Theodore H. Kwan

Generalized exanthematous pustulosis induced by medications.

A 79-year-old white woman was admitted for repair of a ventral hernia. She took no regular medications and had documented allergies to penicillin and cephalosporins, but had no prior history of psoriasis or pustular drug reactions, Preoperatively, she received 500 mg of vancomycin and 80 mg of gentamicin. Five hours following the uneventful hernia repair, she developed a tender erythematous, rash over her trunk and proximal extremities. On postoperative day (POD) #1, the onset of hypotension, oliguria, hypothermia, and leukocytosis (19,9 X 10̂ cells per L) indicated sepsis which was treated with vancomycin, gentamicin, and metronidazole. By POD #6, her eruption had evolved to a generalized edematous erythroderma studded with numerous 1 to 2 mm pustules and focal superficial exfoliation, exhibiting a positive Nikolsky sign (Fig. 1), Hematogram revealed 5% eosinophilia of 5,8 X 10̂ white blood cells (WBC) per L. Histopathologic examination demonstrated subcorneal pustules, spongiosis,and a superficial perivascular infiltrate, composed of lymphocytes, polymorphonuclear leukocytes, and a few eosinophils, supporting a diagnosis of acute generalized exanthematous pustulosis (AGEP) (Fig, 2),Vancomycin was presumed to be the causative agent and was discontinued along with gentamicin and metronidazole, Imipenem and rifampin were started to cover coagulase-negative staphylococci that had grown from concomitant surgical wound and blood cultures.

Nodular Hidradenoma: A Report of Three Cases and Review of the Literature

background. Nodular hidradenoma is a rare adnexal tumor most likely arising from the eccrine gland. objective. We describe three cases of a nodular hidradenoma presenting as an expanding nodule on the forehead (case 1), left lower extremity (case 2), and left neck (case 3). We discuss the clinical and histologic features of this tumor and present a review of the literature. conclusions. This report highlights the salient histologic findings that distinguish nodular hidradenomas from other adnexal tumors and emphasizes the benefit of complete local excision to prevent recurrence of these tumors.

Unexpected vascular response to epinephrine in port wine stains.

Success of argon laser therapy as a therapeutic modality for port wine stains has been correlated with the degree of vascular congestion within the lesions. Epinephrine causes vasoconstriction and erythrocyte stasis within normally innervated vessels. We tested the hypothesis that subcutaneous injection of epinephrine would cause vasoconstriction, altered hemodynamics, and increased red cell mass in port wine stains and thus allow more directed and less nonspecific damage and a better cosmetic result. Two clinically similar and adjacent areas within port wine stains were biopsied from 10 patients following subcutaneous injection of either Xylocaine or Xylocaine with epinephrine. Erythrocytes within vessels of the superficial cutaneous vascular plexus were increased in areas pretreated with Xylocaine plus epinephrine (55.3 versus 45.9 percent; p less than 0.09). This increase was seen in 9 of 10 patients studied (p less than 0.05). Epinephrine appears to increase erythrocytes within ectatic vessels of port wine stains and thus would likely improve laser energy absorption and cosmetic results.