Sandra S. Osswald

Viral-associated trichodysplasia in a patient with lymphoma: A case report and review

Viral‐associated trichodysplasia is a recently described entity associated with immunosuppression. We describe a 68‐year‐old man with a history of treated lymphoma who developed numerous, disfiguring, papular and spiny lesions involving most of the central face. Both facial and body alopecia was noted. Histopathologic findings of a facial papule showed dramatic alterations of the hair bulbs, including bulbar distention, lack of hair shaft formation and a marked expansion of inner root sheath type epithelium. These findings were identical to those of previously described cases, so electron microscopy was performed. Numerous intranuclear virus particles were identified. Shortly after the diagnosis of trichodysplasia was made, the patient was found to have a relapse of his lymphoma, which may represent the source of his immunosuppression. Based on his skin biopsy findings, successful antiviral therapy was initiated. This case and a review of previously reported cases are discussed in this study.

Bright red papules in a HIV-positive 20-year-old man: Answer

DISCUSSION Bacillary angiomatosis (BA) was first reported in 1983 by Stoler et al in a 32-year-old AIDS patient. It is an angioproliferative disease caused by gram-negative bacilli: Bartonella henselae and Bartonella quintana. It predominantly occurs in severely immunocompromised individuals, such as those with AIDS. The principal reservoir of B. henselae is the domestic cat, and the organism is transmitted to humans through a cat scratch or bite. The vector for B. henselae is the cat flea. On the other hand, B. quintana is usually transmitted by the bite of the human body louse, and it is more often seen in the homeless population. Cutaneous lesions of BA present clinically in 2 forms: dermal or subcutaneous. BA can affect other organs also, including the lungs, central nervous system, brain, and bone. Bacillary peliosis refers to the blood-filled peliotic changes of the liver or spleen parenchyma. Abdominal magnetic resonance imaging in our patient revealed no hepatic abnormalities. Nevertheless, there was concern for hepatic peliosis given abdominal pain and strikingly elevated alkaline phosphatase level (1080 IU/L). Furthermore, magnetic resonance imaging revealed multiple enhancing splenic lesions with lymphadenopathy in the abdomen. Fine needle aspiration of the patient’s cervical node did not demonstrate B-cell abnormality, and nodal excision revealed compressed reactive appearing nodal tissue with scarring. On histologic examination, BA may exhibit some or all the following 5 features: epithelial collarettes, lobular proliferation of small blood vessels lined by large endothelial cells, edematous stroma, scattered polymorphonuclear leukocytes and neutrophilic debris, and eosinophilic granular clumps of material that stain positively with Warthin–Starry (Fig. 3). Clusters of neutrophils and neutrophilic debris are mainly found adjacent to the capillaries. There is often marked atypia of endothelial nuclei with numerous mitoses and central zones of necrosis. The endothelial cells of BA are polygonal. The diagnosis of BA can be confirmed by electron microscopy, which shows clumps of pleomorphic bacilli that have gram-negative trilaminar cell walls. Clinically and histologically, the differential diagnosis for BA would include pyogenic granuloma, Kaposi sarcoma, epithelioid hemangioma, and verruga peruana. The lobular proliferation of small blood vessels architecturally resembles pyogenic granuloma; however, the endothelial cells found in BA are often larger, polygonal, and sometimes markedly atypical. Kaposi sarcoma clinically presents as patches that then progress to papules or nodules, or tumors, whereas BA often initially presents as papules or nodules. Histologically, the presence of neutrophils, leukocytoclastic debris, and granular material distinguishes BA from Kaposi sarcoma. Furthermore, unlike Kaposi sarcoma, BA is marked by the absence of spindled cells and hyaline globules. Epithelioid hemangioma can look histologically similar to BA, and numerous Weibel–Palade bodies are seen in both under electron microscopy. However, unlike epithelioid

Bright Red Papules in a HIV-Positive 20-Year-Old Man: Challenge.

CLINICAL FINDINGS A 20-year-old man with prenatally acquired HIV presented with fever, cough, abdominal pain, and 1-month-old skin lesions consisting of red papules scattered all over his body. The red papules had been increasing in both number and size and bled with trauma. On examination, there were 10+ red to dark red smooth, dome-shaped papules scattered on the neck, trunk, upper extremities, and lower extremities (Fig. 1). In addition, there were a few larger, dark red to purple exophytic tumors approximately 2 to 3 cm in size on the left posterior thigh and occipital scalp. Bilateral firm and matted cervical lymphadenopathy were also noted. Laboratory studies were significant for elevated alkaline phosphatase of 1080 IU/L. Abdominal magnetic resonance imaging revealed multiple enhancing splenic lesions with

Taking Care of Uncle Bob’s Rash: Should One Treat Family Members?

Should physicians treat their family members? In general, physicians should not treat themselves or family members because of the loss of professional objectivity. In addition the physician may not be qualified to treat the relative’s condition, may be to close to do a complete examination or probe for intimate historical details or disclose bad news. Physician involvement can create intrafamilial conflict or create an awkward situation if the relative is either non-compliant or dissatisfied with the care delivered. But, despite these potential risks, many physicians do and will continue to do so. This chapter discusses the opinions, questions and evaluation of risks and hazards in treating family members through case scenarios.