Robin C. Billick

Minocycline-induced Sweet's syndrome

This is the second reported case of minocycline-induced Sweets syndrome (and the first such case to appear in the American literature). The syndrome developed in a 32-year-old man 10 days after minocycline therapy for acne was begun and resolved rapidly after discontinuation of the medication and start of oral prednisone therapy.

Dermatomyositis presenting as panniculitis

A patient with dermatomyositis presenting initially as a nonspecific panniculitis, a rare event, is discussed .

Eruptive vascular tumors associated with chronic graft-versus-host disease

We report the occurrence of benign angiomatous and mesenchymal tumors following chronic graft-versus-host disease. Our patient is a 23-year-old man who had undergone allogenic bone marrow transplantation for chronic myelogenous leukemia in 1978. Over the past 3 years he has developed poikiloderma and sclerodermatous tightening of the upper and lower extremities. From 1981 until the present time, violaceous to black friable tumors have erupted on the lower extremities. Histopathologic findings show an active mesenchymal and vascular tumorous response of variable-sized channels.

Hiccups, eructation, and other uncommon prodromal manifestations of herpes zoster ☆

Although the most frequent presentation of herpes zoster involves sensory neurons, motor and autonomic symptomatology is also known to occur in this disease. An unusual symptom of hiccups is described here. Other infrequent manifestations of this common illness, including the Ramsay Hunt syndrome, herpes zoster ophthalmicus, urinary and fecal retention, sexual dysfunction, and zoster sine herpete, are reviewed. Greater awareness of unusual presentations of herpes zoster is necessary for proper diagnosis and timely management of complications that may otherwise lead to disability and serious long-term sequelae.

Evaluation of Varicella Zoster Virus Infection Morbidity and Mortality in Pancreas and Kidney-Pancreas Transplant Recipients

BACKGROUND Solid organ transplant recipients are at increased risk of infection due to chronic immunosuppression. The incidence of varicella zoster virus (VZV) infection is known to be increased in these patients compared with the immunocompetent population. Previous reports suggested that these patients are likely to experience a morbid disease course. Few data currently exist on the course of VZV infections in pancreas or pancreas plus kidney (PK) transplant recipients. OBJECTIVE The goal of this study was to evaluate the incidence and severity of VZV infections in pancreas or PK recipients. STUDY DESIGN We analyzed the transplantation patient database of the Royal Victoria Hospital, identifying 137 pancreas or PK transplantation procedures performed between January 1999 and October 2010, among which we included 98 patients in the study. We subsequently performed a retrospective chart review to evaluate the incidence and severity of VZV infections posttransplantation. RESULTS Our analysis revealed that 11/98 patients developed VZV infections. The majority of infections (~90.9%) occurred within the first 5 years. Most patients (63.6%) were treated on an outpatient basis, whereas only 4 (36.4%) were hospitalized with a mean hospital stay of 9.5 ± 8.42 days. The initial immunosuppressive regimen remained unchanged for the majority of patients. All patients experienced a mild disease course without intensive care unit admission or death. Only 3 patients (27.3%) developed postherpetic neuralgia. CONCLUSION These findings suggest that with timely diagnosis and proper treatment, most patients recover well from a VZV infection.

Pustular flagellate dermatitis after consumption of shiitake mushrooms

Lentinula edodes, or shiitake mushroom (SM), is typically grown in Eastern Asia and used in traditional Asian medicine and cuisine. Recently, SM became popular in Western culture and is now the second most commonly consumed mushroom in the world.1, 2 Although rare, adverse reactions to SM have been previously reported. In mushroom farm workers, contact dermatitis, contact urticaria, rhinitis, and hypersensitivity pneumonitis have been described. In the general population, oral intake of raw SM has been associated with a typical flagellate eruption, known as shiitake dermatitis (SD).3 Shiitake dermatitis, also termed shiitake toxicoderma or flagellate mushroom dermatitis, classically manifests 12 hours to 5 days after the ingestion of SM.1, 4 Since its first description in 1977, SD has been described in approximately 100 patients, predominantly Japanese.3, 5 Recently, a few cases were reported in Europe and in the United States.1 The mechanism underlying SD has not been fully elucidated. Although the eruption is usually considered nonallergic,6 5 cases of SD resulted in positive delayed skin prick testing, suggesting that delayed-type systemic hypersensitivity may be important in its pathogenesis.2, 3, 4, 7, 8, 9 We report the first case of SD in Canada and, to our knowledge, the first case of pustular SD. In our patient, positive delayed skin prick testing to SM was documented.

Hook-Shaped Needle-Guided Shave Biopsy: A Modified Technique Applied to Difficult Anatomic Locations

Shave biopsy describes the technique of sharp removal of epidermal or dermal lesions by horizontal slicing cut parallel to the surface of the surrounding skin. It usually extends to the level of the mid-dermis, with the subcutaneous tissue left undisturbed, and is useful for any elevated lesion when a full-thickness of tissue is unimportant, as in nevi, where it often produces excellent cosmetic results. However, pigmented lesions suspected of being a melanoma should be sampled using a punch, excisional, or incisional biopsy. Skin lesions with a minimal dermal component, such as seborrheic keratoses or fibrous papules of the nose, are also excellent candidates for this technique. Shave biopsy is the ideal method of diagnosis for basal cell carcinoma, squamous cell carcinoma, warts, domeshaped nevi, cutaneous horn, dermatofibroma, acrochordon, and angiofibroma.

Hypopigmented Segmental Darier Disease

Background: Darier disease is a genodermatosis caused by a mutation in the ATP2A2 gene. It classically presents as hyperkeratotic greasy papules in a seborrheic distribution. Several variants have been reported, notably the hypopigmented variant, which predominantly targets dark-skinned individuals, and a segmental variant that often follows the lines of Blaschko. Methods: We report a case of a 41-year-old African-Canadian female with a long-standing history of macular hypopigmented pruritic eruption following the lines of Blaschko on her back. The eruption was persistent and recalcitrant to various treatments. Dyskeratosis with corps ronds and grains, acantholysis, and parakeratosis were observed on histopathology. Those findings were consistent with the diagnosis of segmental hypopigmented Darier disease. Results and conclusions: To our knowledge, this is the first case reporting a combined segmental and hypopigmented variant of Darier disease. We further present a literature review for hypopigmented and segmental variants of Darier disease.

Iatrogenic Kaposi's sarcoma after immunosuppressive treatment for granulomatosis with polyangiitis (Wegener's)

Kaposis sarcoma (KS) is a lymphoangioproliferative neoplasm induced by human herpes virus 8 (HHV-8). Four clinical variants have been recognized: classical, African endemic, AIDS-related, and KS caused by iatrogenic immunosuppression. The latter is typically associated with the use of immunosuppressive therapy in organ transplant recipients; however, iatrogenic KS can also occur in patients receiving immunosuppression for other indications, such as autoimmune disorders.1 Granulomatosis with polyangiitis (GPA), formally known as Wegeners granulomatosis, is a multisystem necrotizing autoimmune vasculitis, which can be fatal and is classically treated with cyclophosphamide (CP) and prednisone.2 To our knowledge, only 3 cases report the development of iatrogenic KS in the context of GPA.3, 4, 5 We describe a case of an HIV-negative patient who had iatrogenic KS after GPA therapy, did not improve after first-line treatment reduction or withdrawal of immunosuppression, and consequently required systemic treatment with liposomal doxorubicin.

Rapidly progressive melanoma differentiation–associated protein 5–positive amyopathic dermatomyositis in an HIV-positive patient

ART: antiretroviral therapy CADM: clinically amyopathic dermatomyositis DM: dermatomyositis ILD: interstitial lung disease MDA5: melanoma differentiationeassociated protein 5 MFU: median fluorescence units INTRODUCTION Dermatomyositis (DM) is an idiopathic inflammatory myopathy that can affect children and adults and is characterized by muscle inflammation and characteristic cutaneous findings. In addition to multiorgan involvement, adult patients with DM may have up to a 30% risk of associated malignancy. Clinically amyopathic DM (CADM) accounts for approximately 20% of all cases and is diagnosed based on the presence of pathognomonic cutaneous involvement. Antibody against melanoma differentiatione associated protein 5 (MDA5)was recently found to be specific for CADM associated with rapidly progressive interstitial lung disease (ILD). To our knowledge, there are no other cases of MDA5-positive CADM in an HIV-positive patient. However, multiple cases of classic DM have been reported in seropositive patients and are summarized in Table I.