Woon-Kyong Chung

Giant dermatofibroma with granular cell changes: side‐effect of bee‐venom acupuncture?

Dermatofibroma (DF) is a common benign fibrohistiocytic tumour with a predilection for the legs in middle‐aged women. Giant DF, a rare clinical variant of DF, is characterized by its unusually large size. Granular cell change is typical of granular cell tumour, but can be observed in diverse cell lineages. Traumatic factors may be involved in the pathogenesis of giant DF and cellular granularity. We describe a 49‐year‐old Korean man with a giant DF showing granular cell differentiation, which may have been caused in part by multiple treatments with bee‐venom acupuncture.

Paradoxical darkening of unperceived tattoo ink after relatively low fluence from a Q-switched Nd:YAG (1064-nm) laser in the course of treatment for melasma

Although Q‐switched (QS) lasers are the mainstay of modern tattoo removal, paradoxical darkening of tattoo ink may occur. This darkening of tattoo ink is dependent on laser wavelength, pulse duration and fluence, with high‐energy, nanosecond‐pulsed lasers more prone to induce tattoo‐ink darkening. Laser toning, consisting of multiple‐passed QS neodymium:yttrium–aluminum–garnet (Nd:YAG), 1064‐nm laser treatment with low fluence, short pulse duration (< 10 ns), and a repetition rate of 10 Hz has been successful in the treatment of melasma. A mistake commonly made during laser toning is to scorch scalp hair, eyebrows or eyelashes, but this phenomenon is reversible. A more problematic error is caused by treatment of eyeliner or eyebrow tattoos. We report a patient who experienced changes in unperceived, skin‐coloured tattoos, turning them blue after QS Nd:YAG laser treatment of melasma.

A case of cutaneous metastasis of small-cell neuroendocrine carcinoma of the uterine cervix.

report of granular perineurioma with special interest because we recently encountered a unique case of multiple hybrid granular cell tumor-perineurioma. Our case and Dr. Al-Daraji’s case are similar (and quite unusual), both in the association of cells having granular cytoplasm with neoplasms having classic features of perineurioma, and because each patient had more than 1 histologically similar lesion. Dr. Al-Daraji’s patient had a dermal and subcutaneous lesion of the trunk and also an intraneural lesion of the sciatic nerve that was discovered 3 years later, whereas our patient had multiple (>20) cutaneous nodules on all 4 extremities, present since childhood. The neoplastic granular cells in Dr. Al-Daraji’s patient stained positive for epithelial membrane antigen (EMA), claudin-1, glut-1, and NKI-C3, but negative for S-100 protein, whereas the neoplastic granular cells in our patient stained positive for S-100 protein, NKI-C3, and CD 68, but negative for EMA. In each case, the neoplastic granular cells were associated and interspersed with extensive areas of histologically classic EMA-positive perineurioma. Multiple tumors in our case contained discrete areas of classic S-100–positive, CD 68–positive, EMA– negative granular cell tumor in addition to areas of hybrid granular cell tumorperineurioma. The granular component of both Dr. Al-Daraji’s lesions was focal within otherwise classic perineuriomas. We believe that our case and

Glomeruloid hemangioma as a very early presenting sign of POEMS syndrome

To the Editor, Glomeruloid hemangioma (GH) is a distinctive cutaneous angioma with unique histological features resembling those of renal glomeruli. GH has been considered as a specific marker for POEM (polyneuropathy, organomegaly, endocrinopathy, M-protein and skin changes) syndrome.1 However, four reports have claimed that GH is not always associated with POEMS syndrome.2– 5 Here, we report on a 40-year-old Korean woman with multiple GHs who was diagnosed with POEMS syndrome 6 years after first GH onset. A 40-year-old Korean woman presented with 6year history of multiple eruptive purple red papules on her face and neck (Fig. 1). As she also had generalized edema, 5 kg of weight loss over the preceding month and hypertrichosis, she was admitted and generally evaluated. Examination revealed bilateral pleural effusions, ascites, hypothyroidism [T3<50 ng/dl (normal, 98–180 ng/dl); thyroidstimulating hormone 11.0 mIU/l (normal, 0.4–5.0 mIU/l); free T40.71 ng/dl (normal, 0.8–1.9 ng/dl)], hepatosplenomegaly, retroperitoneal lymphadenopathy, resting pulmonary hypertension and sensorimotor polyneuropathy. Serum protein electrophoresis was positive for lambda-type immunoglobulin A, and urine immunofixation electrophoresis revealed Bence-Jones proteins of the lambda type. Skin biopsies revealed a vascular tumor composed of capillaries and sinusoid-like spaces resembling renal glomeruli (Fig. 2). Sinusoidal endothelial cells had eosinophilic globules, which stained with periodic acid-Schiff (PAS) reagent (Fig. 3A). Capillary endothelial cells were positive for CD31 (Fig. 3B) and CD34 (Fig. 3C) but negative for CD68 (Fig. 3D). Sinusoidal endothelial cells were positive for CD31 (Fig. 3B) and CD68 (Fig. 3D) but negative for CD34 (Fig. 3C). The histopathologic and immunohistochemical findings were consistent with GH. (A)

Primary cutaneous intravascular large B-cell lymphoma treated with combination chemotherapy and complicated by rituximab-induced interstitial lung disease.

© 2010 The Authors. doi: 10.2340/00015555-0817 Journal Compilation

A case of incontinentia pigmenti associated with multiorgan abnormalities.

Incontinentia pigmenti is a systemic disorder affecting the skin, teeth, eyes, nervous tissue, hair, nails, musculoskeletal system, and heart. We describe an 11-month-old girl with incontinentia pigmenti associated with a ventricular septal defect, left hemiatrophy, hemangiomas, an abnormal labial frenum, and spastic cerebral palsy manifested as left hemiplegia and developmental delay. We believe this patient illustrates that incontinentia pigmenti is a systemic disorder necessitating a multidisciplinary approach to management.

Treatment-resistant Scopulariopsis brevicaulis Infection after Filler Injection

Sir, Scopulariopsis, which is a genus of non-dermatophytic filamentous fungi, contains a number of common sa-prophytic fungi found in soil, vegetables, air, and organic waste. To date, eight species of Scopulariopsis have been reported to cause human infections. Of these, S. brevi-caulis is the most common; although is not generally considered to be a skin pathogen, the organism is isolated relatively frequently from onychomycosis patients (1). However, deeper cutaneous infection caused by S. brevi-caulis is extremely rare. We describe here a woman with treatment-resistant S. brevicaulis facial infection after a filler injection performed by an unlicensed practitioner. A 42-year-old woman presented in June 2008 with an ulcer covered by a black crust and surrounding palpable tender no-dules on the right temple (Fig. 1). In September 2006, she had received collagen injections into both temples, administered by an unlicensed practitioner. About 6 months later, she detected palpable nodules on both temples. She visited the unlicensed practitioner again, and received intralesional injections of an unknown material (described as a neutralizing agent) into both temples. Thereafter, her face became gradually more swollen, and an ulcer developed on her right temple. The patient was otherwise healthy, and routine laboratory tests, including blood tests and a chest roentgenogram, yielded data within normal limits. A skin biopsy was performed of a palpable nodule beside the crusted ulcer. Histology disclosed numerous branching septated hyphae and conidia in the deep dermis and subcutaneous fat (Fig. 2a). Fungal culture revealed entire-edged flat colonies with powdery, buff-to-brown, rugose surfaces. The reverse of the specimen culture was more waxy and yellow-white in colour. Lactophenol cotton blue mounts revealed numerous branching and septated hyphae with conidiophores and conidia in basipetal chains (Fig. 2b). As a Scopulariopsis infection was suspected, internal transcribed spacer (ITS) sequencing was performed to identify the isolate. An ABI PRISM 3130xl genetic analyser (Applied Biosystems, Foster City, CA, USA) and a Big-Dye Terminator Cycle Sequencing kit (Applied Biosystems) were employed. We found 100% homology with S. brevicaulis IFM 54315 (GenBank accession no. AB363754) and 99.5% (593 bp/596 bp) homology with S. brevicaulis CTSP F6 (GenBank accession no. EU862178) (2). Because the species showing the next-best homology (98.7%) was S. flava (GenBank accession no. AY494711), we identified the isolate as S. brevi-caulis (Fig. 3S, Treatment with itraconazole (200 mg daily) and terbinafine (250 mg daily) was commenced, but, after one week, the crusted ulcer was much enlarged. We decided to …

Cutaneous Mycobacterium chelonae infection presenting as symmetrical plaques on both shins in an immunocompetent patient.

Sir, Mycobacterium chelonae exists widely in soil, fresh water, and dust throughout the world and is usually nonpathogenic in humans. The organism is a rapidly growing mycobacterium, and belongs to the Runyon group IV classification. Cutaneous M. chelonae infections can be classified into two types according to patient immune status. In immunocompetent patients, lesions usually follow trauma and present as localized abscesses, nodules, erythemas, or ulcers. In immunocompromised patients, however, lesions frequently develop without any trauma, and show a sporotrichoid or disseminated pattern. We report here a case of a 52-year-old immunocompetent man with bilateral symmetrical lesions but no history of trauma.

A crescent-shaped nodule in the temple: a quiz. Nodular fasciitis.

A 32-year-old Korean woman presented to our clinic with a solitary crescent-shaped protruding nodule on the right temporal area (Fig. 1). Approximately one year previously, a single tiny papule that had not been associated with trauma had suddenly increased in size to a 2 × 1 cm, protruding, crescent-shaped nodule. At that time, the patient was pregnant and refused treatment; however, she returned to the clinic after giving birth. In the intervening period, the size and shape of the nodule had not changed. Histopathological examination showed a poorly circumscribed mass in the lower dermis, and subcutaneous fat, infiltrating into the muscular structure (Fig. 2a). Cellular atypia was not prominent. Abundant fibrous tissue and mild infiltration of inflammatory cells were also noted. Dermal collagen bundles were densely packed. Immunohistochemical analysis showed that spindle-shaped cells were positive for smooth muscle actin (Fig. 2b), but negative for CD34, CD31, factor XIII and factor VIII.

A case of cutaneous nerve hypertrophy: association with multiple endocrine neoplasia type 2 or neurofibromatosis type 2?

To the Editor, Hypertrophy of small nerves in the dermis may be a mucocutaneous manifestation of multiple endocrine neoplasia type 2b (MEN2b). Association with linear pigmentation of the trunk, secondary to scratching and trauma, has been described. Multiple idiopathic mucocutaneous forms also have been reported. We report a case of cutaneous nerve hypertrophy in a patient with neurofibromatosis type 2 (NF2). A 20-year-old Korean woman presented with two asymptomatic nodules on her back, which were incidentally discovered during routine physical examination. The patient had been diagnosed previously with NF2, accompanied by bilateral acoustic neuromas, multiple neurogenic tumors on the trigeminal nerve and cauda equina and multiple meningiomas in the central nervous system. The patient had no other history of endocrine, ophthalmologic or orthopedic disorders, and there was no family history of neurofibromatosis. Physical examination showed two discrete, about 1 cm, brownish nodules on her back, with no pain or tenderness. Exaggerations of the papillary structure of her tongue and nodular protuberances on its ventral surface were noted (Fig. 1). Other mucous membranes and lips were normal. Routine ophthalmologic findings were normal, including eye acuity, retinal examination and ocular pressure. The patient complained of a tendency to constipation, but gastroenterological and hematological examinations were normal. Routine laboratory data were generally within normal limits, except for a mild increase in sedimentation rate (37 mm/h; reference value, 0–20 mm/h). Hormone concentrations, including parathyroid hormone, calcitonin, urinary vanilmandelic acid and thyroid hormones (T3, free T4 and thyroid-stimulating hormone), were within normal limits. Sequencing of her polymerase chain reaction-amplified NF2 gene showed a normal sequence in its coding region. A biopsy of one nodule on her back showed increases in the number and size of organized nerve tissue throughout the dermis, but without surrounding inflammation. The large nerve fascicles, composed of parallel masses of spindle cells and nerve fibers, were larger than normal dermal nerves, and some showed mild internal disorganization as in neuromas (Fig. 2A,B). A second biopsy, taken from the other dorsal lesion, was identical. Further staining with the Bielschowsky’s silver showed proliferation of axons within the enlarged nerve fascicle (Fig. 2C). Clinically, our patient showed the localized dermal nerve hypertrophy of a patient with NF2. These are not tumors such as schwannomas or neurofibromas but there were increases in the number and size of structurally normal nerves. To date, only a few cases of cutaneous nerve hypertrophy, dermal hyperneury’, have been reported: mucocutaneous findings in MEN2b, in association with linear erythema and subsequent hyperpigmentation on the trunk, secondary to scratching or other trauma or of idiopathic origin. Abnormalities of cutaneous nerves, comparable to changes in the mucosa, gastrointestinal tract and eye, have been described in normal skin of MEN2b patients, suggesting that pathologic proliferation of cutaneous nerve tissue is part of the syndrome. In addition to cutaneous nerve hypertrophy, our patient had some dermatologic features similar to MEN2b: exaggeration of the papillary structure of the tongue and nodular protuberances on its ventral surface. Although our patient had no indication of endocrine tumors, an incomplete or mild form of MEN2b