Disseminated protothecosis: Case report and review of the literature.

BACKGROUND: Human protothecosis is an uncommon infection caused by Prototheca spp that rarely infects humans. AIM: Description of a rare disease and a review of its articles. MATERIALS AND METHODS: We reported a 24-year-old man who presented with red-brown papules and plaques on the trunk's lateral side. We reviewed the literature about disseminated protothecosis and reported our experience with a patient with protothecosis between 2021 and 2023. RESULTS: Overall, 54 cases of disseminated protothecosis were evaluated, 39 were due to P. wickerhamii, 12 were due to P. zopfii (22.2%), and three were due to Prototheca spp. We found that males were more affected (37 cases, 68.5%) than females (16 cases, 29.6%). The mean age of patients was 39.53 ± 22.48 years. However, disseminated protothecosis can affect people of any age (1-80 years). In contrast to P. wickerhamii, which causes blood, skin, brain, and gastrointestinal tract infections, P. zopfii was mainly found in the blood (7/22) and did not have a significant difference in the mortality rate (P = 0.11). DISCUSSION: Disseminated protothecosis is a rare disease in immunocompromised patients but is generally rarer in immunocompetent hosts. Several underlying disorders include immunocompromised patients, prolonged application of steroids, diabetes mellitus, malignancies, organ transplantation, AIDS, and surgeries. Amphotericin B has been the most effective agent for protothecosis and is reserved for visceral and disseminated infections. Regarding localized cutaneous types, excision or surgical debridement is used. CONCLUSION: Mulberry's appearance and appropriate cultural environments are helpful in diagnosing it.

A keratotic nodule on a cobblestone plaque: A rare case presentation.

The manuscript describes a case of a 68-year-old woman with a pruritic nodule and yellow cobblestone plaque on her abdomen. Biopsy results showed trans epidermal illumination of basophilic elastic fibres in the reticular dermis with calcium deposits. The diagnosis was perforating calcific elastosis, an acquired rare condition mostly seen in obese, multiparous, middle-aged women.

Clinicopathological Survey of 204 Rosacea Patients Regarding Rosacea Subgroups and Severity.

INTRODUCTION: Few studies have evaluated the histopathological characteristics of clinical rosacea subtypes in detail. OBJECTIVES: To assess rosacea histopathological features in correspondence to clinical subgroups. METHODS: The histopathological findings of 204 rosacea patients were analyzed retrospectively and were compared among clinical subtypes. RESULTS: Thirt-Two Percent of patients were male and 68% were female. Seventy-three patients had erythematotelangiectatic rosacea (ETR) and 110 had papulopustular rosacea (PPR), 12 were ETR + PPR, 4 ocular, 2 phymatous, and 3 had Morbihan's edema. Perivascular and perifollicular lymphohistiocytic infiltration, perifollicular exocytosis, follicular spongiosis, and ectatic vessels were almost found in all subtypes. Solar elastosis was higher in ETR. Spongiosis, exocytosis of inflammatory cells into epidermis, acanthosis, and granulomatous reaction were higher in PPR. Inflammatory cells exocytosis was more in PPR and phymatous. Demodex folliculorum was identified in 27% of ETR, 33.6% of PPR, 50% of phymatous, one ocular patient, and none of Morbihan edema. Demodex brevis were found in 5% of ETR, 3% of PPR, and 50% of phymatous. Demodex brevis not folliculorum was more in phymatous. Spongiosis was the most common finding in ocular rosacea. CONCLUSIONS: Spongiosis, exocytosis of inflammatory cells, and granulomatous reactions were more in PPR. Solar elastosis was more in ETR. Histopathological findings were compatible with clinical subgroups.

Punctate Pattern and Pemphigus: Is There Any Evidence of Punctate Pattern Among Iranian Patients?

AIM: To examine the prevalence of this novel pattern among Iranian patients with pemphigus and peruse the relationship between the presence of a punctate pattern with clinical severity of disease and histopathological findings. METHODS: One hundred recently diagnosed patients with pemphigus were enrolled. DIF evaluation and routine light microscopy were performed on their biopsy specimens. Disease severity was determined using the Pemphigus Disease Area Index. Serum samples were collected to measure autoantibody titers using enzyme-linked immunosorbent assay. RESULTS: All the samples evaluated by DIF showed a continuous linear pattern of intercellular IgG deposition, whereas none of them had a punctate pattern. Despite a significant correlation between the Pemphigus Disease Area Index score and autoantibody values, no association between histopathological findings and disease severity has been found. CONCLUSION: We could not detect any punctate pattern among Iranian patients with pemphigus. The importance of this pattern in the diagnosis of pemphigus might be different among patients with different ethnic and genetic factors.

A rare case of plexiform schwannoma on the foot.

Plexiform schwannoma is an uncommon soft tissue tumor that could even rarely presented on the foot and toes.

Clinical and histopathological evaluation of cutaneous angiofibromas.

BACKGROUND: Angiofibromas are common benign skin lesions that are diagnosed clinically and histopathologically. Fibrous papule (FP) is one of the clinical types of angiofibromas located primarily on the nose. METHODS: The cases with the confirmed diagnosis of angiofibroma were enrolled. Demographic features of the patients and clinical characteristics of the lesions were extracted. Moreover, histopathological features of the available slides were microscopically reviewed. RESULTS: From 83 cases of cutaneous angiofibromas, 57 (69%) had lesions consistent with FP. The mean age at diagnosis was 37.7 ± 16.3 years and the most common site of involvement was the nose (53% of cases). Regarding the histopathological evaluation of 71 slides, most cases represented vascular changes (97%) and dermal fibroplasia (87%). Melanin incontinence (41%), acanthosis (31%), and lichenoid features (25%) were other common histopathological findings. Moreover, a sparse inflammatory cell infiltrate was present in 68% of cases. The most prevalent inflammatory cells were lymphocytes (61%) and histiocytes (34%). CONCLUSION: This study presented the histopathological findings of a series of cutaneous angiofibromas. Dermatopathologists should be aware of these features, especially those that are less common, to better diagnose and differentiate them from malignant neoplasms.

Cutaneous Lymphadenoma: A Case of Recurrence after Shave Excision.

Cutaneous lymphadenoma (CL) is a rare skin tumor supposedly derived from the pilosebaceous unit. Since its description in 1987, fewer than 60 cases have been documented. Herein we report a case of CL presenting as a small nodule on the forehead of a young female. The lesion recurred two years after shave excision of a similar lesion. The histopathological examination revealed interconnected islands, sheets, and trabeculae consisting of two distinct types of cells within a sclerotic stroma, a peripheral rim of palisading basophilic cells, and central epithelial cells with eosinophilic to clear cytoplasm. A dense infiltration with prominent lymphocytes and few plasma cells dominated the stroma and permeated the epithelial nests. This case represents the recurrence of this type of skin tumor after shave excision and thus highlights the importance of complete margin-free excision of such lesions.

A comparative study of long interspersed element-1 protein immunoreactivity in cutaneous malignancies.

BACKGROUND: Skin cancer is the most common cancer worldwide and commonly classified into malignant melanoma (MM) and Nonmelanoma skin cancers (NMSCs), which mainly include basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). The extent to which Long Interspersed Element-1 (LINE-1, L1) ORF1p is expressed in cutaneous malignancies remains to be evaluated. This study aimed to assess LINE-1 ORF1p immunoreactivity in various skin cancer subtypes. METHOD: The expression level of LINE-1 ORF1p was evaluated in 95 skin cancer specimens comprising 36 (37.9%) BCC, 28 (29.5%) SCC, and 31 (32.6%) melanoma using the tissue microarray (TMA) technique. Then the association between expression of LINE-1 encoded protein and clinicopathological parameters was analyzed. RESULTS: We showed that LINE-1 ORF1p expression level was substantially higher in BCC and SCC patients compared with melanoma samples (p < 0.001). BCC cases had a higher LINE-1 histochemical score (H-score) compared with SCC cases (p = 0.004). In SCC samples, a lower level of LINE-1 ORF1p expression was associated with age younger than the mean (p = 0.041). At the same time, no significant correlation was found between LINE-1 ORF1p expression and other clinicopathological parameters (all p > 0.05). CONCLUSIONS: According to our observation, LINE-1 ORF1p immunoreactivity in various skin tumor subtypes extends previous studies of LINE-1 expression in different cancers. LINE-1ORF1p overexpression in NMSCs compared with MM can be considered with caution as a tumor-specific antigen for NMSCs.

Cutaneous cysts: a clinicopathologic analysis of 2,438 cases.

BACKGROUND: Benign cutaneous lesions, so-called cysts, are frequently seen in clinics and might evoke cosmetic and psychosocial concerns. AIM: This study aimed to demonstrate the clinicopathologic findings of these lesions and also the importance of histological evaluation for prevention of misdiagnosing a benign-appearing malignant lesion. METHODS: A descriptive study was conducted of 2,438 cases who had a diagnosis of cyst confirmed with pathology. The data of patients over the 6-year period between 2011 and 2017, including gender, age, location, prevalence, complications, and microscopic evaluation, were gathered. RESULTS: From a total of 2,438 records with a clinical diagnosis of mucocutaneous cyst, 2077 had the pathologic diagnosis of cysts. They consisted of 910 women (43.8%) and 1167 men (56.1%) with a mean age of 42. The most common mucocutaneous cysts were epidermal cyst 994 (47.8%) followed by trichilemmal cyst 495 (23.8%). In 479 (19.6%) records, the clinical diagnosis was not congruent with histopathological diagnosis including 45 malignant cases. Basal cell carcinoma in 22 (48.9%) was the most common one. CONCLUSIONS: This study reports on clinical characteristics of cutaneous cysts and the need for a decent diagnostic investigation, like histopathology, for achieving a reliable diagnosis regarding the benign mimicking malignant lesions, especially high risk ones.

Granuloma annulare after Botulonium toxin A injection: A rare association.

BACKGROUND: Botulinum toxin is generally considered safe and has been used in constantly expanded cosmetic and therapeutic indications. However, long-term side effects such as granulomatous reactions have been associated with this drug. AIMS: We aim to evaluate a rare reaction to Botulonium toxin A injection. PATIENTS/METHODS: A 44-year-old woman, developed annular plaques eleven months after botulinum toxin A injection for the correction treatment of wrinklesglabellar rhytides. RESULTS: Histopathological examination revealed granuloma annulare formation. Clinical and biological investigations were negative, ruling out the hypothesis of systemic sarcoidosis. Triamcinolone acetonide injection was followed by a regression of the plaques. CONCLUSION: There are previous reports in the literature of sarcoidal and foreign body granuloma at the sites of injection of botulinum toxin A injection. To our knowledge this is the first report of granuloma annulare occurrence after botulinum toxin A injection.

Eosinophilic infiltration: an under-reported histological finding in urticarial vasculitis.

BACKGROUND: Urticarial vasculitis (UV) is a clinicopathologic entity in which skin lesions resemble urticaria clinically but last more than 24 hours and resolve with residual purpura. In this study, we evaluated distinguishing histological features of UV from common urticaria to differentiate between these two entities. METHODS: During 1 year, 55 urticaria and 245 UV samples were assessed. The selection criteria for UV included: (1) samples that the histological diagnosis was confirmed by two independent dermatopathologists, (2) the histological diagnosis of UV was inconsistent with the first clinical impression and lesion characteristics. RESULTS: Of our 245 UV patients, 96% had endothelial swelling, 18% had red blood cell (RBC) extravasation, neutrophilic infiltration was seen in 46.7%, and perivascular, interstitial, and perineural eosinophilic infiltration in 198 (81.8%), 181 (74.2%), and 118 (48.1%), respectively. Among different histological findings, endothelial cell swelling as well as neutrophil around vessels and eosinophilic infiltrations were statistically different between two groups (P-value Ë‚ 0.001). Both urticaria and UV samples showed a predominantly lymphocytic infiltration more than 10 cells per high power field (HPF) (98.2% of urticaria, 98.8% of UV), and only two patients (0.8%) with UV had predominant neutrophilic infiltration (more than 10 cells/HPF). CONCLUSION: We have found that both urticaria and UV showed a predominantly lymphocytic infiltration along with RBC extravasation, endothelial cell swelling, and fibrin deposition in UV. Moreover, significant perineural, perivascular, and interstitial infiltration of eosinophil in UV lesions compared to urticaria was another point that indicates special contribution of these cells in UV pathogenesis.

Distinguishing immunohistochemical features of alopecia areata from androgenic alopecia.

BACKGROUND: Distinction between alopecia areata (AA) and androgenic alopecia (AGA) can be made according to clinical presentation and biopsy findings. However, it is sometimes difficult to differentiate them, especially when the diffuse pattern of both AA and AGA is in the differential diagnosis of hair loss in androgen-dependent areas. OBJECTIVES: To evaluate the characteristics of inflammatory cell infiltration using CD3, CD4, CD8, and CD20 antigens, in AA and AGA to find some consistent histological clues for distinguishing these two entities. METHODS: A retrospective analysis of patients with diagnosed AA (30 cases) and AGA (30 cases) was performed based on the clinical and histopathological criteria. We studied immunohistochemical findings for CD3, CD4, CD8, and CD20 in all selected cases. RESULTS: Immunohistochemical stains for CD4 and CD20 were not helpful in differentiating AA from AGA, but the inflammation density for AA was significantly (P-value = .025, .001) higher than AGA in CD3 (specificity= 86.7% and sensitivity= 96.7%) and CD8 (specificity= 50% and sensitivity=86.6%). Our findings revealed that intrafollicular CD3 (P-value = .017) and CD8 (P-value = Ë‚.001) infiltrations were significantly higher in AA samples in comparison with AGA. CONCLUSION: Characterization of CD3 and CD8 in IHC samples is helpful, especially when the density of CD3 and CD8 T cells are significant in more than 50% of the infiltrated cells and are located intrafolliculary. Moreover, the most specific and sensitive test for differentiating of AA from AGA is CD3.

Nail Changes in Early Mycosis Fungoides.

BACKGROUND: Mycosis fungoides (MF) has a wide range of clinical presentations and it has been reported rarely to involve the nail apparatus. OBJECTIVE: We intended to evaluate the frequency and characteristics of nail changes in patients with biopsy-proven MF. METHODS: A retrospective analysis of 60 patients with MF who were evaluated at our cancer center from 2013 to 2014 was performed to identify patients with nail changes. Histological examinations of the skin around the nail apparatus were obtained from 10 patients with periungual skin erythema and scaling. RESULTS: In 45 patients out of 60 cases, the skin around the nail apparatus was normal, and only in 5 patients of these 45 cases, nail changes were detected. These changes included leukonychia, longitudinal ridging, nail thickening, and opacity. In the remaining 15 patients, erythema and scaling was observed in periungual skin, and 13 of them demonstrated nail changes including longitudinal ridging, nail thickening, fragility of the nail plate, subungual hyperkeratosis, pigmented nail band, Beau's lines, onychomadesis, koilonychia, nail thinning, distal notching, subungual debris, leukonychia, and pitting. In biopsies of periungual skin, none of 10 cases revealed histological findings consistent with MF. CONCLUSIONS: Evidence of nail changes was observed in 18 cases (30%). The most common nail changes detected in MF patients included longitudinal ridging, nail thickening, nail fragility, and leukonychia.

Characteristic features of cutaneous melanoma in a dermatology referral centre in Tehran, Iran.

BACKGROUND/OBJECTIVES: The characteristics of cutaneous melanoma in the Middle-Eastern countries is poorly described. Therefore we conducted this study to determine the characteristics of melanoma in Iran. METHODS: A retrospective, cross sectional study of melanoma patients seen at a tertiary referral centre, Iran, from May 2004 to October 2014. Clinical data included age and gender of the patients at the time of diagnosis, tumour location and tumour size. Histological characteristics included Breslow thickness, Clark level and subtype of tumour. RESULTS: A total of 450 cases of melanoma with a male/female ratio of 1.1:1 were reviewed. The mean age of patients was 57.5 years. The most frequent histological subtypes were acral lentiginous melanoma (30%) and lentigo maligna melanoma (29%). In 215 cases (49%) the tumour was located on the extremities. The second most common site was the face. Tumour invasion was mainly at Clark level III and IV. The mean Breslow thickness was 2.8 mm; 143 (38%) melanomas had a Breslow thickness less than 1 mm (T1) and 86 (23%) were more than 4 mm (T4). CONCLUSION: This study indicates that clinical and histological features of melanoma in Iranians (who are mainly of skin phototypes 3-4) are different from those observed in Western countries. Further cohort studies are required to evaluate the role of ethnic and environmental risk factors for melanoma in different populations.

Longitudinal melanonychia in an Iranian population: a study of 96 patients.

BACKGROUND: Longitudinal melanonychia (LM) can be a challenging sign since it may be caused by a wide variety of benign and malignant conditions. Cutaneous melanoma is the most important cause of LM. Objective: We performed this study to examine different aspects of LM in Iran, where cutaneous melanoma is rare. METHODS: In this cross-sectional study, we reviewed medical records and pathology reports of a total of 96 patients presenting with LM. These patients had been visited and undergone nail biopsy in Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran. Demographic, clinical, and pathological data were recorded. RESULTS: The most common diagnosis was junctional nevi in 28 patients (29.2%) followed by melanoma in 19 patients (19.8%). Patients had a mean age of 42.4 years (± 19.4). The mean ages in the groups with junctional nevi and melanoma were 33.3 (± 19.5) and 51.9 (± 17.8), respectively; their difference was statistically significant (P value = 0.001). Hutchinson's sign was present in 10 patients, 9 of which had melanoma. Also, melanoma was only observed in patients presenting with a solitary nail lesion. Nails mostly affected by melanoma were middle fingers of the hands (7 patients) and thumbs (6 patients). Out of 18 patients with nail dystrophy, 13 (72.2%) were diagnosed with melanoma. LIMITATIONS: Only patients who have undergone biopsy were studied. CONCLUSION: Melanoma is an important cause of LM in Iranian patients and should especially be suspected in older patients who present with a solitary nail lesion on their middle finger or thumb. Other findings that direct us toward melanoma are presence of Hutchinson's sign and nail dystrophy.