Mary Jane Zimarowski

Lupus erythematosus-like reaction in imiquimod-treated skin: a report of 2 cases.

Imiquimod (Aldara) is a topical immune response modifier effective against a variety of cutaneous tumors. Post therapy histologic reaction patterns have not been well characterized. Here, we present 2 patients treated with imiquimod, whose biopsies showed interface dermatitis of the epidermis and the adnexae with prominent periadnexal and perivascular lymphocytic inflammation. Without the clinical history, these histologic findings may be misinterpreted as lupus erythematosus. This report describes a new finding in imiquimod-treated skin and supports the diversity of reaction patterns that may be seen in association with imiquimod treatment.

Churg-Strauss syndrome presenting as scar reactivation: histopathologic features and an illustration of ‘locus minoris resistentiae’†

We report a 33‐year‐old female with cutaneous involvement by Churg‐Strauss syndrome confined to surgical scars that were obtained 13 years before. She presented to the emergency department with 2‐day history of fever, night sweats, right‐sided weakness, hoarseness and worsening asthma symptoms. She was found to have an eosinophilia and two sub‐5‐mm pulmonary nodules. The patient also reported that the scars on her right thumb, inner wrist and back had been swollen, red and painful for 2 days. Examination revealed tender, erythematous, well‐healed edematous scars studded with small skin colored papules. She had no clinical findings that were classic for cutaneous vasculitis. A skin biopsy of a scar revealed perivascular and palisading granulomatous inflammation consisting of histiocytes and neutrophils with leukocytoclasia. Focal vascular injury was identified. Scattered tissue eosinophils were seen. Special stains were negative for infection. Thereafter, she was started on intravenous steroids, at which point the fever, pulmonary and cutaneous symptoms subsided. Although scar sarcoidosis is a well‐described phenomenon, granulomatous inflammation and vasculitis seen in Churg‐Strauss syndrome exclusively manifesting in well‐healed surgical scars highlights the unique features seen in this case and draws attention to the concept of locus minoris resistentiae. This case also highlights how a skin biopsy in the setting of suspected systemic vasculitis can confirm the presence of vasculitis and/or granulomatous inflammation and obviate the need for more invasive, higher risk procedures such as lung biopsy.

Metastatic peritoneal mesothelioma in the setting of recurrent ascites: A case report

Malignant peritoneal mesothelioma is uncommon but rapidly fatal with a median survival of less than 1 year. The diagnosis of this entity is often delayed because of the nonspecific presenting symptoms and nonspecific cytological features of the mesothelial cells in the peritoneal fluids.

Contact Dermatitis Associated with Alopecia and Hyperpigmentation

To the Editor: We read with interest the publication by Admani et al (1), who reported three cases of allergic contact dermatitis (ACD)-associated alopecia that resolved after avoidance of the allergen balsam of Peru. Recently we noted three adults with skin phototype V who presented with alopecia and facial dermatitis. All described sensitivity to personal care products, two had positive patch testing to fragrances, and all reported improvement of symptoms after avoidance of allergens. These three cases further support a potential role of ACD in alopecia. Patient 1 was a 43-year-old woman with skin phototype V with a 2-year history of hyperpigmented, slightly erythematous, scaly, pruritic patches on bilateral eyelids and the anterior neck and a 1-year history of frontal hairline recession without evidence of scarring. A punch biopsy specimen of her frontal scalp favored alopecia areata and possible superimposed contact dermatitis (Table 1). Patch testing at 96 hours revealed positive reactions to 4-phenylenediamine base (1+), nickel sulfate hexahydrate (2+), fragrance mix (1+), and glyceryl monothioglycolate (1+) (Table 1). Six months later her dermatitis had improved with allergen avoidance. Patient 2 was a 46-year-old woman with skin phototype V with 11 years of hair loss and hyperpigmented pruritic patches on the lateral face bilaterally for 1 year. A punch biopsy specimen of her frontal scalp revealed changes consistent with central centrifugal cicatricial alopecia with a component of androgenetic alopecia (Table 1). Patch testing revealed a positive reaction to fragrance mix (1+ at 96 hours; Table 1). After avoidance of fragrances, her contact dermatitis was successfully controlled. Patient 3 was a 44-year-old woman with skin phototype V with 5 years of significant eyebrow alopecia with erythematous, minimally scaly patches; a regressed anterior hairline with follicular spines; and hyperpigmentation of the forehead, cheeks, and neck. A punch biopsy specimen of her temple revealed focal vacuolar interface change, dermal macrophages, and perivascular and perifollicular lymphocytic inflammation with follicular apoptosis, taken together suggesting frontal fibrosing alopecia (FFA) and lichen planus pigmentosus (LPPigm) (Table 1). Use of sunscreen worsened her rash, although patch testing resulted in no positive reactions (Table 1). This series further highlights the association between inflammatory alopecia and ACD given the topical triggers and positive reactions to fragrance on patch testing (2,3). The third patient’s presentation is consistent with FFA/LPPigm (4), and she reported sensitivity to sunscreen. FFA is associated with the

Continuous positive airway pressure-associated cutaneous amoebiasis in an immunosuppressed patient

Organisms of the genus Acanthamoeba are environmentally ubiquitous and colonizers of the oral mucosa in humans. While largely asymptomatic in healthy persons, Acanthamoeba infection can cause disseminated disease with poor prognosis in immunosuppressed populations. Here we report a unique case of cutaneous amoebiasis associated with continuous positive airway pressure use in an immunosuppressed patient.

Recurrent lobular capillary hemangiomas in a patient with neurofibromatosis type 1 (NF1) and von Hippel-Lindau syndrome (VHL)

Lobular capillary hemangiomas, also known as pyogenic granulomas, are common, benign, vascular proliferations of the cutaneous or mucous surfaces that grow rapidly and are prone to ulceration and bleeding.1, 2 Recurrence of lobular capillary hemangiomas in the same location after treatment is common with rates ranging from 3.7% to 43.5%.3 Well-known causes of lobular capillary hemangiomas are trauma, infection, medication, chronic irritation, viral oncogenes, increased levels of female sex hormones, and microscopic arteriovenous anastomoses.1 Patients commonly seek treatment because of associated pain or discomfort from ulceration, bleeding, or both. Surgical excision and cryotherapy show best therapeutic outcomes for lobular capillary hemangiomas, although electrodessication, shave excision, imiquimod cream, topical timolol, and sclerotherapy are also used.3, 4

A woman with night sweats, arthritis, and two distinct eruptions

A 44-year-old Caucasian woman presented to the dermatology clinic with a 3-week history of a pruritic eruption affecting her neck. On further questioning, the patient reported fatigue, myalgias, decreased appetite, drenching night sweats, and joint pain affecting her bilateral wrists and hands over the preceding few months. Her medications included ibuprofen and loratadine, which temporarily relieved the joint pain and pruritus, respectively. On physical examination, the patient was found to be afebrile. On her upper back and posterior neck, linear arrays of excoriated brown and red papules were seen (Fig. 1a). A wispy, blanching reticulate eruption of salmon-pink macules on the thighs was noted incidentally (Fig. 1b). Cervical lymphadenopathy and fullness of the bilateral wrist joints were found. Laboratory results were notable for the absence of leukocytosis and an elevated erythrocyte sedimentation rate (69 mm/h; normal: < 25 mm/h), C-reactive protein (43.1 mg/l; normal: < 8 mg/l), and ferritin (689 ng/ml; normal range: 10–200 ng/ml). The results of liver function tests were within normal limits. Tests for antinuclear antibody, rheumatoid factor, and anti-cyclic citrullinated peptide antibody were negative. Parvovirus B19 immunoglobulin M (IgM) titers were normal. (a) (b)