Leukemia cutis in a patient with chronic neutrophilic leukemia.

Chronic neutrophilic leukemia (CNL) is a rare myeloproliferative disorder. Less than 50 cases have been reported. We report the first case of CNL with an associated leukemia cutis. CNL was diagnosed in a 74-year-old white woman in 1998, based on neutrophilic infiltration of the bone marrow and absence of the Philadelphia chromosome. The patient presented to the dermatology service in August 1998 with a 2-week history of a pruritic eruption on the arms, hands, and legs. Physical examination revealed red to violaceous plaques on both thighs and knees, in addition to purpuric patches and plaques on the dorsal hands, arms, and legs. Leukemia cutis was demonstrated on biopsy specimens of several lesional sites. The eruption progressed, despite treatment with topical and systemic corticosteroids. Treatment with systemic chemotherapy did affect partial resolution of the eruption, with parallel decreases in bone pain and white blood cell count, but the disease progressed and the patient ultimately died 5 months after her initial skin findings. Only one other case of CNL with dermatologic manifestations has been reported, CNL associated with a reactional neutrophilic dermatosis. Comparison to and differentiation from this case is discussed. The importance of distinguishing the specific infiltrates of leukemia from the nonspecific infiltrates of reactional dermatoses, such as Sweet's syndrome, is illustrated.

Diagnostic and therapeutic dilemmas of a large scrotal lesion in an AIDS patient.

In the setting of HIV infection, chronic genital ulcerations may be challenging both diagnostically and therapeutically. The differential diagnosis of these lesions is very broad, and the causes can be multifactorial. We present a case of a chronic, extensive, ulcerating scrotal mass and review the salient clinical, diagnostic, and therapeutic considerations.

Unusual presentation of secondary syphilis in 2 HIV-1 positive patients.

Due to diverse clinical and histopathological presentations, diagnosis of secondary syphilis can occasionally prove challenging. This is especially true in the setting of human immunodeficiency virus (HIV) infection. Variable clinical presentations of secondary syphilis in HIV disease may result in an incorrect diagnosis and an inappropriate treatment regimen. Similarly, the histology of secondary syphilitic lesions may show considerable variation, depending on the clinical morphology of the eruption. We report 2 cases of secondary syphilis in HIV-1-infected patients with cutaneous lesions of variable clinical presentation and an unusual lymphoid infiltrate simulating mycosis fungoides.

Fox-Fordyce disease: diagnosis with transverse histologic sections.

Fox-Fordyce disease (FFD) is an uncommon chronic follicular based dermatosis with distinctive clinical characteristics consisting of pruritic papules confined to apocrine gland-bearing skin. Histologic confirmation of this entity is often time-consuming and difficult with conventional histologic sectioning. We describe a case of FFD occurring in a 26-year-old woman, in which we used transverse histologic sectioning to easily demonstrate the histopathologic features of this condition. With conventional sectioning of a punch biopsy specimen of an affected area, more than 23 serial sections were required to locate a follicle with pathognomonic features of the disease. In contrast, only one transverse section of a biopsy specimen was required to confirm the diagnosis. We propose that transverse histologic sectioning of biopsy specimens of patients suspected of having FFD more effectively demonstrates the diagnostic features.

Acute generalized exanthematous pustulosis induced by chromium picolinate.

A case of acute generalized exanthematous pustulosis (AGEP) due to chromium picolinate is described. This supplemental form of chromium has received a great deal of interest recently because of its possible beneficial effects on both muscle strength and body composition. There have been no previous reports to our knowledge of adverse cutaneous reactions to this agent. Various aspects of AGEP are reviewed.

Ovarian cancer presenting as leukocytoclastic vasculitis.

We describe a 53-year-old woman with a 4-month history of palpable purpuric papules on the upper and lower extremities. Biopsy of the skin lesions revealed leukocytoclastic vasculitis. Although she denied any systemic symptoms, urinalysis demonstrated hematuria and proteinuria. Although the patient's skin lesions responded to prednisone, her urinalysis did not improve. A 10-cm complex mass involving the left ovary and adnexa was incidentally discovered on renal ultrasound. Serum CA-125, an ovarian cancer marker, was elevated. Laparotomy revealed ovarian carcinoma confined to the left ovary. After the cancer was resected, the patient's urinalysis slowly improved. Leukocytoclastic vasculitis (LCV) is infrequently associated with underlying malignancy and only rarely with solid tumors. We postulate that the patient's vasculitis represented a paraneoplastic phenomenon that allowed a diagnosis of asymptomatic ovarian carcinoma. To our knowledge, this is the first report of LCV occurring as the presenting sign of ovarian cancer.

Viral folliculitis.

Viral folliculitis is an infrequently reported entity. We describe two patients with viral folliculitides, including a case of herpetic sycosis caused by herpes simplex (HSV) and a case of herpes zoster (HZ) without blisters. Clinicians should consider viral etiologies in the differential diagnosis of superficial infectious folliculitis, especially those cases refractory to antibacterial or antifungal therapy.

Felodipine-induced gingival hyperplasia.

Felodipine is a calcium channel blocking agent used in the management of hypertension and angina. We report a case of gingival hyperplasia in a patient with chronic use of this drug. Gingival changes occurred soon after initiation of felodipine and improved upon its discontinuation. The clinical characteristics, inciting agents, proposed pathogenetic mechanisms, as well as prevention and treatment of drug-induced gingival hyperplasia are briefly reviewed.

Nodular cutaneous microsporidiosis in a patient with AIDS and successful treatment with long-term oral clindamycin therapy.

BACKGROUND: In AIDS, nodular skin disease can result from various causes. OBJECTIVE: To report a new manifestation of microsporidial infection presenting as nodular skin disease with underlying osteomyelitis. DESIGN: Case report. SETTING: Tertiary-care military medical center in Washington, D.C. PATIENT: A 36-year-old woman with late-stage AIDS who presented with disseminated, nodular cutaneous lesions and underlying osteomyelitis. MEASUREMENTS: Disseminated microsporidial infection with an Encephalitozoon-like species was diagnosed by electron microscopic examination of material obtained from the skin lesions. INTERVENTION: The patient received long-term oral clindamycin therapy, which cured her disseminated infection. CONCLUSIONS: Microsporidia can cause disseminated cutaneous infections in AIDS patients. The response of this patient to long-term clindamycin therapy merits further evaluation.

Viral folliculitis. Atypical presentations of herpes simplex, herpes zoster, and molluscum contagiosum.

BACKGROUND: Viral folliculitis is an infrequently reported entity. The patients described herein were seen over a 12-year period of practice in a referral dermatologic setting. The cases involve a variety of viral infections limited to the hair follicle. OBSERVATIONS: We describe 5 patients with a variety of viral folliculitides: 2 with herpetic sycosis caused by herpes simplex; 1 with herpex simplex folliculitis (this patient also had human immunodeficiency virus); 1 with herpes zoster without blisters; and 1 with molluscum contagiosum. CONCLUSIONS: These 5 cases demonstrate that viral folliculitis has varied causes and presentations. Clinicians should consider viral agents in the differential diagnosis of superficial infectious folliculitis, especially in cases that are refractory to antibacterial or antifungal therapy.

Phialophora verrucosa: a new cause of mycetoma.

A 29-year-old Thai woman had draining sinus tracts, tumefaction, and granules on the plantar aspect of the foot. Phialophora verrucosa was isolated from the lesion. P. verrucosa is a major agent of chromoblastomycosis, which is known to rarely cause subcutaneous phaeohyphomycosis. This dematiaceous fungus has not been previously reported to cause mycetoma. This case illustrates the clinical spectrum of disease of this fungus. The salient features of mycetoma and management options are presented.

Cutaneous findings in HIV-1-positive patients: a 42-month prospective study. Military Medical Consortium for the Advancement of Retroviral Research (MMCARR).

BACKGROUND: Cutaneous disease is common in patients infected with HIV-1. OBJECTIVE: The aim of our study was to identify cutaneous markers associated with HIV-1 infection and disease progression as measured by Walter Reed (WR) stage. METHODS: For 42 months we have observed 912 HIV-1-positive patients in all WR stages. All patients had an extensive past and present medical history taken as well as a complete physical examination, periodic visits, and appropriate diagnostic procedures. RESULTS: Increasing dryness of the skin and seborrheic dermatitis are early findings in a large percentage of patients in WR stage 1; the occurrence and severity of both conditions increase with disease progression. Tinea infections, condylomata acuminata, and verrucae are seen early, but with disease progression, although there is no clear increase in occurrence, these infections become more diffuse and resistant to treatment. Flares in acne vulgaris and folliculitis show a peak occurrence in early and mid-stage disease with a decreased occurrence in late-stage disease. Herpes simplex infections, oral candidiasis, molluscum contagiosum, Staphylococcus aureus infections, and oral hairy leukoplakia show a marked increase in occurrence with advanced disease. Conditions that have a statistically significant association with disease progression as measured by a change in a stage include drug eruptions, seborrheic dermatitis, oral candidiasis, oral hairy leukoplakia, molluscum contagiosum, herpes zoster, and hyperpigmentation (nail, oral, skin). CONCLUSION: The most frequent and persistent cutaneous disorders were asteatosis (with or without asteatotic eczema) and seborrheic dermatitis. Conditions that were associated with a change in WR stage include drug eruptions, seborrheic dermatitis, oral candidiasis, oral hairy leukoplakia, molluscum contagiosum, herpes zoster, and hyperpigmentation. In addition to Kaposi's sarcoma, patients with HIV-1 disease have an increased potential for the development of both cutaneous epithelial and probably melanocytic malignancies. Epithelial tumors were seen in patients in all stages of disease.