Inpatient dermatology consultation.

Common dermatologic conditions and skin signs of systemic disease are routinely present in hospitalized patients. Rapid detection and identification of these changes can have a significant impact on the patient's hospital course. Inpatient dermatology consultation can improve diagnostic accuracy, efficiency, and treatment of hospitalized patients with cutaneous findings. This article discusses the clinical aspects of inpatient dermatology consultation and the features of effective consultation.

Antiphospholipid antibodies and the antiphospholipid antibody syndrome.

The antiphospholipid antibody syndrome is a multisystem disorder characterized by persistently elevated antiphospholipid antibodies and/or arterial or venous thrombosis, thrombocytopenia and recurrent spontaneous abortion. Anticardiolipin antibodies and the lupus anticoagulant are different classes of antiphospholipid antibodies associated with this disorder. Various hematologic, neurologic, obstetric and cutaneous abnormalities are manifest in this syndrome. This article reviews the characteristic features of the antiphospholipid antibody syndrome.

Primary cutaneous T-cell-rich B-cell lymphomas with flow cytometric immunophenotypic findings. Report of 3 cases and review of the literature.

BACKGROUND: Primary cutaneous T-cell-rich B-cell lymphoma is a relatively rare entity that has been diagnosed most commonly using immunohistochemical and molecular techniques. Flow cytometric immunophenotyping (FCI) has not been described in this entity. We report the demonstration of B-cell monoclonality by FCI in 3 cases of primary cutaneous T-cell-rich B-cell lymphoma. METHODS: Clinical and pathologic data were recorded for 3 cases of primary cutaneous T-cell-rich B-cell lymphoma. Immunohistochemical and FCI data were available in all cases; DNA analysis was performed in 1 case. RESULTS: Flow cytometric immunophenotyping revealed a monoclonal B-cell population exclusively in the monocyte (large cell) region in all 3 cases. Immunohistochemistry confirmed the T-cell richness of the infiltrates within the cutaneous lymphomas; T cells accounted for 65% to greater than 90% of the cells within the infiltrates. DNA analysis by polymerase chain reaction in 1 case did not demonstrate a monoclonal rearrangement of the immunoglobulin heavy-chain gene. CONCLUSIONS: Flow cytometric immunophenotyping in primary cutaneous T-cell-rich B-cell lymphoma may be useful in demonstrating monoclonality in these cases, especially if there is selective gating on the relatively small population of cells in the large cell region. The FCI data should be correlated with histology and immunohistochemistry.

Oxalate kinetics and reversal of the complications after orthotopic liver transplantation in a patient with primary hyperoxalosis type 1 awaiting renal transplantation.

We present the case of a young woman with end-stage renal disease secondary to primary hyperoxaluria type 1, who after 3 years and 6 months of maintenance hemodialysis, and despite intensification of the dialytic treatment, developed severe livedo reticularis in her extremities leading to ischemic cutaneous ulcerations, necessitating continuous intravenous infusion of narcotics for pain control. She received a liver transplant after native hepatectomy. However, due to positive crossmatch, she could not receive a kidney from that donor. After transplantation, following serial serum oxalate levels, the hemodialysis regimen was safely reduced from 4 h daily to 3 h three times weekly. Over the course of 6 weeks after liver transplantation, her livedo reticularis resolved, the ischemic ulcers markedly improved, she was weaned off all pain medications, and her erythropoietin-resistant anemia resolved. Our results suggest that in patients with primary hyperoxaluria type 1, who have received a liver transplant and are on maintenance hemodialysis, after serial serum oxalate determinations, some may safely be changed to a thrice-weekly maintenance hemodialysis regimen. Moreover, with this regimen the complications of systemic oxalosis can reverse.

Clinical reactogenicity of intradermal bacille Calmette-Guérin vaccination.

Clinical, microbiological, and immunologic responses were evaluated in volunteers vaccinated intradermally with bacille Calmette-Guérin (BCG). Most volunteers (98%) developed ulcerative lesions that drained for a mean +/- SE of 4.3 +/- 0.29 weeks. Mycobacterial DNA was detected by a polymerase chain reaction-based amplification technique in biopsy specimens from BCG ulcers 2 weeks after vaccination and in blood specimens 3 days after vaccination. Mycobacteria were cultured from ulcer drainage 2 months after vaccination, demonstrating a prolonged potential risk of contact spread of the vaccine strain. The duration of ulcer drainage was inversely correlated with prevaccination lymphoproliferative (r = -0.515; P < .002) and interferon gamma (r = -0.841; P < .002) responses specific to mycobacteria and directly correlated with postvaccination increases in lymphoproliferative (r = 0.498; P < .002) and interferon gamma (r = 0.688; P < .02) responses specific to mycobacteria. These results demonstrate the clinical reactogenicity of BCG and the potential risk of contact spread of the vaccine strain and suggest that clinical reactogenicity is a trade-off for the induction of protective mycobacterial immunity.

Fluoroscopy-induced radiodermatitis after transjugular intrahepatic portosystemic shunt.

Transjugular intrahepatic portosystemic shunt is a nonsurgical procedure used to manage the complications of portal hypertension. This report describes three cases of fluoroscopy-induced radiodermatitis after transjugular intrahepatic portosystemic shunt and reviews the characteristics and treatment of radiation-induced skin reactions.

Acute radiodermatitis after radiofrequency catheter ablation.

Radiofrequency (RF) catheter ablation is used in the treatment of a variety of arrhythmias. This report describes the development of acute radiodermatitis after two prolonged RF catheter ablation procedures for supraventricular tachycardia. It also reviews the characteristics and treatment of radiation-induced skin reactions.

Antiphospholipid antibodies and the antiphospholipid antibody syndrome.

The antiphospholipid antibody syndrome is a multiple-system disorder characterized by persistently elevated antiphospholipid antibodies and/or arterial or venous thrombosis, thrombocytopenia, or recurrent spontaneous abortion. Anticardiolipin antibodies and the lupus anticoagulant are different classes of antiphospholipid antibodies associated with this disorder. Cutaneous manifestations are common and may be the presenting sign of the underlying disease. This article reviews the clinical manifestations, laboratory assays, histopathologic features, and treatment of the antiphospholipid antibody syndrome.

Cutaneous reactions following herpes zoster infections: report of three cases and a review of the literature.

Three patients, one healthy and two immunocompromised, developed cutaneous reactions that histologically mimicked granuloma annulare at sites of resolved varicella-zoster virus (VZV) reactivation infections. Variable latency periods between the infection and the granulomatous reaction were noted. As in other case reports, the presence of VZV DNA in these lesions was inconsistently demonstrated by the polymerase chain reaction (PCR) and appears more common in early, as opposed to late, post-zoster granulomas. In addition to various granulomatous reactions, vasculitic and neoplastic eruptions following resolved VZV infections have been described and are reviewed here. Therapeutically, topical, intralesional and systemic corticosteroids, as well as acyclovir, have been tried with inconsistent results. Although the pathogenesis remains unclear, the presence of VZV DNA in early lesions that histologically do not display viral cytopathic changes, suggests the virus induces an atypical delayed hypersensitivity reaction not affected by antiviral therapy.

Prevalence of cutaneous findings in hospitalized medical patients.

BACKGROUND: Cutaneous signs may represent a systemic process or a primary cutaneous disorder. Prompt observation and identification of cutaneous abnormalities should improve care of hospitalized medical patients. OBJECTIVE: Our purpose was to determine the prevalence of cutaneous abnormalities in newly hospitalized medical patients and the frequency with which these findings were noted by the admitting team. METHODS: All new medical patients were offered a complete skin examination within 48 hours after admission to the hospital, and 231 participated. Cutaneous diagnoses were based on characteristic clinical features or skin biopsy in patients in whom a diagnosis could not be made clinically. RESULTS: Ninety-three cutaneous findings were present in 83 (35.9%) of 231 patients. In 31 (13.4%) we found cutaneous signs related to the reason for hospitalization or associated with a systemic disorder. These were not noted by the admitting medical service in 14 patients. In two patients, one with metastatic adenocarcinoma and one with sclerosis, the cutaneous findings were manifestations of the new diagnosis. In 52 patients (22.5%) we found 62 primary cutaneous disorders. Fifty-eight disorders (93.5%), including 10 nonmelanoma skin cancers, were unrecognized at the time of admission. CONCLUSION: Cutaneous findings representative of systemic disease or primary cutaneous disorders are commonly present and frequently overlooked in medical patients newly admitted to the hospital. These data suggest that a complete skin examination is necessary in all newly hospitalized medical patients.

Analysis of the polymerase chain reaction in the detection of herpesvirus DNA from fixed and stained tissue sections.

BACKGROUND AND DESIGN: The polymerase chain reaction (PCR) is a molecular diagnostic technique that has been applied to many infectious processes. Stained and unstained Tzanck smears, vesicle fluid swabs, and crusts have all been used as the source for template DNA for the PCR to document evidence of herpes simplex virus and varicella-zoster virus infection. Thirty-five cases with histologic evidence of acute herpesvirus infection were retrieved from archival tissue blocks that were up to 5 years old. Paraffin and hematoxylin-eosin-stained tissue sections obtained from routinely prepared glass slides from these cases were then examined for herpesvirus DNA using the PCR. RESULTS: The PCR-detected herpesvirus DNA from 34 (97.1%) of 35 paraffin tissue samples. Herpes simplex virus and varicella-zoster virus DNA were detected in eight and 26 of these cases, respectively. For hematoxylin-eosin-stained tissue samples, PCR detected herpesvirus DNA sequences in 16 (45.7%) of 35 cases. Herpesvirus DNA was isolated from paraffin tissue sections and recently prepared hematoxylin-eosin-stained tissue samples obtained from archival tissue blocks that were up to 5 and 2 years old, respectively. CONCLUSIONS: The PCR can detect herpesvirus DNA in extremely high yield from unstained paraffin-embedded tissue samples with histologic evidence of acute herpesvirus infection that are up to 5 years old. Herpesvirus DNA can also be identified in approximately 50% of these cases from hematoxylin-eosin-stained tissue sections obtained from routinely prepared glass slides.

Detection of herpes simplex and varicella-zoster infection from cutaneous lesions in different clinical stages with the polymerase chain reaction.

BACKGROUND: The polymerase chain reaction (PCR) can be used to diagnose a variety of infectious processes. OBJECTIVE: We sought to determine whether Tzanck smear debris, vesicle fluid swabs, crusts, or fixed tissue specimens are the best source for template herpes simplex virus (HSV) or varicella-zoster virus (VZV) DNA for the PCR. METHODS: Patients with both clinical and histologic evidence of HSV (n = 6) or VZV (n = 16) infection were examined. Stained Tzanck smears, vesicle fluid swabs, dried crusts, and skin biopsy specimens were obtained at the same time from each patient. DNA was extracted from the different clinical specimens and then examined for HSV or VZV DNA with PCR. Fifteen control subjects did not have clinical or histologic evidence of herpesvirus infection. RESULTS: In cases of suspected VZV infection, PCR detected VZV DNA sequences from all 15 Tzanck smears, all 15 vesicle swabs, one of one crust, and 14 of 16 fixed tissue specimens. HSV DNA sequences were detected from all six Tzanck smears, all four vesicle fluid swabs, two of two crusts, and five of six fixed tissue specimens. CONCLUSION: PCR can detect VZV and HSV DNA sequences from a variety of sources including formalin-fixed tissue specimens. Although viral DNA was detected slightly more frequently from Tzanck smear debris, crusts, and vesicle fluid swabs compared with fixed tissue specimens, each was an excellent source of target DNA for the PCR to confirm the diagnosis of herpesvirus infection.

Merkel cells in neurofibromas and neurilemomas.

Merkel cells are an integral component of the cutaneous nervous system. They are commonly associated with dermal nerves under normal physiological conditions. We postulated that Merkel cells may be present in increased numbers within the epidermis overlying benign peripheral nerve sheath tumours such as neurilemomas and neurofibromas. Paraffin-embedded skin biopsy specimens from 21 patients with neurilemomas and 26 with neurofibromas, were analysed for the presence of Merkel cells using a standard immunohistochemical assay (avidin-biotin-peroxidase complex system) with an antibody to cytokeratin 8 (CAM 5.2). Ten cases of leiomyomas were examined as controls. Merkel cells were identified in the interfollicular area of the basal cell layer overlying 14 of 21 (67%) neurilemomas and nine of 26 (35%) neurofibromas. Merkel cells were more frequently observed in increased numbers in a linear array within the basal cell layer in neurilemomas than in neurofibromas, where they were found as individual cells. No Merkel cells were found in the epidermis overlying leiomyomas. The results of this study suggest that Merkel cells are quantitatively increased in the basal cell layer of the epidermis overlying benign peripheral nerve sheath tumours, particularly neurilemomas.