Scott Murray

Cutaneous sarcoidosis and foreign bodies

A histopathological diagnosis of sarcoidosis is, by convention, one of exclusion and is reached only when other potential causes of granulomatous disease, such as foreign bodies, are eliminated. We report herein three cases of systemic sarcoidosis with cutaneous manifestations of the disease, in which polarizable foreign particles were associated with the granulomata in the skin. We submit (a) that a granulomatous foreign body reaction and sarcoidosis are not mutually exclusive, (b) that paniculate foreign matter may actually serve as a nidus for granuloma formation in sarcoidosis, and (c) that the occasional presence of extraneous material within the granulomata of sarcoidosis requires greater recognition by pathologists.

Histopathology in erythroderma: review of a series of cases by multiple observers

This study examines the utility of objective histopathological studies in the evaluation of adult patients with erythroderma. A series of 56 skin biopsies, from 40 erythrodermic patients, was reviewed sequentially by 4 Canadian dermatopathologists who were unaware of clinical details of the cases. The final diagnosis (gold standard), in each instance, had already been determined by others, based on clinicopathologic data and response to therapy. Direct comparison revealed that the mean accuracy of I he histopathological diagnoses was 53% (range: 48‐(i6%). a favorable result in view of the difficulty of the task at hand. Additional points of information which evolved from the study are as follows: (i) identification, by microscopy alone, of spongiolic dermatitis, cutaneous T‐cell lymphoma and psoriasis, as underlying causes of eryihroderma was more successful than that of drug eruptions and pilyriasis rulira pilaris; (ii) the1 epidermotropism which characterizes cutaneous T‐cell lymphoma may be mistaken for inflammatory interface changes seen in drug eruptions and vice versa, thus constituting a pitfall in diagnosis; (iii) finally, it appears dial submission of multiple simultaneous biopsies, rather than a single specimen, from patients with erythroderma would be likely to enhance the accuracy of histopathological diagnosis.

The specificity of histopathology in erythroderma

Conflicting views about the diagnostic value of skin biopsy in the investigation of erythrodermic patients are extant. The objective of the present study was to establish the frequency with which a correct diagnosis can be based on histopathological assessment alone. This was achieved by comparison of the “blinded” microscopic diagnosis with the final diagnosis (based on combined clinico‐pathologic parameters and response to therapy). In a retrospective review of 56 skin biopsies from 40 patients with erythroderma, we found a positive correlation between the pathological diagnosis and the final diagnosis in 66%; furthermore, when the microscopic characteristics observed in different diagnostic categories were assessed, these proved lo simulate those seen in conventional manifestations of the various underlying diseases but tended to be subtle in the setting of erythroderma. We conclude that, despite the homogeneity of the clinical expression of erythroderma, diagnostic histopathological features of the underlying disease are retained in the majority of cases.

Chronic urticaria: a Canadian perspective on patterns and practical management strategies.

Background: Chronic urticaria is a common condition and is a source of great frustration to patients. It has been suggested that there may be differences among physicians in their approach to this common clinical entity. Objective and Method: A questionnaire was distributed Canada-wide to allergists, dermatologists, and a selection of practitioners with an interest in alternative medicine. The survey included questions on demographics, epidemiology, causative factors, diagnostic methods, therapeutic strategies, follow-up advice, and efficacy of therapies, with emphasis on personal experience. Results: The response rates of allergists and dermatologists were 31% and 36%, respectively. There was wide representation from all regions of Canada and from physicians from all age groups, both genders, different types of practice, and years in practice. The reported incidence per month was 13 and 4 patients for allergists and dermatologists, respectively. The prevalence was 199 and 44 patients by allergists and dermatologists, respectively. Comparison of causative factors showed differences in the experiences of the two groups. Diagnostic investigations were requested in a similar pattern with respect to timing. The specific tests ordered by the groups showing statistical difference were complete blood count (CBC), differential, C4 complement, antinuclear antibodies, and IgE antibody assay. Allergists chose the skin prick test (100%) as the most important allergy test. Dermatologists ranked skin prick (50%), radioallergosorbent test (RAST) (20%), and skin patch (30%) as the most important tests. The top six choices of pharmaceutical therapies chosen by the groups were similar, but in a slightly different order. The responders ranked their personal selection of antihistamines according to effectiveness. Hydroxyzine (Atarax®) and cetirizine (Reactine®, Allegra®) were selected as first and second most effective agents by both groups. The results also show effective experience by both groups with nonsedating and sedating antihistamines. Also, doxepin, ketotifen, and cimetidine are used frequently by both groups. The experience of dermatologists in Canada with respect to other modalities including psoralen ultraviolet A (PUVA) therapy, danazol, chelation, calcium channel blockers, and acyclovir is limited and efficacy is ranked either neutral or ineffective. Allergists reported even less experience with these therapies. Conclusion: Allergists and dermatologists across Canada show interesting similarities and differences in their practical approach to the management of chronic urticaria. With the sharing of this information, these two specialties will be better equipped to effectively manage patients suffering from chronic urticaria.

Eruptive xanthomata with urate-like crystals

The microscopic manifestations of eruptive xanthomata are variable and although they are most frquently characterized by aggregations of foamy macrophages in the dermis, they can, on occasion, simulate granuloma annulare. We have recently encountered a further unusual histopathological variant of eruptive xanthomata in 3 skin biopsies from 2 patients with hypertriglyceridemia. The lesions had a granuloma annularelike pattern at low magnification, the exceptional feature being their content of polarizable, needle‐shaped crystals. These bore a strong resemblance to monosodium urate mono‐hydrate and displayed negative birefringence under polarized light. In the case of each patient, an initial pathological diagnosis of gout was rendered, and the true nature of the lesions came to light only after clinicopathologic correlation. While it is clear that the chemical composition of these crystals requires further study, recognition of this microscopic variant of eruptive xanthomata should help to reduce errors in diagnosis.

Concurrent pemphigus and myasthenia gravis as manifestations of penicillamine toxicity

The efficacy of n-penicillamine in rheumatoid arthritis and various other diseases is well established, but its use is limited by toxicity. Pemphigus and myasthenia gravis are known individual complications of this therapy. Although their spontaneous concurrence has been reported previously, this combination of autoimmune diseases has not been previously related to D-penicillamine. Its capacity to unmask two immunologically mediated disorders simultaneously emphasizes its immunomodulatory function. Furthermore, it raises speculations regarding the cause of these diseases and implicates a possible role for the thymus in their genesis.

A novel inflammatory reaction in a tattoo: challenge.

CASE A healthy nondiabetic 36-year-old woman attended a dermatologist with a 2-year history of a skin lesion on the right lower leg centered on a tattoo. Two weeks after the initial tattoo application, names were added. Two weeks after this, a rash developed around the tattoo. Of note, another tattoo of the same color was applied simultaneously to the low back without any skin reaction. Physical examination revealed a slightly atrophic yellowish plaque localized to the tattoo site with some extension into the surrounding skin (Fig. 1). A punch biopsy of skin revealed scattered deposits of tattoo pigment in dermal macrophages in addition to a more pronounced diffuse dermal inflammatory process. This was characterized by a perivascular and periadnexal lymphoplasmacytic infiltrate associated with interstitial granulomatous inflammation. The latter incorporated focal zones of degenerated collagen without excess interstitial mucin deposition (Fig. 2). Elsewhere, the dermal collagen seemed sclerotic with a horizontal banded pattern in areas (Fig. 3). What is your diagnosis?

Expectantly waiting: a survey of thyroid surgery wait times among Canadian Otolaryngologists

BackgroundOur objective is to highlight discrepancies between actual wait times and perceived appropriate wait times for various thyroid pathologies among Otolaryngology- Head and Neck Surgeons in Canada; and to identify specific diagnoses/pathologies where wait times could be improved.MethodsA questionnaire was distributed to all practicing CSO-HNS members. Questions focused on actual wait times for initial consults and surgery within individual practices, in the setting of various thyroid pathologies. Respondents were also asked to state wait times that they felt were appropriate for each scenario. Wilcoxon signed-rank tests were performed to determine statistically significant differences between actual and appropriate wait times.ResultsFor most scenarios, the actual wait times were significantly longer than most physicians felt were appropriate; these scenarios included time to initial consult for undiagnosed nodules, time to surgery for confirmed malignancies, and time to completion thyroidectomy for surgically confirmed malignancies.ConclusionsWait times for thyroid consults and surgeries in Canada are longer than physicians feel are appropriate. The authors hope that this survey may spur a move towards a national consensus on appropriate wait times for the treatment of thyroid pathology.

Undergraduate dermatology education in Canada: a survey.

Background: Two reviews done in the 1980s showed that many Canadian medical schools scheduled relatively little time for dermatological teaching. Many students did not have a real clinical exposure to dermatology. Objective: The purpose of this study was to obtain new data to reevaluate the undergraduate training in dermatology in Canada. Methods: A survey was sent to the coordinators of undergraduate dermatology of all 16 Canadian medical schools. Results: The survey of medical schools demonstrates the current status of dermatology undergraduate teaching across Canada. Although many improvements have been made in the way dermatology is taught to medical students, many of the problems noticed in the 1980s remain unresolved. Conclusion: Because dermatological care in Canada is often rendered by nondermatologists, the dermatologists should emphasize the importance of undergraduate training in their specialty.

Necrobiosis lipoidica diabeticorum in a tattoo site.

Background: Trauma is an immediate triggering factor in the development of necrobiosis lipoidica diabeticorum (NLD). NLD has previously never been documented in a tattoo site. Objective and Conclusion: Here we report an otherwise healthy 35-year-old woman with an area of NLD located in a tattoo site. Initial injection with intralesional triamcinalone acetonide showed no benefit. Subsequent application of betamethasone valerate cream did not lead to improvement of the lesion.