Peripheral neuropathy for dermatologists: what if not diabetic neuropathy?

BACKGROUND: Patients with cutaneous manifestations associated with peripheral neuropathy often present to the dermatologist's office. OBJECTIVE/METHODS: This article outlines a practical approach for obtaining the history, performing a screening physical examination, and ordering initial diagnostic testing to diagnose the cause of nondiabetic neuropathy. When to refer for neurologic consultation and principles of management of neuropathic pain and neuropathy-related ulcers are also discussed. RESULTS: Cutaneous manifestations of peripheral neuropathy may be secondary to a medical condition predisposing the patient to neuropathy or a manifestation of neuropathy itself. In the latter category, skin affected by neuropathy may show characteristics of xerosis, anhidrosis, rubor, edema, callus, ulceration, muscle wasting, and foot deformity. Most often these findings occur in association with diabetic neuropathy; however, many other infectious, inflammatory, metabolic, paraneoplastic, hereditary, and medication- or toxin-related causes should be considered. The treatment of cutaneous manifestations of neuropathy includes pressure downloading, control of edema, and optimal ulcer and neuropathic pain management. CONCLUSION: It is important for dermatologists to have a basic approach to neuropathy in patients with related skin disease. Referral to Neurology is warranted when basic workup for reversible causes is negative or for any severe, rapidly progressive symptoms.

Vascular lesions.

Advances in laser and light-based technology have increased their potential applications, safety and efficacy for the management of vascular lesions in dermatology. Light devices for vascular lesions include the variable-pulse 532 nm potassium titanyl phosphate laser, 577 to 595 nm pulsed dye laser, intense pulsed light devices, and 800 to 940 nm diode, long-pulse 755 nm alexandrite and 1,064 nm Nd:YAG lasers. This review will discuss the various different laser and light-based devices, and provide a focused treatment approach for the management of common congenital and acquired vascular lesions.

Gianotti-Crosti syndrome in two adult patients.

BACKGROUND: Gianotti-Crosti syndrome was first described in Italy by Gianotti in 1955. It is considered a benign, self-limited exanthem that occurs in younger children. Adult cases are rare. OBJECTIVE: We report two cases of Gianotti-Crosti syndrome in a previously healthy 37-year old Asian and 21-year old Caucasian female. METHODS/RESULTS: Histopathological analysis of 4-mm punch biopsies from the upper extremity of both patients revealed an interstitial dermatitis with mild to moderate perivascular lymphocytic infiltrate and occasional scattered eosinophils in the superficial and mid-dermis. Clinicopathological correlation was consistent with Gianotti-Crosti syndrome. CONCLUSION: Since both patients experienced significant pruritus, patient 1 was initially treated with a high potency topical corticosteroid followed by a two-week course of oral prednisone and patient 2 was treated with a potent topical corticosteroid. Both patients were asymptomatic at follow-up 3 to 4 weeks after their initial presentation.

Cutaneous myiasis from Panama, South America: case report and review.

BACKGROUND: Myiasis is a cutaneous infestation with larvae of Diptera, the two-winged arthropod order. Eggs and/or larvae are transmitted directly from the environment or via arthropod vectors. Larvae are able to burrow into the dermis of intact skin or external body orifices. Three clinical variants of myiasis are furuncular, migratory (creeping), and infestation of wounds. METHODS: A 35-year-old male presented with a 1-month history of worsening furuncles on the left knee and posterior thigh following his return from Panama, South America. Clinical examination revealed tender 6 cm and 2 cm erythematous to violaceous furuncles with surrounding desquamation and central puncta draining serosanguinous fluid. Five-millimeter punch biopsies and tissue swabs were performed. RESULTS: All larvae were of the Dermatobia hominis species. The patient was empirically treated with cephalexin and ciprofloxacin for secondary bacterial cellulitis. Tissue swabs later cultured group B streptococcus. A tetanus booster was recommended. CONCLUSION: This case report describes a relatively rare cutaneous infestation with D. hominis, a Central and South American endemic larva of the human botfly. Increasing trends toward immigration and global travel to tropical and subtropic areas will likely increase the frequency of encounters with such parasitic cutaneous infestations in North American outpatient dermatology clinics.

Ophthalmologic manifestations of cutaneous conditions.

Many cutaneous conditions have associated ophthalmologic findings, which are important to recognize for both dermatologists and ophthalmologists. This review highlights some important ophthalmologic manifestations associated with neurocutaneous syndromes and inherited connective tissue diseases.

Use of etanercept in human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) patients.

BACKGROUND: Etanercept (Enbrel, Amgen, Thousand Oaks, CA), a soluble p75 tumor necrosis factor receptor:FC (TNFR:FC) fusion protein for plasma cytokines, specifically tumor necrosis factor-alpha (TNF-alpha), is used in the treatment of immune-mediated rheumatic diseases. To our knowledge, the use of etanercept in patients with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) is relatively uncommon. OBJECTIVE: The main purpose of this short review is to examine the safety of etanercept in patients with HIV/AIDS. METHODS: A Medline search was conducted using the keywords etanercept and HIV and/or AIDS for any published articles between 1966 to the present (September 2004). RESULTS: A case report, one case series, and one clinical trial pertained to the use of etanercept in HIV patients. No reports were found on the use of etanercept in AIDS. In addition, two case reports were found documenting the use of infliximab in HIV patients. DISCUSSION: Preliminary reports indicate that the administration of etanercept does not appear to increase the morbidity or mortality rates in HIV. The inhibition of TNF-alpha may actually improve the symptoms of HIV/AIDS-associated aphthous ulcers, cachexia, dementia, fatigue, and fever, as well as help manage concomitant rheumatic diseases and psoriasis. CONCLUSION: The use of etanercept shows promise for applications in disease management in patients with HIV/AIDS. Continued research efforts are necessary to establish the long-term safety and efficacy of etanercept and other biologic agents in this patient population.

Metastatic basal cell carcinoma: report of two cases and literature review.

BACKGROUND: Metastatic basal cell carcinoma (MBCC) is defined as primary cutaneous basal cell carcinoma (BCC) that spreads to distant sites as histologically similar metastatic deposits of BCC. There are less than 300 reported cases of MBCC in the literature. METHODS: This article examines two cases of MBCC and provides a literature review of risk factors inherent in epidemiology, patient demographics, and the clinicohistopathological characteristics of primary and metastatic BCC lesions. RESULTS: MBCC is a rare complication of BCC with high morbidity and mortality rates. Patients with MBCC often begin with long-standing primary BCC lesions that are either large or recurrent after treatment. Cases of MBCC have a higher incidence of the more aggressive histologic patterns (morpheic, infiltrating, metatypical, and basosquamous). Perineural space invasion may be an indicator of aggressive disease. Metastases often involve regional lymph nodes, lungs, bone, and skin. CONCLUSION: These case reports and review provide important diagnostic and management considerations for primary BCC and MBCC. Early intervention with aggressive treatment measures may improve the prognosis and survival of MBCC patients.

Clinical, microbiological, and epidemiological findings of an outbreak of Mycobacterium abscessus hand-and-foot disease.

In 2003, we identified an outbreak of clinically distinct lesions involving the hands and feet associated with a public wading pool in Edmonton, Alberta, Canada. A total of 85 cases were identified. The management and follow-up of 41 children and 1 adult patients is presented. Skin lesions occurred within a median incubation period of 29 days and approximately 88 days for the adult patient. Lesions resolved within a median of 58 days and approximately 150 days for the adult patient. Patients were treated with clarithromycin, topical antibiotic dressings, and/or incision and drainage of pustules or followed without treatment. All resolved without complication. The pool was closed and cleaned. The M. abscessus hand-and-foot disease is characterized by the onset, mainly in children, of tender, erythematous papules, pustules, and abscesses with a self-limited course. This is the first documented M. abscessus outbreak associated with wading pool exposure.

Papulonecrotic tuberculid: a rare form of cutaneous tuberculosis.

We describe a case of papulonecrotic tuberculid, a rare form of cutaneous tuberculosis, in a 25-year-old Philippino woman who had immigrated to Canada 8 years previously. The patient presented with a 3-week history of tender left cervical adenopathy; 1 week later, she developed multiple ulcerated erythematous nodules and emboluslike lesions scattered over her fingers. Results of a biopsy performed on the lymph node revealed granulomatous lymphadenitis, and Mycobacterium tuberculosis grew from the lymph node. Histopathologic analysis of an ulcerative finger lesion demonstrated nonnecrotizing granulomas with dense lymphocytic inflammation of the superficial dermis; however, results of acid-fast staining, mycobacterial culture, and polymerase chain reaction for M tuberculosis complex were all negative. Different conditions can mimic papulonecrotic tuberculid. Therefore, the diagnosis can be difficult unless M tuberculosis is isolated from a site other than the skin, because stain and culture results from skin biopsy specimens are typically negative and the polymerase chain reaction is positive in only 50% of cases. We review the epidemiology, clinicopathologic features, and differential diagnosis of papulonecrotic tuberculid. Awareness of this entity is important to distinguish it from other conditions and to institute appropriate therapy in a timely fashion.

Intravascular pulmonary metastases from sarcoma: appearance on computed tomography in 3 cases.

INTRODUCTION: Various common malignant neoplasms (ie, liver, kidney, stomach, and breast) have been reported to embolize to the pulmonary arterial system. This uncommon occurrence can also result from metastatic sarcoma. We report 3 cases--2 chondrosarcomas and 1 osteosarcoma-associated with intravascular metastases to the pulmonary vasculature and discuss the clinical presentation and differentiating radiologic features on computed tomography (CT). DISCUSSION: Intravascular pulmonary tumour emboli may present with nonspecific respiratory symptoms or remain completely asymptomatic, and therefore, many patients are often misdiagnosed with thromboembolic disease or undiagnosed until autopsy. Chest CTs in all our patients demonstrated a striking pattern of multifocal tubular branching beaded opacities along the pulmonary vasculature in a multilobular distribution. CONCLUSION: Our observations and a review of the literature indicate that chest CT is the most useful diagnostic tool for detecting intravascular pulmonary tumour emboli. CT can distinguish this entity from mucous plugging by demonstrating the normal adjacent bronchus. The tubular nature of these metastases distinguishes them from the more common parenchymal metastases.

Allergic contact dermatitis to propolis.

A 35-year-old Asian woman was referred to the dermatology clinic with a 2-week history of enlarging, fluid-filled, pruritic lesions on the right foot. The affected area had a recent history of minor trauma for which the patient applied an over-the-counter propolis ointment. At presentation, the patient was also noted to have been using the following, as prescribed by her primary care physician: valacyclovir, ciprofloxacin, terbinafine cream, mupirocin ointment, and 2% hydrocortisone cream. No clinical improvement was observed with these agents. Examination revealed grouped erythematous papules progressing into vesicles and bulla on the lateral side of the right foot. A KOH scraping was negative. We diagnosed the patient with allergic contact dermatitis to propolis.