Soon Bahrami

CD10 Expression in Cutaneous Adnexal Neoplasms and a Potential Role for Differentiating Cutaneous Metastatic Renal Cell Carcinoma

CONTEXT Recent investigations have demonstrated the utility of CD10 as a marker for renal cell carcinoma (RCC). Cutaneous metastases occur in up to 11% of patients with RCC and may be the presenting sign of widespread disease. The differential diagnosis in histopathologic evaluation of these cases includes cutaneous adnexal neoplasms, and describing the expression of CD10 in these tumors may be helpful in delineating the differential diagnosis. OBJECTIVE To determine CD10 expression in a variety of adnexal lesions and to determine the diagnostic utility of CD10 in an immunohistochemical panel differentiating metastatic cutaneous renal cell carcinoma from cutaneous adnexal neoplasms. DESIGN We studied 57 primary adnexal neoplasms of eccrine (n = 31), apocrine (n = 16), and sebaceous (n = 10) differentiation as well as normal skin (n = 3) and RCC metastatic to the skin (n = 4). A CD10 monoclonal antibody was applied to formalin-fixed, paraffin-embedded tissue. Specimens were randomized and categorized as immunopositive or immunonegative by a pathologist with expertise in immunohistochemistry who was blinded to the diagnoses. RESULTS Two (6.5%) of 31 eccrine, 1 (6%) of 16 apocrine, and 4 (40%) of 10 sebaceous neoplasms demonstrated CD10 immunopositivity. Four (100%) of 4 RCC were CD10 immunopositive. CD10 expression was significant for eccrine and apocrine neoplasms (P < .001) compared to metastatic RCC, but not for sebaceous neoplasms (P = .08). CONCLUSION Based on these results, CD10 is a useful additional immunostain for the discrimination of RCC metastatic to the skin and cutaneous adnexal neoplasms with eccrine and apocrine differentiation, but not with sebaceous differentiation.

Golimumab-Exacerbated Subacute Cutaneous Lupus Erythematosus

BACKGROUND Subacute cutaneous lupus erythematosus (SCLE) is characterized by annular, nonscarring, photodistributed, or papulosquamous lesions. The disease may be idiopathic, drug induced, or drug exacerbated. OBSERVATIONS A 66-year-old woman with a history of hypertension, parkinsonism, rheumatoid arthritis, anxiety and depression, and symptoms of Sjögren syndrome was seen with a 1-month history of an eruption on her upper extremities and upper trunk. The eruption had begun 2 to 3 weeks after subcutaneous injection of golimumab for rheumatoid arthritis. She had developed SCLE 2 years previously due to furosemide use and 10 years previously due to hydrochlorothiazide use. Physical examination revealed scaly, annular, erythematous plaques photodistributed on the arms, legs, and upper trunk. A punch biopsy specimen demonstrated vacuolar interface dermatitis and lymphohistiocytic perivascular inflammation. Serological abnormalities included a positive antinuclear antibody, an elevated anti-La/SS-B antibody level, and an elevated anti-Ro/SS-A antibody level. She was diagnosed as having SCLE and was initially treated with desonide lotion, photoprotection, prednisone (40 mg/d) tapered over 6 weeks, and hydroxychloroquine sulfate (200 mg twice daily). Because of persistent disease, methotrexate sodium (12.5 mg/wk) was subsequently added to the regimen, and her eruption cleared completely. CONCLUSIONS Golimumab should be added to the list of medications capable of inducing or exacerbating SCLE. Our patient demonstrated variable times to the resolution of SCLE, possibly attributable in part to the different half-lives of the agents administered.

Atypical Fibroxanthoma With Regional Lymph Node Metastasis: Report of a Case and Review of the Literature

BACKGROUND Atypical fibroxanthoma (AFX) is a low-grade sarcoma usually occurring on sun-damaged skin of the head and neck in elderly patients. Metastatic disease has been reported very rarely. The potential aggressiveness of AFX is controversial. OBSERVATIONS We describe herein a patient who developed metastatic disease in cervical lymph nodes. Our patient was an 87-year-old man with a 7-week history of a rapidly growing AFX presenting as a 1.5-cm sessile nodule on his right mandible. Two months following excision, the patient developed cervical lymphadenopathy. Histopathologic analysis of the cervical lymph nodes revealed spindle-cell tumors with histologic characteristics identical to those of the primary AFX, and the tumors were immunonegative for cytokeratin MNF-116 and S-100. In addition, we review and analyze cases from the literature and articles related to immunohistochemical stains used to diagnose AFX. CONCLUSIONS Atypical fibroxanthoma is a diagnosis of exclusion, and only a small number of metastatic AFX cases have been reported. A review of the literature pertaining to immunohistochemical stains suggests the potential benefit of use of CD10, procollagen I, CD99, CD117, p63, and LN-2 in differentiating AFX from other spindle-cell tumors. The metastatic potential of AFX may not be fully appreciated, and clinicians should be reminded of its potential aggressive behavior.

An immunohistochemical comparison between MiTF and MART‐1 with Azure blue counterstaining in the setting of solar lentigo and melanoma in situ*

Background: Evaluation of cutaneous pigmented lesions can be diagnostically challenging and represents an activity often supplemented by immunohistochemistry. Immunohistochemical studies typically employ 3,3′‐diaminobenzidine (DAB) resulting in brown staining of both melanocytes and melanin. Difficulty may thus arise in distinguishing different cell types in heavily melanized lesions. Azure blue counterstaining has been used in conjunction with melanoma antigen recognized by T‐cells (MART‐1) to differentiate melanocytes from melanin by highlighting the latter blue‐green. Microphthalmia transcription factor (MiTF) represents an alternative immunomarker that shows nuclear reactivity, which facilitates ease of interpretation.

Tissue eosinophilia: not an indicator of drug-induced subacute cutaneous lupus erythematosus.

OBJECTIVE To investigate whether tissue eosinophilia is a differentiating histopathologic feature of drug-induced subacute cutaneous lupus erythematosus (DI-SCLE) compared with non-DI-SCLE. DESIGN Retrospective medical record review with prospective blinded histopathologic analysis. SETTING University-affiliated dermatology and dermatopathology practice. PATIENTS Fifty-nine patients with SCLE were divided into DI (n = 15) and non-DI (n = 44) groups. MAIN OUTCOME MEASURES A dermatopathologist masked to the etiologic associations reviewed corresponding histopathologic specimens. For each patient, an eosinophil ratio was calculated as the mean eosinophil score (averaging eosinophil counts from 10 high-power histologic fields) divided by the intensity of inflammation. Eosinophil ratios for both groups were compared using the Mann-Whitney test. RESULTS No significant difference was found in mean eosinophil ratios in the DI vs non-DI groups (0.11 vs 0.004; P = .34). Mucin deposition was present in both populations and was not significantly different (P = .18). The inflammatory infiltrate was superficial and deep in 10 patients (67%) in the DI group vs 24 (55%) in the non-DI group. Periadnexal inflammation was observed in 12 patients (80%) in the DI group vs 37 (84%) in the non-DI group, and basal layer liquefaction with dyskeratosis was seen in 15 patients (100%) in the DI group and in 37 (84%) in the non-DI group. CONCLUSIONS Tissue eosinophilia is not a differentiating histopathologic feature of DI-SCLE. Careful review of a patients drug history in correlation with clinical findings remains the standard for identifying a drug as an etiologic or exacerbating factor in patients with SCLE.

Anagen Effluvium Caused by Thallium Poisoning

recognizing that the absence of a bite or scratch does not preclude RBF. Moreover, clinicians with a high degree of suspicion for RBF should immediately notify the laboratory to prepare for the unique collection and culture requirements of S moniliformis and, while awaiting the PCR or blood culture results, consider empirical antibiotic treatment.5,6 With increased awareness and understanding of RBF, timely diagnosis and treatment are likely to improve patient outcomes.

Cutaneous Presentation of Methicillin-Resistant Staphylococcus aureus Sepsis in a Healthy Child

Report of a Case | A healthy male toddler presented to the emergency department with abdominal pain and distention, fever, and vomiting of 1 day’s duration. He was found to have “bruises” on both flanks (Figure 1A). Workup for child abuse was initiated, and he was treated with enemas for constipation and intramuscular penicillin after positive streptococcal findings. Over the next 2 days, he developed diffuse papules on the trunk and extremities; his condition rapidly deteriorated requiring intubation, vasopressors, and empirical broadspectrum antibiotics. A dermatology consult was obtained to evaluate his skin eruption. At the time of consult, he was hyponatremic and neutropenic, and the following laboratory values were recorded: aspartate aminotransferase (AST), 45 U/L; alanine aminotransferase (ALT), 142 U/L; C-reactive protein (CRP), greater than 270 mg/L; erythrocyte sedimentation rate, 43 mm/h; and ferritin, 603 ng/mL. (To convert AST and ALT to microkatals per liter, multiply by 0.0167; CRP to nanomoles per liter, 9.524; and ferritin to picomoles per liter, 2.247.) Urinalysis showed proteinuria and hematuria. Computed tomography of the chest and abdomen demonstrated cavitary lesions in his lungs representing necrotizing pneumonia. Areas of nonenhancement within both kidneys were suspected to represent renal abscesses. On physical examination, purpuric retiform patches were found on each flank (1 of them studded with 2 pustules) with erythematous to violaceous papules diffusely scattered on the extremities and trunk (Figure 1B). Punch biopsy specimens were taken from an area of purpura for analysis by frozen section, from a pustule for tissue culture, and from a papule for hematoxylin-eosin staining. Within an hour of obtaining the specimens, the pathologist reported frozen section findings of small organisms within the vasculature suggestive of either fungal spores, likely histoplasmosis, or staphylococcal bacteria. Permanent sections revealed a large neutrophilic pustule with inflammation extending throughout the dermis and prominent necrosis with basophilic structures filling necrotic vascular spaces (Figure 2A). Tissue Gram staining confirmed gram-positive cocci in the vessels (Figure 2B). Tissue culture, blood culture, bronchial washings, and fluid from bilateral empyemas all grew CA-MRSA. Results from transthoracic echocardiogram and bone scans were negative. Magnetic resonance images of the brain showed multifocal lesions, likely septic emboli. Findings from workup for possible immunodeficiency were negative. The patient was sent to a rehabilitation facility to complete a 6-week course of intravenous vancomycin.

Erythematous Plaque to Lower Leg After Tropical Injury

A 70-year-old retired nurse presented with a 3-month history of an asymptomatic, nonhealing lesion of her left leg. It developed after she fell and scraped this specific location on her leg on a creek rock while hiking in the jungle during a vacation in Ecuador. She denies any other trauma at any time between the scraping and presentation. After the fall, she subsequently developed an enlarging erythematous plaque with an overlying hemorrhagic crust without drainage. This crust sloughed but soon thereafter reformed. She was treated with triple antibiotic ointment, an antifungal cream, and one week of trimethoprim-sulfamethoxazole prior to presenting to her dermatologist. She was otherwise asymptomatic with a negative review of systems. Past medical history included hypertension, hypercholesterolemia, and hypothyroidism, and her medications were levothyroxine, lovastatin, atenolol, and sodium bicarbonate. She was born in the United States and had not spent any significant time outside the country before this episode. Examination revealed a 2 cm erythematous crusted plaque with several smaller satellite papules on the left shin at the site of trauma (Figure ​(Figure1A).1A). A punch biopsy (Figure ​(Figure1B1B and C) and tissue culture were performed. What is the diagnosis? Figure 1. (A) Erythematous eroded plaque with satellite papules on left shin. (B) A 40× magnification demonstrating granulomatous infiltrate

Mycobacterium mucogenicum infection following dacryocystorhinostomy and Crawford tube placement.

IMPORTANCE Nontuberculous mycobacterial infections of the skin can be seen in cases of immunosuppression and/or traumatic implantation of contaminated objects. Surgical settings with appropriate sterilization techniques have been immune to these types of infections. We report a case of nosocomially derived infection from a sterile procedure. OBSERVATIONS A woman in her 70s presented with a facial lesion after an ophthalmologic procedure that was discovered to be a nontuberculous mycobacterial infection. It was successfully treated with oral antibiotics. CONCLUSIONS AND RELEVANCE Nontuberculous mycobacterial infections should be considered in the differential diagnosis of new lesions arising after invasive procedures, even in immunocompetent patients in seemingly sterile settings.

Atypical Cells in the Cerebrospinal Fluid of a 43-Year-Old Man With Perioral Parasthesias

1. What is (are) this patient’s most striking clinical and laboratory findings? 2. How do you explain the patient’s most striking clinical and laboratory findings? 3. What is this patient’s most likely diagnosis? 4. What is the characteristic clinical presentation of an individual with this patient’s condition? 5. What are the criteria for making this diagnosis? 6. What is the pathogenesis of this patient’s disease? 7. What is the prognosis for this patient? 8. What treatment options are available for this patient’s condition? 9. How did performing a cell count on the CSF contribute to this case?