovaginal candidiasis: Successful suppression with imiquimod

Dear Editor, Recurrent vulvovaginal candidiasis (RVVC) often runs a protracted chronic course and is usually defined as four or more culture-proven episodes per year. Treatment usually consists of repeated courses of topical and systemic antimycotic drug regimens. Treatment of human papilloma virus (HPV) genital warts is based on ablation, cytotoxic agents and immunomodulation like the Toll-like-receptor (TLR)-7 agonist imiquimod. Imiquimod is able to stimulate the innate immune system by activating surface molecule TLR-7 and subsequently nuclear factor (NF)-jB pathway, leading to the production of pro-inflammatory cytokines ultimately stimulating a strong T-helper (Th)1 immune response. We present the case of a 34-year-old woman with a 17-year history of RVVC with at least monthly infections. Only during continuous systemic antimycotic therapy were eight documented cultures proved to be Candida albicans negative. Acquiring HPV high-risk infection, she underwent three sessions of ablative laser treatment (Revolix Thulium YAG 120 W; LISA laser products OHG, Fuhrberg & Teichmann, Katlenburg-Lindau, Germany), followed by additional treatment with the TLR-7 agonist imiquimod (5%, Aldara; MEDA Pharmaceuticals GmbH & Co KG, Bad Homburg, Germany) twice a week. She took 150 mg fluconazole twice weekly on a regular basis and local nystatine cream and suppositories at that time. After 4 months of imiquimod therapy, surprisingly for the first time the patient did not request further antifungal medication. Treatment stop to prove the possible influence of imiquimod was followed by immediate candidiasis recurrence, as confirmed by positive vaginal C. albicans culture. Restarting imiquimod (twice weekly for 1 month, then once weekly one sachet/~12.5 mg) again sufficed to control candidiasis, as two more cultures for C. albicans and three vaginal swabs (20% potassium hydroxide solution, light microscopy) remained negative. For the last 2 years, the patient has been on low-dose imiquimod therapy (12.5 mg once weekly overnight). Since then, she has experienced not more than one infection with Candida spp. annually in contrast to monthly infections in all previous years. The effect of imiquimod may be due to local pro-inflammatory reaction by activating innate immune response with aand b-defensins, cathelicidins, psoriasin and RNase-7 as central mediators. It was shown that HPV per se induced an increase of human b-defensins; this seems not to be plausible in this case, however, as cessation of imiquimod treatment led to prompt Candida re-infection. Also, activation of NF-jB by imiquimod may play a role. Interferon (IFN)-c knockout mice are prone to severe systemic Candida infection as it is a known key molecule in this context. Furthermore, imiquimod exerts some important effects via induction of macrophages and infiltrating T cells by IFN-c production, as well as plasmacytoid dendritic cells (pDC): they are specialized type I IFN-producing cells expressing TLR-7 and TLR-9. Imiquimod may sense pDC via TLR7 and induce IFN-c production. By chance, we observed an impressive, long-lasting effect of imiquimod on RVVC, documented it well and followed this patient for over 2 years at the time of writing. Although spontaneous improvement can never be excluded by a single case report, the long lasting course of the infection and the reappearance after cessation of imiquimod makes a causative effect of this drug quite plausible.

Serpiginous Lesions in an Infant

A 1-year-old infant presented at our department with a 6-week history of skin lesions, starting 1 month after a holiday trip to Sri Lanka. There the boy ingested some sand at a beach, where local dogs were present. The physical examination showed irregular and serpiginous erythematous papules and stripes at the right lower leg (A), the perianal region (B), and the left cheek crossing the mouth and the oral mucosa. The clinical picture is characteristic for cutaneous Larva migrans. Reports on infected oral mucosa are rare. We treated our patient with topical albendazol 10%, which resulted in complete healing. Visual Dermatology 748887 CMSXXX10.1177/1203475417748887Journal of Cutaneous Medicine and SurgeryMaier et al. other2017

An unexpected result following sentinel lymph node biopsy for desmoplastic cutaneous squamous cell carcinoma

Sentinel lymph node biopsy (SLNB) is a procedure used in the diagnostic workup of advanced malignancies including cutaneous squamous cell carcinoma (cSCC) [1–4]. The risk of metastasis depends on various factors such as tumor thickness, tumor diameter, recurrence, perineural invasion, immunosuppression, and tumor site [2, 3, 5]. As lymphatic spread is a major route of metastasis in cSCC, SLNB is employed as an additional diagnostic method in high-risk cSCC, theoretically allowing for exact staging of the regional lymphatic basin [6]. However, the role of SLNB in cSCC and its value in clinical settings is still subject to controversial debate. Compared to melanoma of the head/neck region, fewer positive sentinel lymph nodes have been found in cSCC, although both tumor entities are capable of lymphatic spread and characterized by proliferation of intratumoral lymphatic vessels [6–9]. This discrepancy might be due to different mechanisms of metastatic spread in melanoma and cSCC as well as staged surgical procedures performed in advanced cSCC. Moreover, extensive inflammatory stromal reactions observed in cSCC are associated with reduced detectability of sentinel nodes [10]. Besides lymphatic dissemination, cSCC can metastasize by direct extension. There have even been reports of cSCC showing metastatic spread to lower cervical lymph node stations, without involvement of lymph nodes further upstream (skip metastasis) [11]. An important source of error is the accidental excision of a non-sentinel lymph node, resulting in a false-negative SLNB. The anatomy of the head/neck region, where the majority of cSCCs are found, results in complex lymphatic drainage. Furthermore, the short distance between primary tumor sites and sentinel lymph nodes may possibly interfere with the detection by radionuclide labeling. SLNB is frequently designed as a staged procedure following excision of the primary tumor and wound closure with a local flap, which changes the original lymphatic drainage pattern. In a systematic review by Ahmed et al., false-negative rates were reported to be 4.7 %; in a retrospective analysis by Krediet et al. 6 %. [2, 12]. Emphasizing the awareness of false-negative sentinel lymph nodes, we present the case of an 81-year-old patient with a desmoplastic squamous cell carcinoma (dSCC) of the temple region (tumor thickness > 5 mm; T2N1M0, stage III). Re-excision of the primary tumor using microscopically controlled surgery and SLNB were performed in a single-stage procedure. SLNB was basically successful as a radionuclide-labeled lymph node was detected in the regional lymphatic basin. While that node was found to be tumor-free on pathological examination, histopathology of the re-excised tissue showed a lymph node at a distance of less than 5 mm from the primary tumor; further immunohistochemical studies revealed this particular lymph node to contain a micrometastasis (Figure 1). This rare case of an “unintentionally” detected SLNB illustrates that lymph nodes considered to be “sentinel lymph nodes” may be false-negative due to the complex lymphatic drainage pattern of the head/neck region as well as due to surgery-related factors. Given that a relevant number of patients experience a fatal outcome, further research in this field is required to ascertain the reliability of SLNB in cSCC and dSCC.

Patient satisfaction in 1,827 patients following various methods of facial reconstruction based on age, defect size and site: Patient satisfaction after facial reconstruction

Defect coverage following tumor excision requires a case‐by‐case decision as regards the optimal reconstruction technique. In the head and neck region in particular, the cosmetic outcome is of major importance. The objective of the present study was to compare various reconstruction methods in terms of their functional and aesthetic outcome based on patient age, defect size and site.

Uncommon ulcers in a patient with diabetes

A 52-year-old man presented at our hospital with digital ulcers on both hands, some of them showing secondary impetiginization (Figures 1, 2 ). He reported tension and stiffness in all fi ngers and diffi culty clenching his fi st. These changes were reported to have been present for over a year. He noticed worsening of the symptoms during winter, especially at work as the driver of a snowplow. The patient did not report any other symptoms such as Raynaud’s phenomenon, dyspnea, fever or fatigue. Type 2 diabetes was diagnosed many years Uncommon ulcers in a patient with diabetes Case for Diagnosis