A diagnostic challenge: inflamed and pigmented seborrheic keratosis. Clinical, dermoscopic, and histopathological correlation.

Pigmented and irritated types of seborrheic keratosis (SK) can be confused with melanoma, basal cell carcinoma, or pigmented actinic keratosis. Dermoscopic examination may give many clues for the diagnosis of SK, but in equivocal cases the accurate diagnosis can only be made by microscopic features. Herein, we report a striking, isolated pigmented and inflamed SK, located on the waist in an elderly man. Although the duration of the lesion was not clear, a recent change in color was reported. The striking dark pigmentation and lack of visible characteristic features for SK led us to consider other pigmented lesions, mainly melanoma, which it closely resembled. Dermoscopic examination was inconclusive with subtle clues for SK, such as brown-gray dots, small brownish clods, a few curved short lines, and few small pinkish round structures. Histopathological and immunohistochemical examinations revealed an inflamed and pigmented SK. In conclusion, pigmented and inflamed SK does not usually tend to show typical dermoscopic features of SK and may mimic other pigmented lesions, including melanoma. All skin lesions that cannot be classified as clearly benign should undergo biopsy.

An unusual lesion on the nose: microvenular hemangioma.

Microvenular hemangioma (MVH) is an acquired, benign type of hemangioma that usually manifests itself as a solitary, slowly growing, red to violaceous, asymptomatic papule, plaque or nodule. It is typically located on the trunk or extremities of young adults. It can be difficult to differentiate MVH from other types of hemangioma and Kaposi sarcoma. Herein we report a case of MVH unusual for its location, age of onset, and morphologic features. A 62-year-old man complained of an asymptomatic, bluish-red discoloration on the tip of his nose that had been present for two years. Dermatologic examination showed a violaceous patch 2 × 2 cm in diameter with indistinct borders. Incisional biopsy revealed irregularly branched small or medium-sized vascular spaces lined with benign endothelial cells, positive for CD34 and negative for HHV-8. MVH is a rare lesion, and less than 70 cases have been published to date. A review of 40 reported cases revealed that 15% of MVH patients were over 40 years of age and only 3% of the cases showed macules or patches. A literature survey showed only two cases of MVH located on the facial region, one on the chin and the other on the cheek. Our case was unique for its location and interesting for other rarely encountered features. MVH should be considered in the differential diagnoses of vascular lesions on nasal skin.

Simultaneous Immunoglobulin G4-associated Autoimmune Hepatitis and Autoimmune Pancreatitis.

How to cite this article: Yilmaz B, Kiziltas S, Yildiz S, Gümüs B, Çevik H. Simultaneous Immunoglobulin G4-associated Autoimmune Hepatitis and Autoimmune Pancreatitis. Euroasian J Hepato-Gastroenterol 2017;7(1):95-96.

A rare complication of follicular hair unit extraction: Kaposi's varicelliform eruption.

Follicular hair unit extraction (FUE) is becoming a popular type of hair transplantation recently. Kaposi's varicelliform eruption (KVE) is an uncommon skin emergency due to cutaneous dissemination of several types of viruses, most notably herpes virus, over the lesions of preexisting skin disorders. A 34-year-old man visited our dermatology outpatient clinic with a blistering, itchy and tender eruption on his head and body. He had undergone follicular FUE for androgenic alopecia 12 days previously, and 5 days after the procedure, umbilicated and/or hemorrhagic vesiculopustules appeared firstly on the occipital scalp skin where the hair units were taken. The lesions had rapidly spread over the upper chest and back. After the operation, he had taken oral methylprednisolone, amoxicillin clavulanate and had used fusidic acid ointment without any benefit. Bacterial culture of the pustules yielded no microorganism, while Tzanck smear from the vesicles revealed multinuclear giant cell groups. Based on a diagnosis of KVE, we treated the patient with oral valacyclovir hydrochloride 1000 mg 3 times a day for 14 days. Symptoms cleared rapidly, pustules and vesicles dried in a few days, and re-epithelialization of the eroded areas started at the end of the first week. The reported complications of FUE include necrosis of the donor site, postoperative hyperesthesia, recipient area folliculitis, keloids, bleeding, infection and pyogenic granuloma. Up to this date there are only three reports of KVE developing just after dermatological surgery, including dermabrasion, laser resurfacing, and skin grafting. According to our knowledge, this is the first case of KVE occurring after the FUE procedure. We think that the traumatic effects and skin barrier disruption due to operation and immune alteration due to postsurgical steroid treatment might have precipitated the activation and dissemination of latent herpesvirus infection.

Acral melanoma with satellitosis, disguised as a longstanding diabetic ulcer: a great mimicry.

Acral lentiginous melanoma affects the palms, soles, and nail apparatus. Around 3-15% of all cutaneous melanomas are located on the foot and have a poorer prognosis than melanoma elsewhere. Possible reasons for this prognostic difference may be omitting this area during routine skin check by both the patient and the physicians, in addition to misdiagnosis of melanoma as other benign skin lesions. We describe here an elderly female patient treated for a non-healing foot ulcer interpreted as a diabetic ulcer, which after 2 years was diagnosed as acral melanoma with satellitosis. Histopathological examination of the amputated distal phalanx revealed an advanced stage melanoma with 1·2 cm Breslow thickness and of Clark level 5. Dermoscopy of the bluish papulonodules scattered on the dorsal foot showed characteristic findings described for metastasis of skin melanoma. This case underlines the importance of considering skin malignancies in case of chronic, non-healing ulcers in diabetic patients. Furthermore, we point out the critical significance of skin examination as a whole, and dermoscopy being an important tool in the diagnosis of melanoma and/or cutaneous melanoma metastasis.

Is it a sarcoidal foreign-body granuloma or a cutaneous sarcoidosis on a permanent eyebrow make-up?

Permanent make-up is a kind of cosmetic tattoo in which the colorants (pigments) are deposited in dermis after piercing the skin by tiny solid needles. It may cause some adverse effects such as local inflammation, infection, and allergic reactions on the skin and even systemic adverse effects such as sarcoidal reactions. Here the case of a 34-year-old woman who has some yellowish hard shiny papules on her eyebrows after having a permanent make-up is described. The histopathological examinations of the papules are diagnosed as sarcoidal foreign-body reactions. All the laboratory investigations were in normal limits except a mild elevation in angiotensin converting enzyme or ACE level. The lesions mostly improved after topical corticosteroid treatment. Sarcoidal foreign-body reaction due to permanent make-up is discussed with this presentation.

Blastic plasmacytoid dendritic cell neoplasm: skin and bone marrow infiltration of three cases and the review of the literature.

Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a distinct and rare neoplastic entity and was classified as a subgroup of acute myeloblastic leukemia by the WHO in 2008. The median survival of patients was 15.2 months in a large case series. Allogeneic or autologous bone marrow transplantation has been recommended by some reports because of the disease's poor prognosis. We present three patients who presented with both skin and bone marrow infiltration. A 57-year-old man, a 62-year-old woman, a 64-year-old man were admitted to our outpatient clinic because of skin lesions. All of the patient's had bone marrow infiltration with positivity of the CD4, CD56, and CD123 staining. Survival of the patient's were 42, 6 and 12 months, respectively. Two of the patients who presented as blastic form didn't respond to any chemotherapy. BPDCN is a difficult disease to diagnosis and manage. CD4, CD56, CD123, CD303, and T cell leukemia/lymphoma 1. Cutaneous lesions can present as isolated nodules, macules, and disseminated macules and nodules. Positivities are crucial to the diagnosis of the disease in histological examination. Bone marrow infiltration or disease relapse at presentation were related to poor prognosis. Complete immunocytochemical staining must be performed for all patients who have cutaneous lesions with or without blood count abnormalities. Bone marrow (allogeneic or autologous) transplantation should be considered at the first remission.

Relationship of P-selectin glycoprotein ligand-1 to prognosis in patients with multiple myeloma.

BACKGROUND: Changes occur in adhesion molecules in the disease course of multiple myeloma. P-selectin glycoprotein ligand-1 (PSGL-1, CD162) works as the ligand of selectin-neutrophil adhesion molecules. The aim of the present study was to investigate the relationship between PSGL-1 expression in the bone marrow and the known prognostic factors for multiple myeloma disease, disease stage, and survival. MATERIALS AND METHODS: This research included 63 patients with multiple myeloma (26 women [41.3%]; 37 men [58.7%]). The bone marrow biopsy samples obtained at disease diagnosis for each patient were stained immunohistochemically in terms of CD162 expression using standard diagnostic immunohistochemical staining methods. The laboratory results, CD162 expression, overall survival, demographic characteristics of the disease, and the relationship between CD162 expression and the disease stage were evaluated. RESULTS: Among the 63 patients included in the present study, the survival rate was 82.3% for 1 year, 73.2% for 2 years, 63.4% for 3 years, 51.7% for 4 years, 40.3% for 5 years, and 33.6% for 6 and 7 years. A statistically significant difference was not detected between the CD162 staining ratio and disease survival (P = .232). A statistically significant difference was not detected between the CD162 staining degree and survival rate (P = .184). However, the overall survival of the patients with no CD162 expression in the bone marrow was lower than that for the patients whose CD162 was stained 1, 2, and 3 degrees (12.33 ± 11.49, 28.65 ± 31.44, 37.25 ± 29.32, and 47.92 ± 45.29 months, respectively; P < .001). CONCLUSION: In the present study, CD162 staining and the staining degree, with the other standard immunohistochemical stains, were shown to be beneficial in the diagnosis of multiple myeloma disease. However, the results did not provide information about the disease course. Studies of a larger number of patients to examine P-selectin and interleukin-6 levels are needed to investigate the disease course.

A rare presentation of langerhans cell histiocytosis tonsil infiltration: review of the literature: atypical presentation of langerhans cell histiocytosis.

Langerhans cell histiocytosis (LCH) is a rare disease that can infiltrate various organs. LCH presents with solitary organ involvement or as a multi-system disease. We present a patient who has tonsillary infiltration with LCH. A 74 year-old Caucasian male was admitted for swelling of the neck and difficulty swallowing for 3 months. Physical examination showed submandibular lymph node enlargement of approximately 3 cm and tonsil enlargement. A tonsillectomy and excisional biopsy of the lymph node were done. Histiocyte-like cell infiltration was seen in the tonsil biopsy. CD3, CD20, CD15, CD30, CD5, CD138, Lambda, Kappa, Bcl-2, ALK, CD23, CD10, Bcl-6, keratin, EMA, HMB-45, and Cyl D1 were negative. CD68, S-100, CD1a, and fascin were positive, and the Ki-67 proliferation index was 20 % in immunocytochemical staining. The most commonly infiltrated bones are the skull, femur, lower jaw, pelvis, and vertebrae in LCH. Oral or perioral lesions are present in 30 % of cases. Oral lesions most often involve bone loss, unexpected tooth loss, and gum inflammation. We administered oral prednisolone to our patient due to the presence of lytic lesion of the bone, mild anemia and a higher sedimentation rate, which was from a separate, explained cause. Isolated tonsillar involvement in adult LCH was reported in only 2 cases in the literature. There is no standard recommendation for treatment. Our patient responded well to steroid therapy.