Acquired perforating dermatosis in diabetes mellitus: an unusual case.

A case of elastosis perforans serpiginosa in a patient who presented with insulin-dependent diabetes mellitus secondary to pancreatic insufficiency in a background of common variable immunodeficiency and endocrinopathy, as evidenced by pernicious anaemia and growth hormone deficiency, is described. In acquired perforating dermatosis occurring in patients with diabetes or renal failure, there is a spectrum of changes that may show an overlap of histological features of the four classic perforating diseases. The biopsy changes of the patient described in the present study most closely resembled those of elastosis perforans serpiginosa.

Intracranial epithelioid hemangioendothelioma arising at site of previously excised atypical meningioma.

Epithelioid hemangioendothelioma is an uncommon vascular tumor which, in most cases, pursues a clinical course intermediate between hemangioma and angiosarcoma. Only four completely documented cases of central nervous system involvement by this tumor appear in the literature. We present an additional case, which is remarkable in its occurrence at the site of a previously excised atypical meningioma and in its unusually aggressive clinical course. To our knowledge this is the first report of intracranial epithelioid hemangioendothelioma with postmortem documentation. The patient initially presented with a 7 cm right post frontal tumor; an atypical meningioma was excised and removal appeared complete on immediate post-operative scans. Seven months later the patient re-presented with tumor recurrence at the previous operative site; a second craniotomy was performed and, on this occasion, the excised tumor had the histological features of an epithelioid hemangioendothelioma without evidence of meningioma: both morphologically and immunohistochemically the two tumors were quite distinctive. Further recurrence prompted radiotherapy but the patient continued to deteriorate and died five months later. Massive recurrence of intracranial tumor was found at postmortem examination.

An alternative regimen of hormone replacement therapy to improve patient compliance.

In order to achieve the long-term benefits from hormone replacement therapy of a markedly reduced incidence of heart disease and osteoporosis, a high degree of compliance is essential. In an effort to obtain high compliance, it was decided to introduce a cyclic therapy of 6 months duration using conjugated oestrogens supported by a 10-day course of progestogens. A total of 85 patients were treated prospectively. Compliance was assessed by the number of patients continuing treatment, and endometrial response was assessed by office biopsy and cytological or histological examination. Five patients withdrew, giving an overall compliance rate of 94%. Two have subsequently resumed therapy, thus 98% of those enrolled are currently receiving hormone replacement therapy. No cases of endometrial carcinoma were detected during the trial period of 4 years. Two cases of mild atypical endometrial hyperplasia were detected but both were mild and reverted to secretory or inactive endometrium following progestogen therapy. This regimen provides a viable alternative for those women who are troubled by progestogenic side-effects and monthly withdrawal bleeding.

Carotid intraplaque hemorrhage: the significance of neovascularity.

Renewed interest in the neovascularity of atherosclerotic plaques has followed the work of Imparato et al., which confirmed the importance of carotid intraplaque hemorrhage in the production of symptomatic extracranial vascular disease. We have studied the detailed histology of 91 carotid atheromatous plaques with particular regard to hemorrhage and neovascularity and have confirmed the findings of earlier investigators while observing degenerative changes (not previously reported) in these new vessels. The possible role of systemic hypertension in intraplaque hemorrhage and the acceleration of the atherosclerotic process is discussed.

Fatal migraine.

A 58-year-old woman, with a past history of classic migraine since youth, suddenly experienced blurred vision and flexor spasms of her left hand, followed by a right hemicrania and photophobia, similar to previous attacks of migraine. Within a few hours a progressive left hemiplegia and paralysis of left conjugate gaze developed. Severe right hemicrania continued. CT brain scans showed a progressing large right parietotemporal infarct. Her level of consciousness declined and she died ten days after admission to hospital. The autopsy showed a large infarct in the area of supply of the right middle cerebral artery, associated with oedema and with a shift of midline structures to the left, with cingulate and right hippocampal herniation. There was secondary midbrain haemorrhage. Recent secondary haemorrhagic infarction was present in the left calcarine cortex. The carotid arteries in the neck showed only minimal atheromatous change and were patent; the cerebral arteries were remarkably free of atheroma, but the right middle cerebral artery contained red thrombus. Histologically the cerebral infarction antedated the middle cerebral artery thrombus by several days, supporting arterial spasm as the cause of infarction. The thrombosis was considered to be a secondary phenomenon.

Progressive multifocal leucoencephalopathy: CT and pathological features.

A case is presented of a 58-year-old woman with treated lymphocytic lymphoma in histologically proven complete remission who developed progressive multifocal leucoencephalopathy (PML) which extended over several weeks until she died from hypostatic pneumonia. The characteristic abnormal findings in this disease are presented together with the features on computerized tomography (CT scan). Attention is drawn to the usefulness of CT scanning in the diagnosis of this disease.

Pelvic actinomycosis in association with an intrauterine contraceptive device.

PIP: A case of pelvic actinomycosis, now seen as a complication of intrauterine contraceptive devices, is reported. A 32-year old nulliparous women who had developed pain and irregular bleeding over the previous month presented initially for removal of a Dalkon shield IUD. For the previous 5 years the IUD had caused no symptoms. The Dalkon shield could not be removed, and vaginal examination revealed a tender mass in the pouch of Douglas. The patient was hospitalized for a laparoscopy and removal of the IUD under general anesthesia. Laparoscopy revealed an acute pelvic inflammatory disease (PID) with pus leaking from bilteral pyosalpinges. The IUD was removed, and the patient was treated with parenterally by administered penicillin and streptomycin for 5 days. 3 weeks later the patient was readmitted, complaining of nausea, vomiting and malaise. Clinically she was febrile, with signs of an acute abdomen. On vaginal examination, a large tender mass was palpable in the pouch of Douglas, and the blood film revealed a leukocytosis. When her condition failed to improve after treatment with penicillin and streptomycin, a laparotomy was performed. Gross PID was found with a large ruptured tubo-ovarian abscess on the right side. A total abdominal hysterectomy with bilteral salpingo-oophorectomy was performed. After the removal of the infected organs, her temperature dropped and her condition improved rapidly. Pathological findings are reported.^ieng