Toxic epidermal necrolysis following allergic contact dermatitis caused by occupational exposure to ultraviolet-cured inks.

Erythema multiforme is a relatively common skin disorder; the most common cause is herpes simplex infection, but topical sensitivities reportedly also provoke this reaction. We report here a case that progressed to toxic epidermal necrolysis due to contact with ultraviolet (UV)-cured inks. The diagnosis was confirmed by patch tests to acrylates in the UV-cured inks, histopathological studies of the lesions, and positive patch test to 1,6-hexanediol diacrylate.

Work-related allergy in medical doctors: atopy, exposure to domestic animals, eczema induced by common chemicals and membership of the surgical profession as potential risk factors.

PURPOSE: To investigate the risk factors associated with work-related allergy-like symptoms in medical doctors. METHODS: Self-administered questionnaire survey and CAP test were conducted among medical school students in the 4th grade of their 6-year medical course in 1993-1996 and 1999-2001. Follow-up questionnaires were sent in 2004 to the graduates. These questionnaires enquired into personal and family history of allergic diseases, lifestyle, history of allergy-like symptoms including work-relatedness and occupational history as medical doctors. Relationships between allergy-like symptoms and relevant factors were evaluated by multivariate logistic regression analysis. RESULTS: Of 261 respondents at the follow-up survey, 139 (53.3%) and 54 (20.7%) had a history of any allergy-like symptoms and any work-related allergy-like symptoms, respectively. Female gender and family history of allergic diseases were significantly associated with any allergy-like symptoms. Personal history of allergic disease, exposure to domestic animals, eczema caused by rubber gloves, metallic accessories, or cosmetics during schooling days, and membership of the surgical profession were significant risk factors for work-related allergy-like symptoms. On the contrary, to work-related allergy-like symptoms, gender, age, and smoking status were not significantly related, and consumption of prepared foods was inversely related. CONCLUSIONS: Personal history of atopy and eczema induced by common goods and the history of keeping domestic animals may be predictors of work-related allergy-like symptoms in doctors. After graduation from medical school, physicians start with exposure to various allergens and irritants at work, which relate to work-related allergy-like symptoms, especially for surgeons.

Dual role for Id2 in chemical carcinogen-induced skin tumorigenesis.

Inhibitor of DNA binding 2 (Id2) is a negative regulator of basic helix-loop-helix transcription factors and is involved in the control of cellular differentiation and proliferation. By using a two-step chemical carcinogenesis protocol, we evaluated the role of Id2 in skin tumor formation in mice. Twenty weeks after the initiation, the number of tumors formed in the Id2(-/-) mice was 3.5-fold higher than that in their wild-type littermates, whereas the diameter of tumors in the Id2(-/-) mice was about half of that of the tumors in the wild-type mice. In the Id2(-/-) mice, epidermal gammadelta T cells, which play a key role in immunosurveillance against skin tumor development, were barely detectable. Although histological analyses demonstrated no apparent difference in tumor cell type, tumor vessel formation or apoptosis, the proportion of proliferating cells was reduced in the tumors in the Id2(-/-) mice compared with those in the wild-type mice. In the wild-type mice, the expression of Id2 was enhanced in skin tumors compared with that in ear epidermal cells. Biochemical analysis demonstrated that cyclin D1 was reduced at the protein level in the tumors in the Id2(-/-) mice, whereas other factors such as cyclin E and p27 were not altered significantly. Our results reveal that Id2 plays a dual role in skin tumorigenesis by suppressing tumor development through the establishment of epidermal gammadelta T cell-mediated skin immunosurveillance and by promoting tumor cell proliferation via the control of the cyclin D1 protein level.

[Case of neuro-Behçet disease with HLA-B54, Cw1, which is difficult in clinical diagnosis from neuro-Sweet disease].

The patient was a 53-year-old woman with an 18-year history of recurrent oral aphtae, genital ulcers and folliculitis-like erupsions without mucocutaneus symptoms. She was admitted to our hospital for headache, and presented with meningeal irritation, dysarthria and right pyramidal signs. Brain MRI showed abnormal intensities extending from the right midbrain to the bilateral corona radiata, accompanied by contrast enhancement. She was diagnosed as having an incomplete form of neuro-Behçet disease (NBD) based on the diagnostic criteria for NBD. However, the HLA-type was defined as B54 and Cw1, which is common and specific in neuro-Sweet disease (NSD). Oral administration of prednisolone was markedly effective for the neurological symptoms and improved radiological findings, suggesting NSD rather than NBD as the clinical diagnosis for this patient Since she presented with clinical features that appeared in both diseases, the definitive diagnosis was clinically difficult. While tapering the dosage of prednisolone, we carefully observed the appearance of skin lesions and erythema nodosum appearing on her right lower leg. Skin biopsy demonstrated the features of erythema nodosum: lobular panniculitis with the accumulation of neutrophils and lymphocytes with necrotic fatty cells in the subcutaneous area, which was compatible with skin lesions in NBD. In our case, pathological findings of the skin lesion were required to differentiate between NBD and NSD, indicating the need for careful follow-up of dermatologic signs appearing in such a case.

Primary cutaneous signet ring cell carcinoma expressing cytokeratin 20 immunoreactivity.

Primary cutaneous signet ring cell carcinoma (PCSRCC) is a very unusual but distinctive clinicopathologic entity that can simulate metastatic adenocarcinomas. It is defined as a diffuse malignant epithelial neoplasia localized in the dermis and subcutis without epidermal involvement, showing variable amounts of signet ring cells, without evidence of visceral adenocarcinoma. We present 2 cases of PCSRCC, which involved eyelids and axilla respectively. Despite thorough systemic workup, primary sources could not be demonstrated in either case. The tumor cells are positive for gross cystic disease fluid protein 15 in addition to a variety of glandular markers. Furthermore, both cases were immunostained with cytokeratin 20 (CK20). In conclusion, we report 2 cases of PCSRCC expressing CK20 immunoreactivity. CK20-positive primary cutaneous tumors should include PCSRCC in addition to Merkel cell carcinoma.

Dominant expression of CXCR3 is associated with induced expression of IP-10 at hapten-challenged sites of murine contact hypersensitivity: a possible role for interferon-gamma-producing CD8(+) T cells in IP-10 expression.

Murine contact hypersensitivity is elicited as a consequence of immunologic reactions triggered by skin-applied antigen, interactions among Langerhans cells, T cells, keratinocytes and mast cells, and a variety of chemokines generated by cellular interactions. In this study, we sensitized and challenged BALB/c mice with hapten, dinitrofluorobenzene or picryl chloride, and examined the expressions of mRNA for chemokines and their receptors by reverse transcription-polymerase chain reaction in the skin of elicited earlobes. CXC chemokines, IP-10 and Mig, were transcribed 24-48 h after challenge. This was associated with the expression of their agonistic receptor CXCR3, while mRNA for TARC and MDC, and their receptor CCR4 were not detected. Since CXCR3 and CCR4 are expressed preferentially on types 1 (Th1/Tc1) and 2 (Th2) T cells, respectively, the results suggested that the former type of T cells predominantly infiltrate at the elicited sites. Immune lymph node cells of the sensitized mice also expressed mRNA for CXCR3 but not CCR4 with concomitant transcription of interferon-gamma (IFN-gamma) but not interleukin-4 subsequent to challenge. The percentage of lymph node CD8(+) T cells was increased from 16% in naive mice to 30-50% in hapten-challenged mice, and in the immune lymph nodes, CD8(+) cells were the major source of IFN-gamma compared to CD4(+) cells. Since IFN-gamma is known to stimulate keratinocytes to produce IP-10 and Mig, it is suggested that these IFN-gamma-producing CD8(+) T cells enhance the production of these chemokines, thereby functioning as not only the effector cells but also the cytokine source to sustain the challenge reaction.

Spindle cell squamous cell carcinoma not expressing stratified but simple epithelial cytokeratin: efficacy of simple epithelial cytokeratin immunoreactivity.

We present two cases of spindle cell squamous cell carcinoma, which were derived from solar keratosis and burn scar in two elderly Japanese patients, respectively. The tumors involved the whole dermis and subcutis in connection with the overlying epidermis. They were composed mainly of anaplastic spindle cells partially forming storiform patterns. The tumor cells were diffusely positive for vimentin and cytokeratin 8/18 (clone CAM5.2, simple epithelial cytokeratin), but negative for cytokeratin 1/5/10/14 (clone 34ßE12, stratified epithelial cytokeratin). Ultrastructural analysis of a patient demonstrated desmosomes and tonofilaments in the tumor cells. Although spindle cell squamous cell carcinoma is usually positive for vimentin, detailed cytokeratin profile is controversial. The present cases revealed immunohistochemistry not expressing stratified but simple epithelial cytokeratin and vimentin. We should be reminded of the efficacy of simple epithelial cytokeratin immunoreactivity in spindle cell squamous cell carcinoma.

Malignant melanoma with preserved hairs: a snap shot could suggest the development from an acquired melanocytic nevus.

63-year-old man presented with a dome-shaped, black nodule on his right forehead, where hairs were preserved. The black surface tone measured 7 mm in diameter and spread irregularly from the periphery of the nodule. He had been conscious of the preceding, black macule for approximately 50 years. A snap shot of the patient in adolescence showed a tiny, black macule, which was a few millimeters in diameter. Histological examination demonstrated irregular proliferation of melanoma cells from the epidermis to the dermis. Partially, there were well-circumscribed, oval nests composed of nevus cells in the acanthotic epidermis and follicles. Nevus cells were also seen in the dermal component, presenting a burnt-out appearance. In this case, the small final size, the preserved hairs and the snap shot suggested a preceding, acquired melanocytic nevus. Malignant melanoma could arise from acquired melanocytic nevus.