Septic embolization arising from infected pseudoaneurysms following percutaneous transluminal coronary angioplasty: a report of 2 cases and review of the literature.

Septic embolization arising from infected pseudoaneurysms following percutaneous transluminal coronary angioplasty (PTCA) constitutes a distinct clinical and histopathologic entity. Pseudoaneurysms are a potential complication of both cardiac catheterization and PTCA. Repeated or prolonged catheterization increases the risk of bacterial seeding of these sites, resulting in septic embolization. Characteristic clinical features include fever within 2 to 5 days, unilateral embolic disease, and Staphylococcus aureus septicemia. Culture and examination of biopsy specimens of the embolic lesions typically demonstrate gram-positive microorganisms. We describe 2 patients presenting with ipsilateral palpable purpura, petechiae, and livedo reticularis caused by septic emboli from infected pseudoaneurysms. The recommended treatment includes administration of appropriate systemic antibiotics and surgical resection of the infected pseudoaneurysm. Both cholesterol and septic emboli should be considered in the differential diagnosis of ipsilateral embolic disease induced by invasive vascular procedures.

Subcutaneous emphysema.

A medical emergency, the detection of subcutaneous emphysema requires thorough evaluation to exclude the multitude of disease processes that may demonstrate this clinical finding. Gas gangrene must be considered in the differential diagnosis of all forms of subcutaneous emphysema and infections with some species, such as C. novyi, may not produce gas at all. Isolation of C. septicum from the blood is almost always associated with colon cancer or hematologic malignancies. Nonclostridial gas gangrene in diabetic patients is indistinguishable clinically from clostridial gas gangrene. A unique and true dermatologic emergency is the detection of nontraumatic subcutaneous emphysema of the thigh with or without associated erythema, tenderness, or bullous lesions. This finding is associated with perforated viscus in a retroperitoneal location. Infections with gas-producing organisms continue to be a source of significant morbidity in modern times.

Pyoderma gangrenosum and cranial osteolysis: case report and review of the paediatric literature.

Pyoderma gangrenosum is a poorly understood, ulcerating cutaneous disorder which is rarely seen in the paediatric age-group. We report a 3-year-old boy who developed an ulcer over the left frontoparietal scalp at the age of 1 year. A 9-cm area of underlying cranial bone was destroyed. The appearance on radiographs and CT scan was suggestive of eosinophilic granuloma, osteomyelitis, or other destructive processes. Biopsies of the scalp lesion and calvaria showed granulation tissue and degenerating bone. After the biopsies the scalp lesion increased in size, and wound dehiscence occurred. Ulceration developed at the site of a PPD skin test, which on biopsy was consistent with the diagnosis of pyoderma gangrenosum. Pyoderma gangrenosum should be added to the differential diagnosis of cutaneous disorders which can result in osteolytic/osteonecrotic defects.

Cat-scratch disease in Hawaii: etiology and seroepidemiology.

OBJECTIVE: To study the etiology and seroepidemiology of cat-scratch disease (CSD) in Hawaii. METHODS: Blood and fine-needle aspirate (FNA) from the lymph nodes of 39 consecutive patients with clinical CSD were cultured for Bartonella henselae, and blood samples from index cats, stray cats, and dogs were cultured and their sera were tested by indirect fluorescence antibody test for antibodies to B. henselae and Afipia felis. Sera from age- and sex-matched human subjects without cat exposure served as controls. RESULTS: Warthin-Starry staining showed positive results in only 4 of 32 FNAs, and B. henselae was isolated from only one FNA specimen. All of 38 patients who had two or more sera tested had elevated titers of antibody to B. henselae. Only 1 of 48 human control sera had antibody to B. henselae. Of 31 kittens, 21 had positive blood culture results and elevated antibody titers to B. henselae. Of three adult cats, all had negative blood culture results, but they had serologic evidence of past infection. Of 23 adult stray cats, 18 had elevated titers of antibody to B. henselae, but in only one was the blood culture result positive. Results of IFA tests were marginally positive for A. felis in 1 of 29 patients with CSD and in one adult stray cat and one dog. CONCLUSIONS: This study shows that the B. henselae IFA test is both highly sensitive and specific for the detection of infection caused by B. henselae and for the laboratory diagnosis of CSD, and that FNA is seldom helpful in confirming the diagnosis. We further demonstrated that CSD in Hawaii is due to B. henselae and that infection is directly linked to the scratch or bite of a kitten. Older cats seldom have bacteremia but often have serologic evidence of past infection. Our study fails to implicate dogs in the epidemiology of CSD in Hawaii, and A. felis was not etiologically implicated in CSD in the human subjects and animals we studied.

Eosinophilic panniculitis.

Eosinophillic panniculitis is a poorly defined entity with variable clinical features. We report a case of rapidly enlarging, asymptomatic subcutaneous scalp nodules in a 6-year-old black boy with atopic dermatitis. The nodules resolved spontaneously over two to three days. Biopsy specimens were remarkable for eosinophilic panniculitis without evidence of epidermal change or vasculitis. We believe that this is the youngest reported patient with this disorder.

Diffuse venous malformation with intraosseous involvement.

A young boy with a large venous malformation of his left arm and hand was evaluated for Maffucci's syndrome. Initial hand films were remarkable for cystic bony lesions suggestive of enchondromas. Additional roentgenograms and magnetic resonance imaging studies showed the bony abnormalities were the result of a venous malformation infiltrating bone. Magnetic resonance imaging is a useful diagnostic tool in differentiating enchondromas from vascular anomalies. Venous malformations infiltrating bone should be included in the differential diagnosis of Maffucci's syndrome.

Pentoxifylline.

Pentoxifylline (oxpentifylline) is a methylxanthine derivative with potent hemorrheologic properties. In the United States it is marketed for the treatment of intermittent claudication. Human and animal studies have shown that pentoxifylline therapy results in a variety of physiological changes at the cellular level, which may be important in treating a diverse group of human afflictions. Immune modulation includes increased leukocyte deformability and chemotaxis, decreased endothelial leukocyte adhesion, decreased neutrophil degranulation and release of superoxides, decreased production of monocyte-derived tumor necrosis factor, decreased leukocyte responsiveness to interleukin 1 and tumor necrosis factor, inhibition of T and B lymphocyte activation, and decreased natural killer cell activity. Hypercoagulable states improve through decreased platelet aggregation and adhesion, increased plasminogen activator, increased plasmin, increased antithrombin III, decreased fibrinogen, decreased alpha 2-antiplasmin, decreased alpha 1-antitrypsin, and decreased alpha 2-macroglobulin. Wound healing and connective tissue disorders may respond to an increase in fibroblast collagenases and decreased collagen, fibronectin, and glycosaminoglycan production. Fibroblast responsiveness to tumor necrosis factor is also diminished. Potential medical uses of pentoxifylline are reviewed.

Failure of prostaglandin induction in an obstructive müllerian abnormality.

Failure of prostaglandins E2 and F2 alpha to induce labor for intrauterine fetal death is infrequent. The factors contributing to these failures remain unclear. We describe a case of failed induction with the use of a combination of vaginal prostaglandin E2 and systemic prostaglandin F2 alpha in a 24-week intrauterine fetal death in association with a noncommunicating rudimentary uterine horn. The implications of this müllerian abnormality for theories of parturition are discussed.

Blister beetle dermatosis in Hawaii caused by Thelyphassa apicata (Fairmaire).

Members of the family Oedemeridae are known as false blister beetles. Although they have a worldwide distribution, oedemerid blister beetle dermatosis has been described only in the Pacific basin and the Caribbean. We report a case of the disorder in the Hawaiian Islands caused by Thelyphassa apicata (Fairmaire). To our knowledge this is the first case report described in that locale, and the first caused by this species.

Generalized perforating granuloma annulare.

Generalized perforating granuloma annulare is characterized by 1 to 4 mm umbilicated papules on the extremities, and is most commonly seen in children and young adults. Transepithelial elimination of mucinous, degenerating collagen fibers and surrounding palisading lymphohistiocytic granulomas are important histologic features. Perforating sarcoidosis and perforating granuloma annulare may be difficult to differentiate because of a similar clinical appearance and the presence of sarcoidal granulomas in biopsy specimens. A particularly high incidence of perforating granuloma annulare has been reported in the Hawaiian Islands.

Tumor necrosis factor.

Tumor necrosis factor is important in systemic and cutaneous defense, homeostasis, and many disease states. The numerous and diverse effects of tumor necrosis factor are best understood when considered as concentration-dependent, with normal homeostasis progressing to defense followed by toxic effects. Understanding tumor necrosis factor is important for the dermatologist as more studies appear in our literature and potential clinical uses of tumor necrosis factor (and possible anti-tumor necrosis factor agents) are realized.