Masanori Ban

Microcystic adnexal carcinoma with lymph node metastasis

Microcystic adnexal carcinoma (MAC) affects predominantly the face and seldom metastasizes. We report a case occurring in the axilla of a 63-year-old male. Histology revealed the characteristic features of MAC. Eleven months after the excision, he underwent a reexcision with wide margins because of local recurrence. Histologically, the central area of the recurrent lesion revealed the typical histologic features of MAC, and the periphery showed a proliferation of irregular duct-like and glandular structures with a mixed pattern. Two lymph nodes that were not adherent to the tumor had metastatic tumor cells. The present case confirms that MAC can metastasize, although it may also be hypothesized that the recurrent lesion represented transformation into a higher-grade carcinoma.

Nail discoloration occurring after 8 weeks of minocycline therapy

Minocycline‐induced nail pigmentation is an uncommon side‐effect. It usually develops after years of the therapy, and coincides with other pigmented sites. We report a 73‐year‐old male and a 33‐year‐old female developing nail discoloration after 8 weeks of therapy of 100 mg minocycline twice daily. No other pigmentation was found elsewhere on the skin, mucous membranes, teeth or sclerae of them. Our cases demonstrate that nail pigmentation can occur after short‐term minocycline therapy, and propose the possibility that nail discoloration may precede other pigmentary changes.

An outbreak of eruptive pseudoangiomatosis-like lesions due to mosquito bites: erythema punctatum Higuchi.

Nonitchy small spotted erythema surrounded by an anemic halo (fig. 1) has been called erythema punctatum Higuchi in Japan for about the past 50 years. The clinical features of the eruptions are described as follows [1–6]. Females are more frequently affected than males. Most of the eruptions develop scatteringly on the extremities, especially in summer. Indurations are associated with erythema and halos at the onset, and vanish in about 3 days. Halos become unclear after 4 or 5 days. Both the erythema and the halo disappear 7–19 days after the onset. On the face, lesions have an unclear halo. The etiology is not well known. Histological studies [3, 4, 6] revealed capillary dilatation and inflammatory cell infiltration in the upper dermis, which are not specific features. Ohara et al. [5] reported 24 cases and suggested that mosquito bites play a significant role in the pathogenesis of erythema punctatum Higuchi. They also observed that the eruption appeared in the skin of a 30-year-old female patient 5 min after the bite of Culex pipiens pallens and saw 3 cases induced by other kinds of mosquitoes. However, to date there have been no other reports about the relationship between mosquitoes and erythema punctatum Higuchi. Since 1990, we have observed several outpatients with similar eruptions in Hashima City Hospital, which is located in a garden city in the Nobi plains near the center of Japan, during every summer. The eruptions do not react to corticosteroid ointments and fade out within 1–3 weeks with or without therapy. Though we had hardly seen the eruptions in inpatients of the hospital, we have recently experienced many inpatients with these eruptions. A great number of C. pipiens pallens attacked Hashima City Hospital in the late autumn of 2001 and flew into the hospital especially at night, though no mosquitoes usually appear in Hashima City in that season. C. pipiens pallens worried the inpatients and the staff of the hospital until the end of December. C. pipiens pallens is common in Japan. When bitten by them, people usually feel an itch. We suspected that the propagation of C. pipiens pallens was caused by drainage works that had been carried out near the hospital in 2001. The mosquitoes breed in the stagnant ditch. C. pipiens pallens passed the winter and appeared again in Hashima City Hospital in the early spring of 2002. While a great number of C. pipiens pallens attacked the hospital, we found many inpatients with erythema punctatum Higuchi: 10 inpatients in the late autumn in 2001, and 16 inpatients in the early spring of 2002 (table 1). They had multiple lesions on the face, neck, hands and forearms. These were not itchy. Most of the patients except for psychiatric inpatients were bedridden. Five inpatients on the same floor developed the eruptions within 10 days. Two of them had stayed in the same room and were found to develop the eruptions on the same day. Some confusion arose on that floor, because most doctors and nurses had no knowledge of erythema punctatum Higu-

Tufted angioma of adult onset, revealing abundant eccrine glands and central regression.

Tufted angioma (angioblastoma) usually occurs in infancy. Some lesions reveal proliferation of eccrine glands and some undergo spontaneous regression. We report a lesion from the left lateral chest of a 58-year-old male, which had appeared 5 years ago and gradually increased in size. Its color had faded out centrally. Histological examination showed many angiomatous lobules on the border of the lesion but few in the central portion. Abundant eccrine sweat glands, small venules and dense connective tissue were seen in both areas. The histology and the clinical course suggested that central regression occurred in the lesion. Out of 211 reported cases, we found 4 cases that had annular lesions spreading centrifugally. Though these lesions were not examined histologically, they were suspected to regress in the central portions. We suggest that central regression can rarely occur in tufted angioma.

Differentiation of eccrine poroma cells to cytokeratin 1- and 10-expressing cells, the intermediate layer cells of eccrine sweat duct, in the tumor cell nests.

It has been shown that an intermediate cell layer exists between a luminal cell layer and a peripheral cell layer in human eccrine sweat ducts by immunohistochemistry using anti‐keratin antibodies 34βB4 and DE‐K10. These antibodies react to cytokeratin 1 and 10 respectively, and stain the intermediate cells specifically, but not luminal cells nor peripheral cells. Cytokeratin 1 and 10 are considered to appear as a differentiated keratin in the terminal process of epidermal keratinization. We examined 5 cases of eccrine poroma with 34βB4 and DE‐K10. Various numbers of the poroid cells reacted to these anti‐keratin antibodies in 4 cases. Some positive cells were observed around the cuticular cells in two of them. The present study demonstrated that terminal differentiation in terms of keratinization can occur in eccrine poromas, and that the 34βB4‐ and DE‐K10‐positive cells around the cuticular cells differentiate toward the intermediate cells in cytokeratin expression profile and location.

A CASE OF RAPIDLY-GROWING ECCRINE POROMA DURING PREGNANCY

To theEditor: It is widely accepted that pregnancy modifies some dermatoses. Many tumors, including Bowenoid papulosis, Langerhans-cell histiocytosis, mycosis fungoides, malignant melanoma, neurofibroma, and some vascular tumors, develop or exacerbate during pregnancy (1). However, the relationship between eccrine sweat apparatus tumors and gestation is not well understood. This report documents a case of eccrine poroma growing rapidly on the abdomen of apregnantwoman. Case Report: A 32-year-old female, who had delivered her third child 2 days before, came to our hospital on October 6, 1994. She had no particular medical history. She had noticed a solid papule about 2 mm in diameter on the left side of her abdomen two and a half years before, when she had been in her second pregnancy. The tumor size had not changed from that time until it began to enlarge rapidly from May of 1994, when she was five months pregnant. Clinical examination showed a black, pedunculated, soft tumor, 20 x 15 x 7 mm in size, on her left abdomen. It was not accompanied by erythema (Fig. 1). We clinically diagnosed it as eccrine poroma. She underFig. 1. A pedunculated black tumor on the left side of the abdomen

Giant sinusoidal hemangioma revealing diffuse ancient change: hyalinization and organized thrombi

change: hyalinization and organized thrombi Sinusoidal hemangioma, a distinctive subset of the group of cavernous hemangiomas, was first described by Calonje & Flectcher in 1991. This entity has been considered to be relatively small in size. We report herein a giant tumor with diffuse ancient change. An 85-year-old female presented with a 10-year history of a nodule on her right shoulder. The tumor had gradually increased in size, and had been asymptomatic. She had noticed the sudden bleeding from the tumor on the day of the first examination. Clinical examination revealed a firm pedunculated tumor, sized 115 · 90 · 75 mm in diameter, on the right shoulder. It was covered by expanded skin and had a small ulcer, 5 · 3 mm in diameter (Fig. 1). She was healthy, not anemic and had no history of particular skin disorders. The surface of the tumor ulcerated widely and rapidly after the first examination. Biopsy in advance of the surgical operation disclosed only hyalinization. Total resection and full-thickness skin grafting were performed under general anesthesia. The tumor mass localized in the dermis and the subcutaneous tissue. The cut surface of the tumor showed a large amount of blood coagulation. Histologically, hyalinized collagen in the stroma and organized thrombi occupied the greater part of all the sections. The thin blood walls containing the thrombi consisted of a single layer of flattened epithelial cells. Some vascular spaces without thrombi showed sinusoidal and pseudopapillary patterns and ‘‘back-to-back’’ arrangements with scant stroma (Fig. 2). Calcification and foamy macrophages were also seen. The diagnosis of ancient sinusoidal hemangioma was made. We thought that the ulceration of the surface resulted from ischemia. Clinical features of sinusoidal hemangioma comprise an acquired solitary lesion in adults, no special predilection for any body parts, and predominance on females. Twelve lesions reported by Calonje & Flectcher ranged from 1 to 3.5 cm in diameter. Their preoperative duration was from 3 weeks to 7 years. Only few cases have been reported since Calonje & Flectcher described this entity. Also, sinusoidal hemangioma has been estimated to be a relatively small tumor. However, we think that it can grow bigger for the long duration. Except for ours, the largest reported lesion measured 5 cm in diameter. Regrettably, Nakamura & Miyachi did not describe the size of a lesion with a 20-year history. Histological features are characterized by the presence of a lobulated mass composed of thin-walled, intercommunicating vascular channels arranged in a sinusoidal pattern, and the pseudopapillary pattern in which crosscut vessel walls are lined by flattened endothelial cells. The dilated vessels have an almost ‘‘back-to-back’’ arrangement without much intervening stroma. Calonje & Flectcher described that older lesions revealed thin bands of hyalinized collagen in the stroma, recent or organized thrombosis, calcification, metaplastic ossification, and foamy macrophage. These ancient changes were

The number and distribution of Merkel cells in Rudimentary polydactyly

Background: Rudimentary polydactyly histologically reveals a marked neural proliferation in the dermis and a large number of Meissner corpuscles in the dermal papillae. Objective: Our study was performed to determine whether this neural proliferation is related to Merkel cells. Method: Using an antibody to cytokeratin 20, we examined the number and distribution of Merkel cells in 5 cases of rudimentary polydactyly, including an immature case without Meissner corpuscles. Results: Only the case without Meissner corpuscles had a markedly large number of Merkel cells and some dermal Merkel cells. Conclusion: The normal number of Merkel cells in the mature cases suggests that abundant Merkel cells may appear at first and disappear after the development of neural proliferation. Merkel cells may be associated with the generation of cutaneous nerve plexus and nerve endings in the upper dermis, and possibly with the development of Meissner corpuscles, at the early stage of rudimentary polydactyly.

Bowen's disease with invasive adnexal carcinoma: the pluripotential nature of Bowen's disease cells.

Bowens disease rarely exhibits multiple combinations of premalignant and/or malignant skin lesions. Bowens disease with invasive adnexal carcinoma was originally described by Kao, but is not well recognized by clinicians due to its rarity and lack of specific clinical features of this condition. Herein, we describe three unusual cases of Bowens disease with invasive adnexal carcinoma. The two distinct neoplastic areas exhibited continuity both clinically and histologically. The plaque lesions possessed clinical features typical of Bowens disease. In cases 1 and 3, we confirmed the adnexal tumor within tumors of Bowens disease, the diagnosis of which is eccrine porocarcinoma. The tumor in case 2 was characteristic to trichilemmal carcinoma. Immunohistochemically, the tumor cells of Bowens disease and the adnexal carcinoma differed in antigenicities. The present cases support a notion that Bowens disease maintains a pluripotential nature.

Cutaneous plasmacytic pseudolymphoma with erythroderma

From the Department of Dermatology, A 64-year-old man visited our hospital on June 29, 1993. He had suffered from Hashima City Hospital, Hashima and erythroderma for the past 18 months, and had been treated by a local physician. He had Gifu University School of Medicine, generalized erythema and severe pruritus, which had resisted anti-allergic medicines and Gifu, Japan topical corticosteroid. He needed continuous oral corticosteroid therapy (5 or 10 mg/day of