Persistent serpentine supravenous hyperpigmentation--a possible cutaneous manifestation of HIV infection or a normal racial variant: a report of 3 cases.

Persistent serpentine supravenous hyperpigmentation (PSSH) describes a hyperpigmentation of the skin overlying peripheral veins. This cutaneous finding is typically seen in association with systemic chemotherapy or collagen vascular diseases such as progressive systemic sclerosis, systemic lupus erythematosus, and rheumatoid arthritis. Three dark-skinned patients with idiopathic serpentine supravenous hyperpigmentation (ISSH) without collagen vascular disease or prior intravenous cytotoxic treatments were reported. All 3 patients were dark-skinned men with symmetric, uniform hyperpigmentation of the supravenous network of the bilateral lower extremities that had been present for years. The serpentine supravenous hyperpigmentation on the lower extremities was uniform in width and color, which contrasts with the darker discoloration near the site of infusion seen with PSSH associated with chemotherapy. Interestingly, 2 of the patients had advanced human immunodeficiency virus (HIV) disease in association with their ISSH while the HIV status of the third patient was unknown. Thus, we contend that ISSH be considered a normal racial variant or a possible cutaneous manifestation of HIV disease.

An unusual cutaneous manifestation of Crohn's disease.

A 61-year-old man with a 12-year history of quiescent Crohn's disease on mesalamine presented to his gastroenterologist in April 2009, complaining of abdominal cramping, diarrhea, and a 25-lb weight loss over 6 weeks. He did not respond to prednisone 50 mg and 6-mercaptopurine 100 mg daily. Abdominal computed tomography findings revealed diffuse submucosal edema consistent with extensive colitis. Colonoscopy demonstrated diffuse inflammation with erythema, friability, and shallow ulcerations in the rectum and colon. Biopsies were consistent with Crohn's colitis. He was admitted for infliximab infusion for his unremitting diarrhea. Five days before admission, the patient noted mild swelling and redness of the left lower eyelid, which progressed to involve the right lower eyelid with frank pus draining from both eyes. He had no visual impairment or eye pain. Two days before admission, an ophthalmologist prescribed a steroid eyedrop with no relief. He also complained of seropurulent painful skin lesions on his face and scalp, which spread to involve his upper trunk and proximal arms. On admission to the hospital, dermatology, ophthalmology, and infectious disease consultations were obtained to rule out disseminated infection before initiation of infliximab therapy. The patient was afebrile and hemodynamically stable. His oral mucosa was normal. He had prominent bilateral lower eyelid edema, erythema, and superficial erosions with hemorrhagic crusting and frank green purulent drainage from both eyes, with crusting along the lower lash line and bilateral sclera injection (Figure 1). On his scalp, face, trunk, and proximal extremities, he had 25 to 30 erythematous, 4- to 8-mm papulopustules with narrow red halos, some with central necrosis and crusting (Figure 2). Cultures from the purulent ocular drainage and pustules on the trunk and arms were all negative for bacteria, virus, and fungi. Gram stain from the eye drainage showed polymorphonuclear leukocytes without organisms. Tissue cultures were negative for bacterial, fungal, and mycobacterial infection. Skin biopsy taken from the central upper back demonstrated subcorneal pustules with areas of eroded epidermis and collections of neutrophils in the superficial dermis (Figure 3). Special stains were negative for organisms. He received infliximab infusion 5 mg/kg for a total dose of 420 mg over 2 hours. Within 48 hours of infusion, there was notable decrease in size of lesions, in addition to reduction of purulent drainage from both eyes. The patient was discharged home following infliximab infusion. His skin lesions resolved during a period of 2 weeks, leaving small pink atrophic scars. He received his second infusion of infliximab 2 weeks after discharge with continued improvement in his gastrointestinal symptoms.

Henoch-Schönlein purpura presenting with anuria in an adult.

Henoch-Schönlein purpura (HSP) is an immune complex-mediated systemic small vessel vasculitis that is most commonly described in children but may affect patients of any age. Our patient, a 91-year-old man, presented with anuria caused by IgA-mediated nephropathy; he later developed cutaneous leukocytoclastic vasculitis, thereby meeting the criteria for a diagnosis of HSP. This case is unique because of the patient's initial presentation with anuria, the possible underlying malignancy associated with his HSP, and his advanced age.

Glomus tumor masquerading for 22 years as osteoarthritis of the hip.

Glomus tumors are rare benign mesenchymal neoplasms that account for less than 2% of soft tissue tumors. These neoplasms typically are small nodules less than 1 cm in diameter, associated with pain that is exacerbated by tactile stimulation and cold hypersensitivity. We present a case of a large glomus tumor of the left lateral hip associated with a long history of severe pain of the left hip interfering with ambulation. Chronic pain as a result of a subcutaneous glomus tumor is rare and frequently misdiagnosed. In the case reported, a solid glomus tumor presented with 22 years of unilateral hip pain attributed to posttraumatic degenerative joint disease. Excision of a 4 x 3-cm nodule resulted in complete resolution of tenderness and joint pain. Subcutaneous glomus tumors can have unusually large size and location and should be considered in the differential diagnosis of chronic, atypical, or treatment-resistant joint pain.

Chlorhexidine gluconate­impregnated central access catheter dressings as a cause of erosive contact dermatitis: a report of 7 cases.

BACKGROUND: Chlorhexidine gluconate-impregnated dressings have become widely adopted as a means to reduce the risk for catheter-associated bloodstream infections. These dressings release antiseptic under occlusion onto the skin surrounding catheter insertion sites. Although chlorhexidine gluconate is a known cause of contact dermatitis, the phenotypic range of this adverse effect of chlorhexidine gluconate­impregnated dressings in critically ill patients has not been described. OBSERVATIONS: We report 7 cases of erosive irritant contact dermatitis due to chlorhexidine gluconate-impregnated transparent dressings. Six of these patients were children (age range, 4 months to 2 years); the adult was a critically ill 62-year-old man. Four patients were immunosuppressed after solid organ transplant and all were receiving blood pressure support at the time of this reaction. The insertion sites of femoral catheters were involved in all but 1 case; 3 catheter sites were involved in the adult patient. Results of extensive infectious workups were negative. All lesions resolved with discontinuation of the chlorhexidine gluconate-containing dressings, local wound care, and alternative antimicrobial dressings. CONCLUSIONS: Erosive contact dermatitis is an under-recognized complication of chlorhexidine gluconate-impregnated dressings. Health care providers should be aware of this risk, particularly in young children and immunosuppressed and/or critically ill patients, who may be more susceptible to the irritant effects of these dressings. When the dressings are used, patients should be monitored closely for skin breakdown.