Yuji Asada

Churg‐Strauss Syndrome (CSS) Manifested as Necrosis of Fingers and Toes and Liver Infarction

We report a case of Churg‐Strauss syndrome (CSS) with necrosis of the fingers and toes and liver infarction. A 59‐year‐old man with asthma suddenly noticed that his fingers and toes felt unusually cold. This condition worsened progressively, and some digits became necrotic within several weeks. Laboratory studies revealed hypereosinophilia and an extremely elevated serum level of IgE. Digital subtraction angiography of the extremities revealed extensive irregular narrowing of small and medium‐sized arteries in the extremities. Abdominal computed tomography (CT) revealed an area of low density at the periphery of the right lobe of the liver. Angiography revealed irregular narrowing of small arteries that corresponded to the ischemic area. A nerve conduction study suggested sensory nerve neuropathy. The preceding asthma, acute onset of digital necrosis, liver infarction, neuropathy, and hypereosinophilia strongly suggested a diagnosis of CSS. The patient was treated with 40 mg of prednisolone and 120 μg of intravenous prostaglandin E1 daily, and all the digits that had turned black and necrotic were amputated. After the amputation, the dose of prednisolone was gradually reduced, and no new lesions appeared on the skin or in the liver. The rare possible complications of CSS, including necrosis of digits and liver infarction, should not be ignored.

A Case of Pencil Core Granuloma with an Unusual Temporal Profile

The patient is a 47-year-old female with a bluish tumor resembling malignant melanoma at the macroscopic level on the medial aspect of her left big toe. The patient had crushed a pencil with this toe about 30 years previously and, since then, a bluish lesion had been present. About 15 years ago, the lesion had suddenly increased in size over the course of a few months. Subsequently, the size of the lesion had not changed noticeably. Ultrasonography, but not magnetic resonance imaging was a helpful preoperative examination to distinguish the lesion from malignant melanoma. The excised lesion contained a piece of material that resembled pencil lead and bluish mud. X-ray microanalysis of the lead-like material revealed that its composition was similar to that of pencil lead. Histologic examination showed features of foreign-body reaction, except for necrotic change and few histiocytes.

Postoperative Hyponatremia in a Patient with ACTH‐Producing Merkel Cell Carcinoma

Merkel cell carcinoma is characterized by specific neuroendocrine features and the expression of several neuropeptides. We report a case of Merkel cell carcinoma with post‐surgical hyponatremia in an 85‐year‐old Japanese woman. A tumor on the left cheek histopathologically showed the characteristics of Merkel cell carcinoma together with Bowens disease. Although an increased level of ACTH was found both in the tumor and in the peripheral blood, the postoperative hyponatremia in our patient seems more likely to have been caused by the stress of the operation and indapamide, considering that the ACTH level in the tumor was much lower than those in other ectopic ACTH‐producing tumors in previous reports.

A case of rheumatoid nodulosis successfully treated with surgery.

We report the case of a 76 year‐old male with multiple subcutaneous nodules, but without joint symptoms or deformities, who was diagnosed histopathologically with rheumatoid nodulosis after resection of the nodules. Rheumatoid nodulosis is a disease characterized by multiple subcutaneous nodules that are histopathologically similar to rheumatoid nodules, a high titer of rheumatoid factor, and radiologically detectable cystic bone lesions, but with none or few of the systemic manifestations or joint activity of rheumatoid arthritis (RA). It is considered to be a benign variant of RA. This rare disease must be considered when a case of multiple subcutaneous nodules is encountered, even in aged males without joint symptoms or deformities.

A case of squamous cell carcinoma of the scrotum associated with invasion of surrounding dermal lymphatic vessels and regional lymph node metastasis.

A-75-year-old man developed a rapidly growing tumor followed by swelling of regional lymph nodes, on the left side of his scrotum. Histopathological examination of the tumor revealed a deep invasion of atypical squamous cells associated with embolism of dermal lymphatic vessels by tumor cells, as far as 4cm apart from the tumor. Wide local excision of the tumor including total scrotal skin and bilateral ilioinguinal lymph node dissection was performed. Subsequently five courses of chemotherapy with cisplatin and fluorouracil and radiotherapy were added. In spite of these treatments, he had a recurrence located on the posterior border of the grafted skin of scrotum one year after the operation. [Skin Cancer (Japan) 2001; 16: 47-50]

A Case of Recurrent Dermatofibrosarcoma Protuberans Invading the Cerebral Parenchyma.

A 22-year-old Japanese man visited our hospital with a large tumor on his occipital region. He first noted a nodule on his scalp when he was 14-years-old in 1986. Although the tumor was excised in 1987, he noticed recurrence one year later. Since then, surgical excision of recurrent tumors had been performed six times. In 1994, he complained of frequent headaches, walking disturbance and visual disorder. Physical examination revealed several large nodules located on the anterior border of the previously grafted skin. Magnetic resonance imaging showed the scalp mass invading the cerebral parenchyma. The recurrent tumors were further resected five times. In spite of the radiotherapy and chemotherapy, the tumor progressively disseminated into spinal cord, and he died of respiratory failure in January, 2000. [Skin Cancer (Japan) 2001; 16: 77-82]