Diagnostic usefulness of immunohistochemical evaluation of CD1a antigen and polyclonal anti-leishmania antibodies in cutaneous leishmaniasis.

BACKGROUND: Different immunohistochemical markers to detect amastigotes in cutaneous leishmaniasis have been proposed with variable diagnostic usefulness. OBJECTIVES: To evaluate the diagnostic usefulness of immunohistochemical amastigotes identification by specific polyclonal anti-Leishmania antibodies and CD1a expression (clone EP3622) in a series of PCR confirmed cutaneous leishmaniasis. MATERIALS AND METHODS: Thirty-three skin samples corresponding to PCR confirmed cutaneous leishmaniasis were included in the study. All samples were stained with Hematoxylin-eosin and Giemsa. Moreover, immunohistochemical studies with anti-CD1a and anti-Leishmania antibodies were performed. The patients clinical features and the observed histopathological features were also recorded. RESULTS: From the selected 33 biopsies, Leishmania spp. amastigotes were detected in 48.4% of cases with conventional Hematoxylin-eosin stain and in 57.5% of cases by Giemsa staining. In 31/33 cases, anti-CD1a allowed us to identify parasitic structures, and in 33/33 cases amastigotes were detected with anti-Leishmania antibodies. Concordance between both techniques, anti-CD1a and anti-Leishmania, was 94% [CI 95%: (79,8%-99,3%)] ; p value <0.05. The sensitivity of anti-CD1a in comparison with the PCR was 94%, with a positive predictive value of 100%. Two cases of low parasitic index were negative for CD1a immunostaining. In cases with high parasitic index, anti-CD1a stained amastigotes in superficial and deep dermis. Only a few cases were originally diagnosed with the available histological techniques, needing PCR for Leishmania spp. CONCLUSIONS: Anti-CD1a antibody seems to be a useful technique to identify amastigotes when PCR and anti-Leishmania antibodies are not available. The sensitivity to detect amastigotes is increased when the CD1a immunostaining is added to the classical Haematoxylin - eosin and Giemsa staining.

Persistent cutaneous ulcers after Yttrium-90 synovectomy, an unusual complication: two case reports and a review of the literature.

Development of persistent deep cutaneous ulceration is a rare and serious complication of radiosynovectomy, an extended procedure used in the treatment of chronic synovitis. Cutaneous radiation necrosis is a rare complication of synovectomy, probably as a result of radiocolloid para-articular injection. This rare phenomenon should be suspected when an ulcer adjacent to an articulation appears several days or even months after a radiation synovectomy. It can turn into a challenging diagnosis for rheumatologists, orthopaedists and dermatologists, especially in those cases with a late development of the skin lesions. Recognition of this potential side effect is important in order to establish a proper therapeutic strategy and avoid unnecessary treatments. Surgical excision appears to be the treatment of choice. We report two patients with knee osteoarthritis treated with intra-articular injection of Yttrium-90 who developed persistent cutaneous ulcers secondary to radiation necrosis.

Use of biological treatments in patients with hidradenitis suppurativa.

Pilosebaceous unit occlusion and secondary inflammatory perifollicular lympho-histiocytic infiltration seem to be the underlying etiopathogenic mechanisms giving rise to hidradenitis suppurativa (HS). Increased levels of tumor necrosis factor (TNF)-alpha and other cytokines such as interleukins 12 and 23 (IL12/23) and interleukins 10 and 17 have been observed in HS lesional skin. Biological drugs have been reported to be effective for HS, but the level and duration of the response are quite variable. Among anti-TNF drugs, adalimumab and infliximab seem to obtain better results in HS. Adalimumab is the only registered systemic agent for HS and results from multicenter clinical trials demonstrate that 58.9% of patients may achieve clinical response without significant adverse events. Continuous treatment seems to maintain the therapeutic response, but discontinuation of the treatment usually results in a rapid relapse of the disease. Infliximab may also obtain a good response profile with 50% improvement of HS lesions. Treatment with ustekinumab for HS resulted in variable results showing a moderate-to-marked improvement in 82% of patients. Anakinra, a recombinant IL-1 receptor antagonist, has been also been postulated as a potential systemic treatment for HS. A reduction in the disease activity in 67% of patients has been reported. Biological drugs seem to represent an effective therapeutic option for HS, but complete and persistent resolution of the disease is rarely achieved. Flares of the disease usually develop regardless the prescribed treatment. Combined treatments including antibiotics and retinoids seem to be a potential additional therapeutic approach. In chronic and severe cases, a surgical approach is mandatory in order to remove persistent scarring tissue. New drugs are currently being evaluated as new insights in the pathogenesis of the disease are elucidated. Several clinical trials with apremilast, anti-IL17 drugs and anti-interleukin-1 alpha are currently ongoing.

Persistent cutaneous abdominal ulcerations secondary to diffuse dermal angiomatosis: an underestimated sign for severe atherosclerosis: A case report.

BACKGROUND: Diffuse dermal angiomatosis (DDA) is a rare, acquired, reactive vascular proliferation, clinically characterized by livedoid erythematous-violaceous plaques, which frequently evolve to ulceration and necrosis. Histopathologically, it is manifested by a diffuse proliferation of endothelial cells within the full thickness of the dermis. DDA has been mainly associated with severe peripheral atherosclerosis. METHODS: We report a 63-year-old woman who presented with multiple erythematous-violaceous plaques with central deep skin ulcers on thighs, lower abdomen, and perianal area, associated with intermittent claudication, low-grade fever, and weight loss. Initially, the clinical picture along with positive cultures for Klebsiella pneumoniae suggested a multifocal ecthyma gangrenosum; nevertheless, a skin biopsy showed a diffuse dermal proliferation of endothelial cells interstitially arranged between collagen bundles. A computed tomography scan revealed severe aortic atheromatosis with complete luminal occlusion of the infrarenal aorta and common iliac arteries. RESULTS: The diagnosis of DDA secondary to severe atherosclerosis was established. The patient underwent a left axillofemoral bypass surgery with a rapidly healing of the ulcers in the next weeks. CONCLUSIONS: DDA should be considered in the differential diagnosis of livedoid ischemic lesions. Recognition of DDA as a cutaneous sign of severe peripheral vascular disease is important for both dermatologists and internists. Recognition of risk factors and their management with an early intervention to correct tissue ischemia can be curative.

Cutis laxa-like mycosis fungoides.

Mycosis fungoides is the most common form of primary cutaneous T-cell lymphoma. Several clinical and clinicopathological variants of mycosis fungoides have been reported. A 75-year-old woman presenting with multiple ill-defined areas of marked cutaneous wrinkling on the trunk and extremities is reported. Histopathological examination showed characteristic features of mycosis fungoides along with an interstitial dermal infiltrate composed predominantly of atypical lymphocytes with histiocytes intermingled within the collagen bundles. A focal reduction and fragmentation of elastic fibers was demonstrated. This observation illustrates a peculiar and previously unreported clinicopathological presentation of mycosis fungoides: cutis laxa-like mycosis fungoides, expanding the spectrum of mycosis fungoides variants associated with abnormalities of the dermal elastic fibers.

Incidence of human papillomavirus infection in male sexual partners of women diagnosed with CIN II-III.

INTRODUCTION: Human papillomavirus (HPV) infection is a very common sexually transmitted disease which has been strongly related to cervical cancer and cervical intraepithelial neoplasia (CIN), penile cancer and intraepithelial and infiltrating anal squamous cell carcinoma. OBJECTIVES: To describe the HPV status of male sexual partners of women diagnosed with CIN II/III and to evaluate the practical usefulness of the HPV detection in urine as a reliable marker of genital high-risk HPV infection in men. METHODS: Ninety-one heterosexual male partners (mean age 32.7) were included in the study. A panel of epidemiological data was recorded. Peniscopy was performed at the first visit and after 6 months. Urine samples and anal and penile scrapings were obtained and Hybrid Capture II test for high-risk HPV was performed. Physical examination disclosed clinically or peniscopic lesions in only 5.4% patients. HPV was isolated in 12.9% and 6.2% of penile and anal scrapings respectively whereas HPV detection was positive in 28% of urine samples. Overall, 41% of the evaluated patients presented at least one finding diagnostic of HPV infection. CONCLUSION: HPV detection in male partners of women with CIN is a frequent event, and urine HPV detection by Hybrid Capture test is a sensitive method for its detection. The determination of HPV in urine samples seems to be a simple method to investigate the subrogated genital HPV infection in men.

CDC28 protein kinase regulatory subunit 1B (CKS1B) expression and genetic status analysis in oral squamous cell carcinoma.

CKS1B is a member of the highly conserved cyclin kinase subunit 1 (CKS1) protein family which interacts with cyclin-dependent kinases and plays a critical role in cell cycle progression. In oral squamous cell carcinoma (OSCC), as in other malignancies, CKS1B overexpression has been correlated with reduced survival. To our knowledge, no studies evaluating the genetic status of CKS1B gene in OSCC have been reported. Herein, genetic and protein status of CKS1B were analyzed by immunohistochemical (IHC) and fluorescence in situ hybridization (FISH) techniques in a series of primary OSCC (n=51) and lymph node OSCC metastases samples (n=14). The observed results were compared with those obtained in either inflammatory (oral lichen planus [OLP]) (n=13) and premalignant oral mucosal lesions (oral leukoplakia) (n=16). A significant CKS1B overexpression was observed in OSCC and lymph node metastases samples than in OLP and oral leukoplakia (mean 70% vs 35%, p<0.001). CKS1B overexpression correlated with p27 loss of expression (p=0.0013) and SKP2 overexpression (p<0.00). FISH study disclosed statistical differences in both gene amplifications and gains between samples corresponding to OSCC and metastases from those of OLP and leukoplakia (p<0.001). Amplifications were present in 53% of OSCC samples and 33% of lymph node metastases vs 14% of oral leukoplakia and 0% of OLP biopsy specimens (p=0.002). Polysomies of chromosome 1 were seen in 46% of OSCC, 33% of ganglionar metastases, 14% of oral leukoplakia and 10% of OLP (p=0.036). Correlation of CKS1B over-expression and gains (both polysomies and amplifications) determined by FISH was statistically significant (p<0.001). Our results indicate that a high CKS1B expression is a common finding in primary OSCC which correlates with p27 low expression and SKP2 overexpression. This phenomenon may be due either to numerical (chromosome 1 polysomy) or structural (amplifications) CKS1B genetic abnormalities. This phenotypical and cytogenetic profile is not observed in premalignant or inflammatory oral mucosal lesions.

Identification of t(17;22)(q22;q13) (COL1A1/PDGFB) in dermatofibrosarcoma protuberans by fluorescence in situ hybridization in paraffin-embedded tissue microarrays.

Dermatofibrosarcoma protuberans is genetically characterized by the translocation t(17;22)(q22;q13) resulting in the PDGFB/COL1A1 fusion gene. Fluorescence in situ hybridization with specific probes enables a rapid detection of this gene. In this study, the presence of the translocation t(17;22)(q22;q13) by fluorescence in situ hybridization in paraffin-embedded tissue microarrays was analyzed. Two tissue microarrays including 40 cases of dermatofibrosarcoma protuberans and 20 dermatofibromas were evaluated. Fluorescence in situ hybridization analyses were performed using a dual-color dual-fusion noncommercial probe. Clinical and histopathologic features were examined, and the association with fluorescence in situ hybridization results was assessed. A total of 29 samples of dermatofibrosarcoma protuberans and 16 of dermatofibromas were successfully evaluated. Twenty-five (86%) dermatofibrosarcoma protuberans samples were positive for the translocation, which was absent in all samples of dermatofibromas. Two of the negative dermatofibrosarcoma protuberans showed unusual, hypercellular areas with marked cytologic atypia, whereas 1 case exhibited overlap features with dermatofibroma. Tumors with fibrosarcomatous areas seemed to have a higher percentage of positive cells and the number of copies of the COL1A1/PDFGB gene. In conclusion, the COL1A1/PDGFB fusion gene was present in most of the dermatofibrosarcoma protuberans tissue samples. The detection of the translocation may be an additional diagnostic tool in cases of dermatofibrosarcoma protuberans showing nonconclusive histologic features.

CKS1B amplification is a frequent event in cutaneous squamous cell carcinoma with aggressive clinical behaviour.

Genetic mechanisms giving rise to the development of cutaneous squamous cell carcinoma (cSCC) are poorly understood and development of genomic high resolution techniques has led to a better knowledge of the genetic basis of several human cancers. In this study, 16 cSCC were analyzed using array comparative genomic hybridization (arrayCGH). The most common aberrations found were gains of 3q11q13, 1q21.3q25, 13q34, and 19p13, and losses of 1p36p31, 3p24p21, 10p15q22, and 13q11q21. We detected gains (3/16) and amplification (1/16) of the 1q21.1q21.3 region. A potential candidate gene in this region, CKS1B (1q21.2), was selected for validation in an independent cohort and correlations with clinicopathological features were carried out. CKS1B gene and protein status were analyzed using fluorescence in situ hybridization (FISH) and immunohistochemistry (IHC) in a series of 53 cSCC, 22 actinic keratoses (AK), and 10 normal skin samples. cSCC presented a higher frequency of chromosome 1 polysomy than AK (70% vs. 46%, P = 0.047). Association between CKS1B protein overexpression and both polysomy and amplification was demonstrated in cSCC (P < 0.001). Regarding amplifications, 11 cSCC patients (21%) presented CKS1B gene amplification. Interestingly, 8/11 (73%) patients who showed a CKS1B amplification had presented metastatic spread (mcSCC). Differences between the presence of CKS1B amplification and the presence or absence of mcSCC were observed (mcSCC [8/14] vs. cSCC [3/39]) (P < 0.001). Several drugs targeting CKS1B have been reported and may be useful for treating patients with cSCC and CKS1B amplifications.

Epidermal growth factor receptor gene numerical aberrations are frequent events in actinic keratoses and invasive cutaneous squamous cell carcinomas.

Epidermal growth factor receptor (EGFR) gene amplification and protein overexpression are common in several cancers. EGFR status has seldom been studied in cutaneous squamous carcinomas (SCCs), or their precursors, actinic keratoses (AKs). We evaluated the presence of EGFR genomic aberrations and EGFR protein overexpression in 25 AKs and 35 invasive SCCs by means of fluorescence in situ hybridization (FISH) and immunohistochemistry. EGFR numerical aberrations were detected in 52% of AKs and 77.1% of SCCs (P = 0.042). EGFR amplification was identified in 12% of AKs and 20% of SCCs. No differences regarding EGFR numerical aberrations were observed when AKs with high-grade dysplasia were compared with SCCs. A good correlation was observed between EGFR numerical aberrations and EGFR overexpression. Our results suggest that EGFR numerical aberrations occur in the early stages of epithelial carcinogenesis in skin, not playing a role in the progression from low-grade SCCs into more aggressive phenotypes.

Treponema pallidum distribution patterns in mucocutaneous lesions of primary and secondary syphilis: an immunohistochemical and ultrastructural study.

To study the different patterns of Treponema pallidum distribution in primary and secondary syphilis, 34 biopsy specimens of 8 patients with primary and 26 with secondary syphilis were assessed. Histopathological features, silver stain, and immunohistochemical T pallidum polyclonal antibody expression were investigated. The number and distribution of spirochetes were evaluated, and ultrastructural studies were performed. Spirochetes were identified with Warthin-Starry stain in 17 specimens (4/8 primary and 13/26 secondary syphilis), whereas immunohistochemical analysis disclosed spirochetes in 29 (8/8 primary and 21/26 secondary syphilis). In secondary syphilis, an epitheliotropic pattern characterized by abundant spirochetes in the lower mucosa/epidermis in an intercellular distribution was observed. In contrast, primary syphilis exhibited a mixed epitheliotropic and vasculotropic pattern further manifested by treponemes surrounding the vascular walls. These differences were statistically significant. Ultrastructural examination confirmed these results. Immunohistochemistry shows greater sensitivity when compared with Warthin-Starry staining. The immunohistochemical pattern of T pallidum distribution may permit the diagnostic differentiation of primary from secondary syphilis.

[Acneiform eruption secondary to cetuximab]. / Erupción acneiforme secundaria a cetuximab.

C225 (cetuximab) is a monoclonal antibody that targets the epidermal growth factor receptor (EGF-R). It is used for the treatment of solid malignant tumors in advanced stages. It works against tumors by inhibiting cell proliferation, angiogenesis and the formation of metastases, as well as by promoting cell apoptosis. We present the case of a 64-year-old male patient affected with a colon neoplasm with hepatic metastases, for which treatment with cetuximab was indicated. He came to our department because of a skin eruption with papules and pustules located on the face, neck, presternal area and upper back, but with no cysts or comedones. The biopsy was compatible with an acneiform eruption. The patient was treated with minocycline, 100 mg/day for 2 weeks, with the clinical symptoms responding favorably. When he was given further doses of cetuximab, he once again presented with new eruptions, but of lesser intensity. Because of the high frequency with which this adverse effect appears, it is recommended that cetuximab be included on the list of drugs causing acneiform eruptions.