Incarcerated Ink: A Case of Mycobacterium chelonae.

A 30-year-old African American male presented with pain and swelling of the right foot one month after receiving a tattoo on this foot in prison. During his admission for presumed cellulitis, he developed a rash on his contralateral (left) leg, which had been tattooed 10 months prior. A biopsy of the contralateral (left) leg showed acute, chronic, and granulomatous inflammation with a differential diagnosis including infection. His overall condition and both legs worsened, prompting biopsy and tissue culture of the right ankle and foot. Pathology of the right foot showed a granulomatous reaction. Culture grew Mycobacterium chelonae. This case highlights the importance of considering infectious etiologies for rashes appearing within tattoos and represents the importance of a full investigation to obtain the correct diagnosis.

Cholestatic Pruritus Mimicking a Cutaneous Drug Eruption.

Pruritus, colloquially known as itch, is a common clinical symptom seen in a variety of dermatological conditions and systemic disorders. Pruritus can broadly be classified into four categories: neuropathic, neurogenic/systemic, psychogenic, and pruritoceptive. Initial categorization depends on anatomical and pathophysiological aspects of presentation and is reflective of underlying etiology. We report a case of an 83-year-old man presenting with generalized pruritus secondary to cholestasis from bile duct malignancy. This case is notable for atypical presenting features, including a trunk eruption comprised of excoriated papules with onset following meloxicam initiation, mimicking a cutaneous adverse drug reaction. Providers should consider systemic etiologies of pruritus in patients presenting with cutaneous eruptions with atypical features. Accurate categorization of pruritus can facilitate treatment and/or additional investigation of systemic disease.

Sclerodermatous Graft-Versus-Host Disease: A Rare Sequela of Hematopoietic Stem Cell Transplantation.

Although graft-versus-host disease (GVHD) is a common immunologic reaction after an allogeneic hematopoietic stem cell transplant (HSCT), progression into sclerodermatous GVHD is a rare sequela. It can present locally or generalized with various cutaneous and mucocutaneous manifestations, resulting in loss of skin elasticity and reduced functional capabilities. One of the most debilitating consequences of sclerodermatous GVHD is its effect on a range of motion due to fibrosis of the skin and subcutaneous fat. We present the case of a 54-year-old male with a medical history of acute myeloid leukemia and an allogeneic stem cell transplant who was diagnosed with sclerodermatous GVHD. We review the characteristic clinical and histopathological findings of sclerodermatous GVHD, as well as its treatment. Early recognition and intervention are crucial to prevent complications, such as joint contractures.

Extranodal Natural Killer/T-cell Lymphoma Isolated to the Leg: A Case Report.

Extranodal natural killer/T-cell lymphoma (ENKTL) is a subtype of non-Hodgkin's lymphoma, and it is exceedingly rare in North America. The "extranasal" subtype of ENKTL frequently involves the skin and typically has an aggressive course with no current standard of treatment available. In this report, we present a case of cutaneous ENKTL in an otherwise healthy middle-aged male.

Nontuberculous mycobacterial infection following cat scratch in the setting of topical steroid use.

Infections due to nontuberculous mycobacteria (NTM) are caused by mycobacterial species other than Mycobacterium tuberculosis, M. leprae, and M. bovis. Patients who are immunocompromised have increased susceptibility to pulmonary, lymphatic, and skin infections by these pathogens. We present a case of a 78-year-old male who presented to dermatology with a left dorsolateral hand infection after sustaining cat scratches in the setting of topical steroid therapy for suspected pyoderma gangrenosum. A shave biopsy of the lesion showed granulomatous dermatitis and associated acid-fast bacilli, while tissue culture grew Mycobacterium chelonae. This case demonstrates cat scratches as an uncommon risk factor for cutaneous NTM disease. Although an association between cat scratches and human NTM infections has only been reported in two previous cases, it must be considered in cases of unusual and persistent cutaneous lesions, especially in immunocompromised patients, even those with only local immunosuppression from topical agents.

Predictive biomarkers for response to trametinib in non-small cell lung cancer.

BACKGROUND: Non-small cell lung cancer (NSCLC) is a leading cause of cancer deaths. Current companion diagnostics use driver mutation sequencing to select patients for molecularly targeted agents (MTA), even though most patients lack actionable mutations. These diagnostics utilize static biomarkers, ignoring real-time tumor cell biology. OBJECTIVE: Trametinib is FDA-approved in combination with dabrafenib for BRAF V600E-positive NSCLC, however, it has plausible utility beyond these patients. We sought to identify novel biomarkers for maximizing trametinib application. METHODS: Trametinib responses were evaluated in 12 EGFR/BRAF wild-type (WT) NSCLC cell lines with diverse RAS mutational status. We identified three response categories by colony assay. Trametinib-induced molecular dynamics were studied using immunoassays and apoptosis/necrosis assays, to identify predictive response biomarkers. RESULTS: p27 accumulation and cyclin D1 downregulation suggested universal cell cycle arrest with trametinib. However, 4 cell lines showed PARP cleavage and 8 showed increased phospho-4E-BP1, suggesting varied cellular outcomes from apoptosis, necrosis, senescence to autophagy. Cleaved PARP, phospho-4E-BP1 and phospho-AKT expression can predict these outcomes. CONCLUSIONS: Trametinib monotherapy outcome may depend upon cellular context more than oncogenic mutation status. In BRAF WT NSCLC, trametinib may be best suited for combination therapy and dynamic biomarkers could select combinations and predict responses.

DUOX2, a New Biomarker for Disseminated Gastric Cancer's Response to Low Dose Radiation in Mice.

Treatment options are rather limited for gastrointestinal cancer patients whose disease has disseminated into the intra-abdominal cavity. Here, we designed pre-clinical studies to evaluate the potential application of chemopotentiation by Low Dose Fractionated Radiation Therapy (LDFRT) for disseminated gastric cancer and evaluate the role of a likely biomarker, Dual Oxidase 2 (DUOX2). Nude mice were injected orthotopically with human gastric cancer cells expressing endogenous or reduced levels of DUOX2 and randomly assigned to four treatment groups: 1; vehicle alone, 2; modified regimen of docetaxel, cisplatin and 5'-fluorouracil (mDCF) for three consecutive days, 3; Low Dose- Whole Abdomen Radiation Therapy (LD-WART) (5 fractions of 0.15 Gy in three days), 4; mDCF and LD-WART. The combined regimen increased the odds of preventing cancer dissemination (mDCF + LD-WART OR = 4.16; 80% CI = 1.0, 17.29) in the DUOX2 positive tumors, while tumors expressing lower DUOX2 levels were more responsive to mDCF alone with no added benefit from LD-WART. The molecular mechanisms underlying DUOX2 effects in response to the combined regimen include NF-κB upregulation. These data are particularly important since our study indicates that about 33% of human stomach adenocarcinoma do not express DUOX2. DUOX2 thus seems a likely biomarker for potential clinical application of chemopotentiation by LD-WART.

Blastic Plasmacytoid Dendritic Cell Neoplasm: A Case Series and Review.

ABSTRACT: Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare and aggressive hematologic malignancy that frequently has cutaneous manifestations. The diagnosis can be a challenge because of its heterogenous clinical presentation, ranging from a brown or violaceous solitary nodule or patch to mixed, disseminated lesions. Furthermore, BPDCN tumor cells express immunohistochemical markers in common with acute myeloid leukemia, which can lead to misdiagnosis. Timely diagnosis requires awareness of its cutaneous manifestations and unique histopathology and immunophenotype. We present a case series of patients diagnosed with BPDCN and review the cutaneous and histopathologic characteristics of this uncommon entity.

What lies beneath: Cutaneous involvement of mantle cell lymphoma underlying an insect-bite-like reaction.

Mantle cell lymphoma (MCL) is an uncommon subtype of mature B-cell non-Hodgkin lymphoma characterized by specific morphologic, immunophenotypic, and genetic characteristics, namely the t(11;14)(q13;q32) chromosomal translocation with resultant cyclin D1 overexpression. MCL has a generally aggressive course and is often widely disseminated at the time of diagnosis. Skin involvement is exceedingly rare and is seldom the first manifestation of MCL. We present a case of MCL in an 84-year-old man with cutaneous involvement as the first manifestation, discovered incidentally after biopsy of a persistent nodule believed to be an insect bite. This case not only serves to raise awareness of the possibility of MCL presenting in the skin but also to point out that MCL can have lesions with both an insect-bite-like reaction and a deeper dermal MCL infiltrate.

Diffuse dermal angiomatosis localized to abdominal striae.

Diffuse dermal angiomatosis is a rare, benign, reactive cutaneous vascular disorder considered to be a distinct variant of reactive angioendotheliomatosis. The disease typically presents in obese patients who smoke and have atherosclerotic risk factors, vasculopathies, or other comorbidities associated with hypoxemia. We present a case of a 40-year-old woman with ulcerated plaques on her abdomen consistent with diffuse dermal angiomatosis on histopathological evaluation. Unique to our patient was localization of the lesions to the abdominal striae.

An unusual case of cutaneous Waldenström macroglobulinemia with the MYD88 L265P mutation.

Waldenström macroglobulinemia is a lymphoplasmacytic lymphoma with bone marrow involvement and a monoclonal IgM gammopathy. Infiltration of the skin by neoplastic cells is very rare, and it can be difficult to distinguish from marginal zone lymphoma. The MYD88 L265P mutation is strongly associated with Waldenström macroglobulinemia, and it may be helpful in differentiating the two disorders, although the presence of this mutation is not specific, and other factors must be considered when making the final diagnosis. We present a diagnostically challenging case of cutaneous Waldenström macroglobulinemia in which the MYD88 L265P mutation was identified in the skin but not in the bone marrow, due to a low tumor burden.

A case of S-100-negative CD1a-positive indeterminate cell histiocytosis.

Histiocytoses are a group of rare disorders characterized by a proliferation of monocytes/macrophages and dendritic cells. We present a case of a 3-year-old girl with a diffuse papular eruption without systemic symptoms demonstrating a proliferation of strongly CD1a+ histiocytes, but negative for S-100 and langerin on histopathology. Systemic work-up including bone marrow biopsy was unremarkable, and the patient received a diagnosis of CD1a+ S- 100-indeterminate cell histiocytosis.

Melanoma patient notification and treatment timelines.

Melanoma is an extremely aggressive cancer for which the American Academy of Dermatology currently does not have formal recommendations outlining a timeline from biopsy to definitive treatment. Our dermatology department investigated our treatment timeline for melanoma. Using the database from our electronic medical record, Epic, we evaluated patients over a one-year period; in total we identified 109 melanomas. We evaluated patient demographics, tumor characteristics, and timelines regarding diagnosis and treatments. There was a statistically significant difference in patient notification of diagnosis and treatment times between stage 1 and stages 2-4 combined (based on the American Joint Committee on Cancer staging system). We found that 84% of melanomas were treated within 4 weeks of diagnosis and 96% within 6 weeks. The lower the stage, the earlier the melanoma was definitively treated; higher stage melanomas had a longer delay to definitive treatment. Herein, we have presented our single institutional experience of the melanoma timeline from diagnosis to definitive treatment and have identified factors that impact timely definitive treatment.

Multiple flat-topped scaly violaceous papules.

Epidermodysplasia verruciformis (EV) is an autosomal recessive genodermatosis characterized by susceptibility to beta-genus human papillomavirus (HPV) infection. Owing to TMC6/EVER1 and TMC8/EVER2 mutations that lead to abnormal transmembrane channels in the endoplasmic reticulum involved in immunological pathways, keratinocytes cannot combat infection from non-pathogenic HPV strains. Mutations involving RHOH, MST-1, CORO1A, and IL-7 have also been associated with EV in patients without TMC6 or TMC8 mutations. We highlight a 27-year-old man with multiple violaceous flat-topped papules with scale and irregular borders distributed on his chest, extremities, abdomen, and back. The striking physical examination and the subsequent biopsy findings of enlarged nests of cells in the granular and spinous layers with blue-gray cytoplasm and keratohyaline granules confirmed the diagnosis. We conclude with a brief discussion on the differential diagnosis, which includes confluent and reticulated papillomatosis, Darier disease, and disseminated superficial actinic porokeratosis.

Endoscopic Three-surgeon Six-handed Transorbital Transnasal Technique for Excision of Juvenile Nasopharygeal Angiofibroma: New Frontier Explored.

Endoscopic endonasal transorbital approach has been described for the removal of orbital lesions located anteromedially in temporal fossa. The same has been observed to be a versatile approach to the anterior and middle cranial fossa only in laboratory studies. This is the first clinical report of combined transorbital transnasal endoscopic approach to the cavernous sinus, superior orbital fissure, and middle cranial fossa in a case of recurrent nasopharyngeal angiofibroma using the three-surgeon six-handed technique.

Infantile epidermolytic ichthyosis with prominent maternal palmoplantar keratoderma.

Epidermolytic Ichthyosis (EI) is a rare autosomal dominant genodermatosis. Although an inherited disorder, 50% of cases represent novel mutations. This disorder presents as a bullous disease in newborns progressing to a lifelong ichthyotic skin disorder.  Other manifestations include palmoplantar keratoderma (PPK).  EI results from mutations in the keratin 1 and keratin 10 genes. Phenotypic variability is seen in affected individuals based on the genotypic mutation.  We present a mother and her newborn son with EI and prominent PPK in the mother, which also developed in the child at a few months of age.  Genotype analysis was performed on the newborn child who was found to harbor a mutation in the keratin 1 gene. This family demonstrates the phenotypic expression of PPK associated with keratin 1 gene mutations and illustrates the importance of genotype-phenotypecorrelation in this disorder.