Martin P. Fernandez

Epstein-Barr virus is not associated with angioleiomyomas, or other cutaneous smooth muscle tumors in immunocompetent individuals

To the Editor, Epstein-Barr virus (EBV) has been associated with a variety of tumors occurring in immunocompetent and immunocompromised individuals, including a spectrum of lymphoid neoplasms, nasopharyngeal carcinomas and gastric adenocarcinomas.1,2 More recently, EBV has been linked with a rare and distinct subset of smooth muscle neoplasms, the EBV associated smooth muscle tumor (EBV-SMT).3– 5 EBV-SMT occurs in immunocompromised individuals, and tends to affect the pediatric acquired immune deficiency syndrome (AIDS) population.3 It typically arises at locations where smooth muscle tumors are uncommon, such as the liver, lung and central nervous system,5 although cases of EBVSMT involving the dermis and subcutaneous tissue have been described.6,7 EBV-SMT is commonly multifocal, and in some cases, the tumors display a close association with small vessels.5 This finding has been interpreted as an evidence that these tumors arise from the smooth muscle elements of blood vessels. Angioleiomyomas are solitary, well-circumscribed smooth muscle tumors that involve the subcutaneous tissue of extremities, and arise from the smooth muscle of vessel walls.8 Pilar leiomyomas, in contrast, are typically multifocal, poorly circumscribed smooth muscle tumors that involve the dermis, and arise from the arrector pili muscle elements. Leiomyosarcomas may involve the dermis or subcutaneous tissue and may develop from the smooth muscle of the vessel walls or arrector pili muscle. The capacity of EBV to infect vascular smooth muscle cells that give rise to EBV-SMT suggests a potential role of EBV in the pathogenesis of other smooth muscle tumors of vascular origin, such as angioleiomyoma. This study was carried out to investigate this potential association. Smooth muscle tumors involving the skin or subcutaneous tissue were identified from the files of the Department of Pathology at the University Hospital in San Antonio, Texas. Angioleiomyomas were identified from the files of South Texas Dermatopathology Laboratory. A total of 21 specimens were retrieved and included in the study: 12 angioleiomyomas, 4 pilar leiomyomas, 1 cutaneous myopericytoma and 4 primary cutaneous leiomyosarcomas. All cases were reviewed and pertinent clinical findings for each case, including age, gender and location were recorded. Any history of immunocompromise was also noted. All specimens were formalin-fixed and paraffin embedded. One section from each block was stained with hematoxylin and eosin (H&E) and reviewed to confirm diagnostic material was available. Each H&E stained section was also evaluated for the presence of primitive round cell areas and presence of tumor infiltrating lymphocytes, features characteristic of EBV-SMT.5 In-situ hybridization (ISH) for EBV was done on each of the 21 smooth muscle tumor samples using a Ventana Benchmark autostainer and Epstein Barr Virus Early RNA (EBER) kit by Ventana (Ventana medical systems, Tucson AZ). Supplier’s recommendations were followed. Tissue sections were placed on glass slides precoated with poly-L lysine, and deparaffinized. Tissue was then digested using ISH protease-1 treatment. Oligonucelotide probes targeting EBER were used to assess the presence of EBV. Detection of the hybridized probes was done with iVIEWblue, from Ventana (Ventana medical systems, Tucson AZ). A red counterstain was used.

Eccrine gland stroma changes in cutaneous hamartoma of infancy

To the Editor, We read with interest the article by Grynspan et al. highlighting the epidermal and dermal adnexal changes that arise in association with fibrous hamartoma of infancy, and would like to comment on our experience with one case featuring a characteristic eccrine gland change. A hairy plaque developed on the upper back of a 12-month-old boy (Fig. 1). A 3 mm punch biopsy was obtained and submitted to our laboratory. The biopsy showed increased numbers of terminal hair follicles and eccrine glands, in addition to an ill-defined proliferation of spindle cells involving the deep reticular dermis (Fig. 2). The cellular proliferation was characterized by coarse bundles of fibrous tissue and mature adipose tissue (Fig. 3), as well as nested collections of primitive undifferentiated mesenchymal cells (Fig. 4). These three mesenchymal components are diagnostic of fibrous hamartoma of infancy. In some areas, the primitive mesenchymal cells replaced the inconspicuous loose connective

Eruptive keratoacanthomas after Jessners and trichloroacetic acid peel for actinic keratosis.

Keratoacanthomas, characterized as a subtype of squamous cell carcinoma (SCC) or a separate benign lesion, remain a management quandary in terms of how to treat these lesions. In our patient, the appropriate therapy was no treatment. Jessner’s and trichloroacetic acid (TCA) peel is a medium-depth chemical peel used on facial and nonfacial skin for treatment of actinic keratoses, photoaging, pigment dyschromias, and melasma. Side effects or complications of TCA peel include erythema, peeling, hyperpigmentation, herpes simplex virus type 1 reactivation, scarring, and keratoacanthomas. Trauma to the skin caused by chemical peels, thermal burns, fractional photothermolysis, and cryotherapy, have all been reported to cause keratoacanthomas. Here we present a case of eruptive keratoacanthomas after Jessner’s and TCA peel for actinic keratoses that resolved spontaneously.

A 48-year-old man with a crusted plaque on the left side of the neck: Challenge

A 48-year-old Hispanic man was evaluated for a suppurative plaque on the left side of the neck. The lesion began as an apparent insect bite several months before the time of consultation. Multiple oral courses of Bactrim and topical application of Neosporin had been advised without improvement. The patient denied constitutional symptoms, and his review of systems was otherwise negative. Social history was remarkable for prior homeless status, marijuana use, and limited alcohol consumption. On examination, he was afebrile and of thin build. Examination of the neck demonstrated a 3 3 2-cm, crusted, lichenified, and suppurative plaque on the left side of the neck, as pictured below (Fig. 1). There was also palpable lymphadenopathy in the left anterior cervical chain. Computed tomography scan demonstrated a focal area of dermal thickening and bilateral upper cervical lymphadenopathy. There were no other cutaneous, oral mucosal, or genital lesions present. The clinical differential diagnosis included scrofuloderma, deep fungal infection, other infectious processes, and malignancy. A shave biopsy showed irregular epidermal hyperplasia with overlying scale crust (Fig. 2) and a lichenoid infiltrate clouding the dermal–epidermal junction (Fig. 3). The infiltrate was composed mainly of plasma cells and histiocytes with scattered neutrophils, eosinophils, and lymphocytes (Fig. 4). The epidermis showed numerous necrotic keratinocytes and collections of neutrophils (Figs. 5, 6). What is your diagnosis?

Synovial sarcoma of the foot: a case report.

We report a case of a 40-year-old woman with synovial sarcoma who presented with neural symptoms in the medial aspect of the right foot and ankle. The radiographic appearance of the foot and ankle was unremarkable, but magnetic resonance imaging showed a relatively well-defined enhancing lesion in the plantar soft tissues extending from the master knot of Henry to the posterior tibialis tendon. After orthopedic oncologic evaluation and workup, the patient was ultimately treated with a transtibial amputation, and no evidence of recurrence or metastatic disease was seen at 6-month follow-up.

A Case Report of Malignant Melanoma of the Great Toe

UNLABELLED Melanoma is reported as the most common malignant neoplasm of the foot and carries with it a very poor prognosis. This neoplasm arises from melanocytes, which are pigment-producing cells found predominantly in the skin, and the malignancy can metastasize to any organ system. Early and accurate diagnosis and treatment are paramount components of a successful course of management, and improve the rate of survival for those affected by this aggressive cutaneous neoplasm. In this report, we describe an invasive case of melanoma of the hallux that was misdiagnosed as a chronic ingrown and infected nail. LEVEL OF CLINICAL EVIDENCE 4.

Histopathology and X-ray microanalysis of foreign material on facial keratoses.

Opaque exogenous material was frequently observed on the surface of keratoses during routine sign out by one of us (H.K.). To investigate this material further, 300 consecutive seborrheic keratoses were reviewed: 100 cases from the face of women, 100 cases from the face of men, and 100 cases from the trunk of men and women. All cases were evaluated by light microscopy for the presence and quantity of exogenous material, and 14 cases were studied by x-ray microanalysis to assess its composition. The material was present on 54% of facial keratoses from predominantly older women (mean age 67 years), 5% of facial keratoses from men, and 9% of truncal keratoses from men and women. The x-ray microanalysis showed the presence of a variety of elements, including titanium (13 cases), silicon (12 cases), iron (9 cases), aluminum (8 cases), magnesium (8 cases), zinc (4 cases), barium (2 cases), and bismuth (2 cases). We believe that the exogenous material represents cosmetic products such as colored facial cosmetics, sunscreens, and moisturizers. Further, because the exogenous material was found predominantly on facial keratoses of older women, the presence of this material in a specimen may serve as a clue to the patients gender, age, and biopsy site.