Gadolinium contrast agent-induced CD163+ ferroportin+ osteogenic cells in nephrogenic systemic fibrosis.

Gadolinium-based contrast agents are linked to nephrogenic systemic fibrosis in patients with renal insufficiency. The pathology of nephrogenic systemic fibrosis is characterized by abnormal tissue repair: fibrosis and ectopic ossification. The mechanisms by which gadolinium could induce fibrosis and ossification are not known. We examined in vitro the effect of a gadolinium-based contrast agent on human peripheral blood mononuclear cells for phenotype and function relevant to the pathology of nephrogenic systemic fibrosis using immunofluorescence, flow cytometry, real-time PCR, and osteogenic assays. We also examined tissues from patients with nephrogenic systemic fibrosis, using IHC to identify the presence of cells with phenotype induced by gadolinium. Gadolinium contrast induced differentiation of human peripheral blood mononuclear cells into a unique cellular phenotype--CD163(+) cells expressing proteins involved in fibrosis and bone formation. These cells express fibroblast growth factor (FGF)23, osteoblast transcription factors Runt-related transcription factor 2, and osterix, and show an osteogenic phenotype in in vitro assays. We show in vivo the presence of CD163(+)/procollagen-1(+)/osteocalcin(+) cells in the fibrotic and calcified tissues of nephrogenic systemic fibrosis patients. Gadolinium contrast-induced CD163(+)/ferroportin(+)/FGF23(+) cells with osteogenic potential may play a role in systemic fibrosis and ectopic ossification in nephrogenic systemic fibrosis.

Cutaneous ciliated cyst of the scalp: a case report of a cutaneous ciliated eccrine cyst and a brief review of the literature.

Cutaneous ciliated cysts (CCC) are rare benign cysts known to occur in the lower extremities of females of reproductive age. Currently, there are 2 theories that attempt to explain the histogenesis of this rare entity. The theory of Mullerian heterotopia provides a plausible histogenetic explanation for the vast majority of CCC. A proposed alternative theory is the ciliated metaplasia of eccrine glands. We believe that previously reported cases of CCC include 2 distinct entities. We report, herein, the first case reported in the literature of a cutaneous ciliated eccrine cyst occurring on the scalp.

The spectrum of histopathologic findings in cutaneous eruptions associated with influenza A (H1N1) infection.

Influenza A (H1N1), like many other viral infections, has been associated with cutaneous eruptions. Differential diagnoses in a viral exanthem generally include spongiotic dermatitis, urticaria and drug reaction. The aim of this series was to retrospectively review three cases (five biopsies) involving patients with a clinical history of H1N1 and an accompanying rash, and to evaluate whether unique histopathologic and immunohistochemical features exist among these patients' cutaneous eruptions. Findings among all cases included a sparse superficial perivascular infiltrate, and interestingly, scattered interstitial and prominent intravascular neutrophils. Two cases demonstrated mild spongiosis and mild interface change. Immunohistochemistry in all cases revealed a CD4-predominant lymphocytic infiltrate of the dermis with a sparse intraepidermal population of admixed CD4 and CD8 positive lymphocytes. Many changes found in the cutaneous eruption associated with H1N1 are similar to those of other viral eruptions, including a mild perivascular lymphocytic infiltrate, mild spongiosis and mild interface change; however, sparse dermal and intravascular neutrophils and intraepidermal lymphocytes appear to be the features unique to these cases of H1N1-associated cutaneous eruptions. Such a distinction may prove diagnostically important in the clinical setting and useful in the surveillance of this historically pandemic virus.

Expression of PTEN in mycosis fungoides and correlation with loss of heterozygosity.

BACKGROUND: Mycosis fungoides (MF) exhibits a variety of underlying molecular defects including aberrations involving the PTEN tumor suppressor gene. Specifically, loss of heterozygosity of PTEN has been previously demonstrated. We hypothesize that abnormalities of PTEN may result in altered immunohistochemical expression of its protein product. METHODS: Thirty-six MF specimens were stained with monoclonal antibody against PTEN protein. The percentage of nuclei retaining PTEN expression and the staining intensity was recorded. RESULTS: Average percentage of lymphoma cells retaining expression of the PTEN protein was 92% within patch-stage lesions, 81.4% in plaque-stage lesions, and 81.1% in tumor-stage lesions. Average intensity of staining for patch-stage lesions was 2.90, 2.50 for plaque lesions and 2.44 for tumor lesions. Cases lacking loss of heterozygozity at PTEN (n = 6) had an average expression of 81% and an average intensity of staining of 2.42. Whereas, cases with loss of heterozygozity at PTEN (n = 6) had an average expression of 75% of cells with an average staining intensity of 2.33. CONCLUSIONS: The percentage of cells retaining PTEN and staining intensity decrease from patch- to plaque-stage lesions, whereas both parameters show mild diminution in tumor lesions compared with plaque lesions. PTEN expression in a small sample seems to correlate with previous demonstration of loss of heterozygosity at the molecular level. Although a trend for loss of PTEN expression exists with histologic progression of MF, the effect is modest and may not represent the pivotal defect in MF pathogenesis.

A case of cutaneous Scedosporium infection in an immunocompromised patient.

Scedosporium apiospermum, the asexual stage of Pseudoallescheria boydii, is a fungus ubiquitous in soil as well as organically polluted areas, where nitrogen-containing compounds are abundant. It is an emerging opportunistic pathogen that can range from cutaneous to disseminated infection and can be fatal within months of diagnosis. Here we present a case of disseminated S. apiospermum infection with cutaneous manifestations in a 59-year-old woman with myelodysplastic syndrome, in remission from chronic lymphocytic leukemia, presented with pneumonia and deteriorating mental status. An X-ray computed tomography scan showed three non-contrast-enhancing hypodensities affecting the brain. Many erythematous, indurated skin lesions, measuring 3-5 mm in diameter, were noted on her chest, shoulders and arms. Biopsies were submitted for culture and histology. Histopathologic examination revealed superficial and deep perivascular and periadnexal inflammatory infiltrates of lymphocytes and neutrophils. Scattered collections of fungal organisms were noted near the eccrine glands. The periodic acid Schiff with diastase stain showed the presence of variable sized spores and hyphae with some acute angle branching. Both tissue and blood cultures were positive for a single Scedosporium species. Histologically, eccrine or peri-eccrine involvement by fungi may be an important finding for Scedosporium infection of the skin.

Misregulation of Rad50 expression in melanoma cells.

DNA double-strand breaks are increased in human melanoma tissue as detected by histone H2AX phosphorylation.(1-3) We investigated two of the downstream effectors of DNA double-strand breaks, Rad50 and 53BP1 (tumor suppressor p53 binding protein 1), to determine if they are altered in human primary melanoma cells. Melanoma cases showed high Rad50 staining (81.8%; 9/11) significantly more frequently than conventional or atypical melanocytic nevi (0%; 0/18). In contrast, the staining pattern for 53BP1 appears similar between melanoma and nevi. This is the first study that shows activation and misregulation of the DNA repair pathway in human melanoma cells. The staining features of Rad50, a component of an essential DNA double-strand break repair complex, are clearly increased in melanoma cells with regards to both staining intensity and the number of positive melanoma cells. Interestingly, among the melanoma cases with increased Rad50 staining, most demonstrated cytoplasmic rather than nuclear staining (88.9%, 8/9). Further studies are needed to determine the cause of this mislocalization and its affects, if any, on DNA double-strand break repair in melanoma.

Collapsing angiokeloidal dermatofibroma.

A heterogeneous group of benign fibrohistiocytic lesions has been assembled under the umbrella term, dermatofibroma. These lesions share a morphology of bland spindled cells encompassed by and intercalating through thick dermal collagen; unique variants have been described based on secondary histologic features, some of which include aneurysmal, myxoid, lipidized, signet ring, angiomatous, and keloidal. Here, we present a distinct dermatofibroma variant henceforth known as collapsing angiokeloidal dermatofibroma identified in 2 patients with slowly growing nodules of the buttock and the arm. Microscopically, the lesions have a characteristic dermatofibroma appearance but are accompanied by unusual diffuse small caliber vessels whose walls are collapsed by a thick, eosinophilic, keloid-like substance. The eosinophilic material resembles the adjacent dermal collagen; however, it does not stain for type-4 collagen or type-1 procollagen, amyloid, or glycogen. Although the exact composition of the keloidal material remains ambiguous, the architectural novelty of collapsing angiokeloidal dermatofibroma serves to further expand the morphologic spectrum of benign fibrous histiocytomas, although highlighting the difficulty in distinguishing between it and similar lesions.

Intraoperative sentinel lymph node analysis in melanoma.

BACKGROUND: The objective of this retrospective cohort study was to evaluate the sensitivity and specificity of touch preparation cytology (TPC) and frozen section (FS) histology in the intraoperative staging of melanoma. METHODS: The cohort was identified from all patients with clinically node negative melanoma undergoing a SLN biopsy using Technetium and/or blue dye mapping from 1/1998 to 10/2008. TPC and FS analysis was performed utilizing Diff-quick and compared to permanent section interpretation with H&E. RESULTS: Of 271 patients undergoing SLN biopsy, 163 underwent intraoperative analysis of the sentinel node (125 underwent TPC alone, 15 underwent FS alone, 23 underwent both TPC and FS), and 108 underwent no intraoperative analysis. Thirty-three patients undergoing intraoperative analysis of the SLN were found to have positive nodes (20%) on permanent histology. There were no false positives identified (specificity = 100%). The overall sensitivity for all methods of intraoperative analysis was 61% (20/33). On a per patient basis, the sensitivity was 47% (9/19) for TPC alone, 75% (3/4) for FS alone, and 80% (8/10) for both TPC and FS. CONCLUSIONS: There were no false positives identified suggesting TPC and FS can be used safely to identify the majority of SLN that harbor metastases from melanoma.

Rapid improvement of nephrogenic systemic fibrosis with rapamycin therapy: possible role of phospho-70-ribosomal-S6 kinase.

Nephrogenic systemic fibrosis (NSF) is a fibrosing disorder that occurs in some patients with renal insufficiency. Exposure to gadolinium-based contrast agents (GdCA) has been associated with the development of NSF. No uniformly effective treatment options exist. We present immunohistochemical evidence to show that the proliferating fibrocytes of NSF express phospho-70-s6 kinase (PI-3-K), a protein downstream of PI-3-K, and the target of the drug rapamycin. In our patient, use of rapamycin resulted in rapid clinical improvement marked by reduced edema, reduced skin induration, and decreased pain. This suggests a possible role for PI-3-K and rapamycin (mTOR) pathways in the pathogenesis of NSF. Drugs that inhibit these pathways may be a target for future therapy. While our patient did attribute disease onset to GdCA exposure, used on a single occasion for abdominal imaging, he was also exposed to iron, calcium, and darbepoetin alpha at the time of imaging.

Concordance of frozen and permanent sections for the diagnosis of skin lesions.

BACKGROUND: There has been little written concerning the use of frozen sections to diagnose skin lesions. OBJECTIVE: To compare the concordance between frozen and permanent sections of the same diagnostic skin biopsy specimen. METHODS AND MATERIALS: Over 3 months, all non-melanocytic skin lesions that were biopsied in a skin cancer clinic were examined using frozen and permanent sections. Diagnoses from a dermatologist and dermatopathologist were recorded for each specimen and later examined for concordance. RESULTS: There was rare (0.5% of specimens) disagreement recorded between interpretations of the dermatologist and dermatopathologist. Permanent and frozen section pathology agreed with one another 90.4% of the time. Specimen processing was the most probable cause of discordance. Most discordance was not clinically relevant, although the patient was clinically affected in 35 of 2009 specimens (1.7%). CONCLUSION: Although there is a high concordance rate between diagnostic frozen and permanent sections, there are significant quality assurance and patient care advantages to following up initial diagnostic frozen sections with permanent sections of the same specimen.

Metal deposition in calcific uremic arteriolopathy.

BACKGROUND: Calcific uremic arteriolopathy (CUA) is an often fatal disease that affects patients with end-stage renal disease. Although animal studies support a role for metals in the pathogenesis of CUA, metal accumulation in human tissue has not been previously evaluated. OBJECTIVE: We sought to evaluate metal deposition in CUA. METHODS: Twelve histologically proven cases of CUA were identified from our dermatopathology database. Five skin biopsy specimens from patients with chronic kidney disease exposed to gadolinium contrast but without CUA were used as controls. Quantification of metals including iron, aluminum, and gadolinium in the lesional skin was performed using inductively coupled mass spectrometry. RESULTS: Seven patients had documented exposure to gadolinium-based contrast in the 2 years before CUA. Three of them had concurrent nephrogenic systemic fibrosis. Highly significant quantities of iron (P = .03) and aluminum (P = .0002) were detected in CUA specimens compared with controls. Significant amounts of gadolinium were present in several CUA biopsy specimens. LIMITATIONS: Observational, retrospective study design and small sample size are limitations. CONCLUSION: Tissue iron and aluminum content is increased in CUA. A significant amount of gadolinium is also present in some CUA specimens. Based on animal studies that strongly implicate metals in the pathogenesis of CUA, our data suggest that metal deposition should be considered in the pathogenesis of human CUA.

Utility of p63 in the differential diagnosis of atypical fibroxanthoma and spindle cell squamous cell carcinoma.

Atypical fibroxanthoma (AFX), spindle cell squamous cell carcinoma (SCSCC) and spindle cell melanoma are the primary entities in the differential diagnosis of a cytologically atypical spindle cell tumor arising on sun-damaged skin. AFX is generally regarded as a diagnosis of exclusion in this context: in the absence of S100 or keratin reactivity, a diagnosis of AFX is favored. However, keratin reactivity may be focal or even absent in SCSCC, and although numerous positive markers of AFX have been proposed, none has shown sufficient sensitivity and specificity for routine diagnostic use. We evaluated 20 AFX and 10 SCSCC with a panel of cytokeratins and p63 to assess the utility of the latter antibody in this differential diagnosis. All 10 SCSCC showed strong expression of p63, whereas all 20 AFX were p63 negative. Two additional cases (excluded from the study) were negative for keratins and S100 on initial shave biopsies, resulting in a favored diagnosis of AFX, but p63 stains performed retrospectively were positive. However, review of the excision specimens in both cases revealed deep subcutaneous extension, excluding AFX. p63 reactivity argues against the diagnosis of AFX and is therefore a useful addition to the standard immunohistochemical panel for cutaneous spindle cell neoplasms.

Malignant cutaneous glomus tumor presenting as a rapidly growing leg mass in a pregnant woman.

A 21-year-old pregnant woman presented with a rapidly growing >2 cm nodule on her right leg, involving dermis and subcutaneous tissue. Histologically, the tumor was composed of sheets and nests of neoplastic cells with variable cytomorphology, including typical round to ovoid glomus cells with clear cytoplasm and well-defined cell borders, small cells and spindle cells. Numerous medium to large vessels were present throughout the tumor. Moderate- to high cellularity, nuclear atypia and frequent mitotic figures (42 MF/50 High power field (HPF)) were noted. Immunohistochemistry showed cytoplasmic and membranous expression of actin (HHF-35) and membranous expression of type IV collagen. The histologic features and immunoprofile were consistent with the diagnosis of malignant glomus tumor, a rare soft tissue neoplasm that typically arises on the extremities. Histologic features that infer malignancy in glomus tumors include the combination of large size (>2 cm) and deep location, or atypical mitotic figures, or moderate to severe cytologic atypia with high mitotic activity (>5 mitoses /50 HPF). Although our case was superficially located, the nuclear atypia and mitotic rate, as well as the large size, fulfilled the criteria for a malignant glomus tumor.

Loss of heterozygosity analysis identifies genetic abnormalities in mycosis fungoides and specific loci associated with disease progression.

Mycosis fungoides (MF) exhibits a variety of underlying molecular defects. Loss of heterozygosity (LOH) is a technique used to detect chromosomal imbalances in neoplastic disorders using archival tissue. We analyzed skin biopsies of MF in different stages for the presence of LOH at specific loci to evaluate underlying genetic aberrations involved in MF and its progression. Twenty-five skin biopsies (15 plaque stage and 10 tumor stage) from 19 patients were evaluated. LOH was examined at 1p22 (D1S2766), 9p21 [IFNA, p15 (D9S1748), p16 (D9S171)], 10q23 [PTEN (D10S185, D10S541, D10S2491)], and 17p13 [p53 (TP53)]. Abnormal lymphocytes were microdissected from formalin-fixed, paraffin-embedded tissue sections. Sixteen of the 25 (64%) specimens evaluated had at least one abnormal LOH locus and LOH was identified in 7 of 15 (47%) plaque and in 9 of 10 (90%) tumor stage lesions, respectively. All 3 patients with sequential biopsies (plaque followed by tumor lesions) had additional LOH abnormalities in tumor specimens compared with plaque stage lesions. LOH most frequently involved chromosome 10, including 7 of 10 (70%) tumor stage lesions. Loss of multiple alleles was only identified in tumor stage cases, with 3 tumors undergoing allelic losses at 3 separate loci. Our results suggest that LOH studies are a robust method for evaluating genetic abnormalities in MF. Tumor stage lesions manifest increasing allelic losses compared with plaque stage. Further, in this series, several loci associated with the tumor suppressor gene PTEN on chromosome 10 appear to be associated with progression from plaque to tumor stage.

Selective heparanase localization in malignant melanoma.

Heparanase (HPSE-1) is an endo-beta-D-glucuronidase that cleaves heparan sulfate proteoglycans (HSPG), and its expression has been associated with increased growth, metastasis, and angiogenesis of tumors. Since metastatic melanoma cells express high levels of HSPG and because melanoma tumors grow highly vascularized, we analyzed melanoma tissue specimens for HPSE-1 expression from experimental animals as well as from patients. Laser capture microdissection microscopy was used to extract melanoma cell populations and to isolate them from adjacent tissue. In experimental animals, a 29-fold upregulation of HPSE-1 expression was detected by real-time PCR in metastatic melanoma compared to normal lung tissue. Additionally, immunohistochemistry (IHC) revealed selective HPSE-1 staining in human metastatic melanoma when compared to primary melanoma tumors from the same patient. IHC also showed a marked staining for the enzyme around blood vessels and in vascularized regions. Our results provide evidence demonstrating that HPSE-1 likely plays important roles in regulating the in vivo growth and progression of melanoma. These results further emphasize the importance that therapies designed to block HPSE-1 activity may aid in controlling this type of cancer.

Necrolytic acral erythema: a cutaneous sign of hepatitis C virus infection.

BACKGROUND: Hepatitis C virus (HCV) infection is globally epidemic. Several mucocutaneous diseases are well established in association with HCV infection. Few case reports describe the recently recognized HCV-related skin disorder termed necrolytic acral erythema (NAE). METHODS: Thirty patients with NAE were identified in a university-based dermatology clinic in Cairo, Egypt. These patients were observed over time to document the clinical and histologic findings of this disorder. RESULTS: All patients were infected with HCV. Erythematous papules arose most commonly on the dorsal aspect of the feet, particularly the dorsal surface of the great toe. Progression resulted in confluence into erythematous dusky plaques with adherent scale and central erosion. The eruption extended to involve the lower leg and other regions in some patients but never affected palms or soles, the nail bed, nail plate, or mucous membranes. Skin biopsy specimens from fully evolved lesions displayed psoriasiform changes in association with more characteristic findings of keratinocyte necrosis and papillomatosis. LIMITATIONS: We did not perform a prospective review of patients known to be infected with HCV. Patients were identified from a general clinic population and then assayed for HCV serology. CONCLUSIONS: NAE is a distinctive skin disorder associated with HCV infection in all cases reported to date. Recognition of this disease should alert practitioners to the need for viral testing and appropriate counseling of patients.

Recurrent status epilepticus as the primary neurological manifestation of CADASIL: A case report.

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) often presents with a history of migraine with aura and eventual manifestations of dementia with unrelenting, repeated cerebral vascular insults. Only 6-10% of patients with CADASIL have been reported to develop seizures, and status epilepticus (SE) is exceedingly rare. Here, we describe a patient who presented with recurrent SE, with eventual biopsy diagnosis of CADASIL. An 80-year-old woman presented to our hospital three times in two years with decreased level of consciousness and subtle intermittent right-sided upper extremity and facial twitching. There was no known significant family history and no past medical history for seizures, stroke, migraine headache, or overt dementia. Electroencephalography revealed recurrent focal seizures with left hemispheric onset and evolution, fulfilling the criteria for focal SE each time. All three admissions required sedation with midazolam to control seizure activity, in addition to high doses of multiple antiepileptic drugs. Brain MRI repeatedly showed extensive abnormalities in the periventricular and deep white matter, subcortical white matter, and bilateral basal ganglia. Skin biopsy was obtained on the third admission, and electron microscopy showed numerous deposits of granular osmiophilic material, which are pathognomonic for CADASIL. Detailed investigations failed to reveal any other etiology for the patient's condition. This case illustrates the potential for nonconvulsive SE to be the sole manifestation of CADASIL. With the appropriate brain MRI findings, CADASIL should be added to the list of rare causes of SE.