Alopecia neoplastica: A manifestation of metastatic breast cancer.

We herein report a typical case of alopecia neoplastica secondary to breast cancer. Alopecia neoplastica is a rare form of alopecia resulting from metastasis of a primary tumour to the scalp and is often misdiagnosed as alopecia areata.

Ganciclovir-induced drug reaction with eosinophilia and systemic symptoms.

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe cutaneous adverse reaction involving multiorgan failure, with a complex interaction of various drugs, human herpesvirus reactivation and immune abnormalities suggested as the aetiology. We herein present the case of a 70-year-old man with a one-week history of fever, facial oedema, erythematous macules and purpura on his trunk and extremities. He had anti-TIF1γ antibody-positive dermatomyositis and was treated with prednisolone sodium succinate (20 mg/day). Three weeks earlier, he was treated with ganciclovir (250 mg/day) for 7 days to treat asymptomatic cytomegalovirus viraemia. Laboratory investigations revealed eosinophilia with atypical lymphocytes and elevated liver enzyme levels. A histological examination showed interface dermatitis with necrotic keratinocytes, perivascular infiltration of lymphocytes and eosinophils in the upper dermis and erythrocyte extravasation without vasculitis. A lymphocyte transformation test (LTT) was positive for ganciclovir (stimulation index: 260%; normal: <180%). We diagnosed DRESS caused by ganciclovir on the basis of clinical findings and course (Definite; RegiSCAR score: 7). He was treated with prednisolone sodium succinate (40 mg/day) and topical clobetasol propionate (0.05%) ointment twice daily. After the initiation of treatment, the skin lesions and laboratory abnormalities gradually improved. To our knowledge, this is the first case of DRESS caused by ganciclovir. The patients in whom ganciclovir is used are often immunosuppressed and may be overlooked as the causative drug for DRESS by conventional skin tests. We considered that LTT is useful for identifying causative drugs of DRESS, especially in immunosuppressed patients, such as the present case.

Usefulness of immunofluorescence overlay antigen mapping in the identification of autoantigen in anti-p200 pemphigoid.

Anti-p200 pemphigoid is a rare subepidermal blistering disease showing immunoglobulin G (IgG) autoantibodies reactive with a 200-kDa protein. In most patients, serum IgG antibodies react with laminin γ1. The diagnosis of anti-p200 pemphigoid is occasionally difficult, mainly due to the lack of standardized tests. We performed fluorescence overlay antigen mapping by laser scanning confocal microscopy (FOAM-LSCM) to identify autoantigens in an anti-p200 pemphigoid patient and assessed its usefulness for the diagnosis. A 71-year-old man presented with blisters and erosions on the bilateral forearms. No mucosal lesions were observed. Laboratory examinations revealed mild leukocytosis and antinuclear antibody negativity. A histopathological examination showed subepidermal blisters with neutrophil infiltration. Direct immunofluorescence showed linear IgG staining along the basement membrane zone. Indirect immunofluorescence using 1 M NaCl-split skin sections revealed IgG reactivity on the dermal side. Immunoblotting detected circulating IgG autoantibodies that reacted with a 200-kDa protein. Accordingly, anti-p200 pemphigoid was diagnosed. FOAM-LSCM revealed that the patient's IgG signals were co-localized with laminin γ1 but were observed above type VII collagens. A direct immunofluorescent analysis for IgG deposition patterns showed an n-serrated pattern. Thus, FOAM-LSCM may be useful for diagnosing anti-p200 pemphigoid.

Detection of FIP1L1-PDGFRA fusion gene-positive cells in the skin lesion of a patient with hypereosinophilic syndrome.

Hypereosinophilic syndrome (HES) is a heterogeneous group of diseases, characterized by persistent hypereosinophilia and end-organ damage. The FIP1L1-PDGFRA (F/P) fusion gene is found in 3-25% of patients with HES and is an oncogenic driver of myeloid neoplasms with clonal eosinophilia. Although cutaneous symptoms are the most common type of symptom in patients who have F/P fusion gene-positive HES (F/P HES), histological reports are limited. We herein present the case of a 78-year-old man with erythematous macules and severe pruritus on his trunk and extremities. Laboratory investigations revealed marked eosinophilia and elevated serum vitamin B12. A histological examination showed massive infiltration of eosinophils and mast cells around the vessels in the upper dermis. Fluorescence in situ hybridization revealed F/P fusion genes in nuclei in the peripheral blood and the skin lesion. The patient was diagnosed with F/P HES, and showed an excellent clinical and haematological response to imatinib.