Paraneoplastic pemphigus: an association with fludarabine?

Paraneoplastic pemphigus is a relatively recently described immunobullous disease with characteristic features. We report three cases of paraneoplastic pemphigus in adult men with chronic lymphocytic leukaemia arising within a week of completion of treatment with fludarabine. In all cases, withdrawal of fludarabine and treatment of the blistering was associated with marked cutaneous improvement. Fludarabine, a synthetic nucleoside analogue, which has only been available in Britain since 1994, is known to be associated with autoimmune phenomena and may have been involved in the development of paraneoplastic pemphigus in these cases.

Treatment of viral warts with cimetidine: an open-label study.

The immunomodulatory actions of cimetidine, an H2-receptor antagonist, and its use in the treatment of viral warts has been described previously but its effectiveness is still debated. We report the results in 47 patients with multiple, nongenital viral warts who were treated with oral cimetidine in a 3-month open-label study. The drug was generally well tolerated and 87% of children and 68% of adults improved with treatment. Follow-up data in 65% of the patients showed that there had been no recurrence in the majority of those whose warts had cleared completely during treatment, whereas warts tended to persist or recur in those who had stopped treatment before all the warts had resolved. Our data suggests that cimetidine may be helpful in the treatment of viral warts in both adults and children and supports the need for a randomized controlled trial.

Unique immunobullous disease in a child with a predominantly IgA response to three desmosomal proteins.

We report the case of a 15-year-old girl who presented at 11 years of age with an interesting, acquired and, to our knowledge, unique blistering disease. It involved both skin and mucous membranes with extensive oral and periungual lesions, clinically resembling paraneoplastic pemphigus. Skin biopsy showed an inflammatory cell infiltrate in the upper dermis with numerous leucocytoclastic nuclear fragments, neutrophilic papillary microabscesses and a small subepidermal bulla. Direct and indirect immunofluorescence studies showed marked intercellular staining with IgA and less prominent staining with IgG. Granular deposition of IgA and, to a lesser extent IgG and C3, was also seen along the basement membrane zone. Immunoblotting and enzyme-linked immunosorbent assay studies showed both IgG and IgA antibodies to desmocollin, desmoglein 3 and desmoplakin. However, despite extensive investigation, no underlying neoplasm was found. Treatment with dapsone and sulphapyridine proved ineffective but methylprednisolone and azathioprine have reduced the blistering. We believe that this patient is unique for her combination of IgA and IgG antibodies to desmoplakin, desmocollin and desmoglein 3, although further studies may provide further clarification.

The problems of rubber hypersensitivity (Types I and IV) in chronic leg ulcer and stasis eczema patients.

The prevalence of Type I and Type IV hypersensitivity to rubber allergens in patients with stasis eczema and/or venous leg ulcers over an 18-month period was studied by prick and patch testing. Results from 109 patients were analysed. Positive patch tests were found in 71 patients (65%). Delayed-type hypersensitivity to rubber chemicals was found in 17 patients (15.6%). However, only 1 patient who had additional risk factors showed Type I hypersensitivity to natural rubber latex. We therefore conclude that, although Type IV hypersensitivity to rubber chemicals is relatively common in our patients, Type I hypersensitivity to natural rubber latex remains rare.

Recalcitrant viral warts: results of treatment with the KTP laser.

We report the use of a potassium-titanyl-phosphate (KTP) continuous wave laser in an open study to treat 25 patients with multiple nongenital warts that had failed to respond to conventional therapies. All patients were treated monthly using the 532 nm KTP continuous wave laser and robotic scanner. Twenty patients (80%) responded to treatment with warts: in 12 patients there was complete clearing. Moderate discomfort was reported during the procedure but subsequent morbidity was slight with no evidence of scarring. Follow-up by postal questionnaire revealed that warts recurred in those patients who had stopped treatment early but not in those whose warts had been treated to complete clearance.

Squamous cell carcinoma associated with lupus vulgaris.

Squamous cell carcinomas are known to arise in certain chronic, scarring dermatoses and also to be associated with exposure to ultraviolet radiation. We now report a case arising in a plaque of lupus vulgaris, the patient having received radiation from a Finsen lamp as a child for a tuberculous abscess in that region.

Use of topical cyclosporin in oral pemphigus.

The use of systemic cyclosporin in the treatment of pemphigus is well recognized. Oral lesions in pemphigus vulgaris are common but can be very difficult to treat. Short use of topical cyclosporin has been reported in a few cases of oral pemphigus. We report the successful use of topical cyclosporin for several years in a patient with debilitating oral pemphigus in whom systemic immunosuppressive agents and topical steroids had been ineffective and in whom cyclosporin was used not only to induce but also to maintain remission.

Merkel cell carcinoma arising after therapeutic immunosuppression.

Azathioprine and cyclosporin have been used as immunosuppressants for many years, but long-term use has also been associated with neoplasia. We report three cases of rapidly fatal Merkel cell carcinoma in patients who had been treated with azathioprine for many years either for rheumatoid arthritis or following organ transplantation. Two of these patients had also received cyclosporin. We suggest that Merkel cell carcinoma may be seen more commonly in immunosuppressed patients than in the normal population and that the oncogenic potential of azathioprine and cyclosporin should be borne in mind when prescribing these drugs.

Cutaneous lymphocytic vasculitis in acute myeloid leukaemia.

We report a 63-year-old woman who presented with an 8-week history of widespread indurated, purpuric lesions associated with weight loss of 7 kg and several episodes of epistaxis. A skin biopsy demonstrated a lymphocytic vasculitis with haemorrhage and parakeratosis. A blood film and bone marrow examination showed features of a myelodysplastic syndrome in transformation to acute myeloid leukaemia. Leucocytoclastic vasculitis and polyarteritis nodosa occur in association with acute myeloid leukaemia, but the association with lymphocytic vasculitis is new.

Does thrombolysis affect the prognostic value of the post-infarct exercise test?

There has been some debate on usefulness of the exercise test in risk stratification after myocardial infarction in the thrombolytic era. This was assessed in 295 patients of whom 184 were treated with thrombolysis. Each had an exercise test using a modified Naughton protocol within 14 days of acute myocardial infarction. The tests were graded as high risk positive (112), low risk positive (83), or negative (100). These gradings predicted use of multiple drug therapy (p = 0.05), severity of coronary artery disease (p < 0.01), and coronary artery bypass grafting (p < 0.01). There was no influence on heart failure, recurrent myocardial infarction or death. This was independent of the use of thrombolytic therapy. The whole group had a good prognosis with a mortality of 2.4% after 56 weeks' follow-up. The exercise test is still a useful screening test after myocardial infarction. In this study, there was a high negative predictive accuracy of 91% for any event. Its use is not altered by thrombolysis. The finding of a lack of influence of the exercise test on major events may be a reflection of the current good prognosis after myocardial infarction and the prompt use of revascularisation.