Group G streptococcal bacteremia. The clinical experience at Boston University Medical Center and a critical review of the literature.

Twenty-six patients with bacteremia caused by group G streptococci were seen during a 29-month period. Our findings suggest that the epidemiology of these infections has not changed appreciably during the last 15 years. The disease occurs most commonly as an acute community-acquired infection in older persons with underlying conditions predisposing to skin breakdown. Patients with these bacteremias fall into three categories: those with associated cutaneous infection only; those with serious focal infection; and those with probable infection. Underlying neoplastic conditions were relatively uncommon (25%) in our series compared with others (65%). In contrast to recent reports emphasizing this complication, endocarditis was uncommon in our patients. A prompt response to therapy with beta-lactam antibiotics occurred in most of our patients.

Figurate and bullous eruption in association with breast carcinoma.

We describe a patient with two coexistent cutaneous eruptions: (1) trauma-induced bullae of the distal extremities and elbows and (2) multiple concentric gyrate lesions on the trunk and extremities, some of which became bullous. The gyrate lesions were stationary and nonpruritic. Biopsy of both types of lesions showed a subepidermal blister and a minimal inflammatory infiltrate. Direct immunofluorescence revealed linear deposition of IgG and C3 at the dermoepidermal junction and indirect immunofluorescence was negative. By immunoelectron microscopy, these immune deposits were localized to the lower lamina lucida. The eruption was not controlled despite high-dose (80 mg/d) oral administration of prednisone and required the addition of an oral administration of methotrexate (20 mg weekly). On further evaluation, an intraductal mammary carcinoma was detected. Following radiation therapy, the methotrexate and prednisone therapy were tapered without recurrence of the eruption during a follow-up period of 18 months.

Unilateral cutaneous emboli of Aspergillus.

A 40-year-old white woman with acute nonlymphocytic leukemia, which relapsed despite bone marrow transplantation and various chemotherapeutic regimens, developed fever and neutropenia. Her fever was unresponsive to broad-spectrum antibiotics, and on hospital day 53 she developed purpuric macules with necrotic centers on her left hand and forearm. Frozen sections of lesional skin were stained with Grocott's methenamine-silver and showed hyphae consistent with a species of Aspergillus; culture of the skin biopsy specimen yielded a pure culture of Aspergillus flavus. Localization of the emboli to the left upper extremity was subsequently explained by magnetic resonance imaging scan of the chest demonstrating invasion of the left subclavian artery by a pulmonary aspergilloma.

Idiopathic CD4+ lymphocyte deficiency. Report of an unusual case associated with atopic dermatitis and allergic contact dermatitis and review of the literature.

BACKGROUND: Idiopathic CD4+ lymphocyte deficiency is a newly described entity of apparently non-human immunodeficiency virus-associated helper T-cell depletion. The clinical spectrum continues to evolve, but, to date, it has included patients ranging from those with minimal symptoms to those who have died with acute opportunistic infections. Several individual cases have been previously reported, many with distinctive, primarily infectious, cutaneous manifestations. OBSERVATIONS: We describe a patient with idiopathic CD4+ lymphocyte deficiency distinguished by a unique clinical presentation of atopic dermatitis exacerbated by contact urticaria and allergic contact dermatitis. She has a persistent markedly diminished CD4+ lymphocyte count (absolute count less than 50), no serologic evidence of, or risk factors for, human immunodeficiency virus infection, and no history of opportunistic infections. CONCLUSIONS: We present a possible new cutaneous manifestation of idiopathic CD4+ lymphocyte disease and summarize the previously reported cases, with an emphasis on the cutaneous features.

Annular erythema in identical twins.

A case of superficial gyrate erythema that was indistinguishable from erythema annulare centrifugum occurred in identical twins. We propose to include a familial cause among the known causes of erythema annulare centrifugum rather than considering this a separate entity, "familial annular erythema."

Water-in-oil emollients as steroid-sparing adjunctive therapy in the treatment of psoriasis.

An open label study of ninety-six patients with chronic plaque-type psoriasis demonstrated the efficacy of the addition of water-in-oil emollients to a topical corticosteroid regimen. Twice daily application of betamethasone dipropionate cream and once daily application of both betamethasone dipropionate cream and either a water-in-oil based moisturizing cream or lotion were equivalent in efficacy (p = 0.05). Once daily application of both betamethasone dipropionate cream and either a water-in-oil based cream or lotion was significantly better than once daily application of betamethasone dipropionate cream alone (p = 0.05). Water-in-oil emollients are useful in the therapy of chronic, plaque-type psoriasis and provide a steroid-sparing effect.

Airborne allergic contact dermatitis from pine dust.

BACKGROUND: Airborne contact dermatitis is a challenging entity that requires comprehensive patch testing and exposure review to diagnose accurately. OBJECTIVE: Four patients with airborne contact dermatitis and positive patch tests to colophony were evaluated. METHODS: Patch testing was performed on all patients using a modified European standard series plus additional applicable allergens. RESULTS: All patients had positive patch tests to colophony and exposure to pine dust. CONCLUSION: Patch testing is a critical element in the evaluation of patients presenting with an airborne pattern of contact dermatitis.

Primary cutaneous B-cell lymphoma. Diagnosis, treatment, and prognosis.

BACKGROUND: An elderly woman with B-cell lymphoma confined to the skin of the lower extremity was treated with combination chemotherapy and radiation therapy. She relapsed with new skin lesions outside the original radiation port that responded to additional radiation therapy and remains in remission 12 months after her last treatment. OBJECTIVE: This article investigates the diagnosis, treatment, and prognosis of primary cutaneous B-cell lymphoma. METHODS: The relevant literature was researched through computer data bases and bibliographies. RESULTS: Patients who present with localized lesions of primary cutaneous B-cell lymphoma have a favorable prognosis regardless of the type of therapy, although relapses may occur in the absence of systemic disease. CONCLUSION: We advocate the use of local therapies as initial treatment in patients with localized primary cutaneous B-cell lymphoma.

Skin and bones. I.

Skin disorders in which a radiograph may detect associated bony changes or abnormalities of calcification are discussed. They are grouped into eight categories: (1) inherited diseases (e.g., alkaptonuria, neurofibromatosis); (2) congenital disorders (e.g., Sturge-Weber and Proteus syndromes); (3) inflammatory conditions (e.g., dermatomyositis, sarcoidosis); (4) infections (e.g., dental sinus, syphilis); (5) neoplasias (e.g., histiocytosis, mastocytosis); (6) drug- and environment-induced (e.g., acroosteolysis, retinoid toxicity); (7) calcinosis cutis; and (8) osteoma cutis. Part I of our review discusses the first two categories.

Skin and bones. II.

Skin disorders in which a radiograph may detect associated bony changes or abnormalities of calcification are discussed. They are grouped into eight categories: (1) inherited diseases (e.g., alkaptonuria, neurofibromatosis); (2) congenital disorders (e.g., Sturge-Weber and Proteus syndromes); (3) inflammatory conditions (e.g., dermatomyositis, sarcoidosis); (4) infections (e.g., dental sinus, syphilis); (5) neoplasias (e.g., histiocytosis, mastocytosis); (6) drug- and environment-induced (e.g., acroosteolysis, retinoid toxicity); (7) calcinosis cutis; and (8) osteoma cutis. The first part of this review, published in the August 1991 issue of this JOURNAL, dealt with the first two categories; part II discusses categories 3 through 8.

The development of lentigines within segmental achromic nevi.

The classic definition of a nevus depigmentosus is a stable congenital leukoderma that may be localized, segmental, or less often, systematized. Herein we report 2 patients whose achromic nevi underwent an unusual change--the development of multiple lentigines. The lentigines ranged in size from 3 to 5 mm and the majority had an irregular outline. Although their color was darker than that of the normal surrounding skin, the most striking clinical finding was their limited distribution. The lentigines were present only within the confines of the nevus depigmentosus. They first appeared at age 3 years in 1 child and at age 1 year in the second. No new pigmented macules were noted in the older child after age 10 years and, by that time, greater than 90% of the nevus depigmentosus was "repigmented." One possible explanation would be the reversion of a mutation in 1 of the genes involved in pigmentation.

Inflammatory cutaneous metastases from cloacogenic carcinoma of the anus.

BACKGROUND: There are a few tumors that exhibit inflammatory cutaneous metastases. This pattern is particularly difficult to diagnose since it can mimic erysipelas or lymphangitis. OBJECTIVE: This is a presentation of a 69-year-old woman diagnosed with poorly differentiated cloacogenic carcinoma who simultaneously was noted to have an abdominal rash. A biopsy confirmed cutaneous metastasis of her carcinoma. METHODS: Previously published literature on cutaneous metastases were reviewed and summarized. RESULTS: This is the first reported case of an inflammatory cutaneous metastasis arising from cloacogenic carcinoma. CONCLUSION: Cutaneous metastases can present in various forms, including the inflammatory pattern. Because this form mimics other conditions, it is prudent to biopsy any suspicious skin lesion in cancer patients, as it may considerably affect prognosis.