Kaposi sarcoma: no longer an AIDS-defining illness? A retrospective study of Kaposi sarcoma cases with CD4 counts above 300/mm³ at presentation.

BACKGROUND: Historically, Kaposi sarcoma (KS) has been considered to occur in patients infected with human immunodeficiency virus (HIV) who have low CD4 counts and high viral loads. However, merging data show that KS also occurs in HIV-positive patients with CD4 counts of > 300/mm(3) and undetectable viral loads. AIMS: To investigate the characteristics of HIV-positive patients with CD4 counts of > 300 cells/mm(3) and presence of KS. METHODS: This was a retrospective study of 23 cases of histologically confirmed KS in HIV-positive patients presenting to King's College Hospital between 2005 and 2011. RESULTS: Of the 23 cases, 7 (30%) had a CD4 count of > 300 cells/mm(3) at diagnosis of KS; 2 were being treated with highly active antiretroviral therapy (HAART) at the time of KS diagnosis, while the remaining 5 patients were HAART-naïve. All 7 patients were men, and all had a lower median age, higher recorded CD4 counts and more recent HIV diagnosis than the 16 patients with lower CD4 counts (< 300/mm(3) ) at the time of KS diagnosis. CONCLUSIONS: We report seven cases of KS in patients with CD4 count > 300/mm(3) , most of whom were HAART-naïve at the time of KS diagnosis. Contemporary data indicate that KS presenting with CD4 counts > 300/mm(3) usually occurs in patients established on HAART, which is not borne out by the results of our study.

Drug reaction with eosinophilia and systemic symptoms: is cutaneous phenotype a prognostic marker for outcome? A review of clinicopathological features of 27 cases.

BACKGROUND: Drug reaction with eosinophilia and systemic symptoms (DRESS) describes a heterogeneous group of severe adverse reactions to medications. The cutaneous phenotype has a number of guises, accompanied by a variety of systemic features including fever, haematological abnormalities and visceral involvement, most commonly the liver. Clinical markers of prognosis have not been identified. OBJECTIVES: To assess the cutaneous signs and dermatopathological features of DRESS in order to identify potential prognostic markers. METHODS: We reviewed the clinical features, dermatopathology and outcomes of 27 consecutive cases of DRESS presenting to a single unit. RESULTS: Four distinct patterns of cutaneous involvement were identified: an urticated papular exanthem (13/27 patients), a morbilliform erythema (three of 27), an exfoliative erythroderma (three of 27) and an erythema multiforme-like (EM-like) reaction consisting of atypical targets (eight of 27). All patients mounted a fever, most developed lymphadenopathy (24/27) and peripheral eosinophilia (25/27) and the most common organ involved was the liver (27/27). Review of the dermatopathic features of patients with DRESS demonstrated a superficial spongiotic dermatitis in the majority of cases (16/27). A smaller number of cases showed basal cell vacuolar degeneration and necrotic keratinocytes (nine of 27). The patients with these biopsy findings more commonly had an EM-like cutaneous phenotype, and more severe hepatic involvement. Three patients died, two following failed liver transplants. CONCLUSIONS: Our series is the first in which a detailed dermatological assessment has been made of consecutive patients presenting with DRESS, and the largest U.K. series to date. Our results suggest a possible prognostic role of the cutaneous and dermatopathic findings in DRESS in predicting the severity of visceral involvement in this syndrome. What's already known about this topic? • Drug reaction with eosinophilia and systemic symptoms (DRESS) has a heterogeneous clinical presentation, with a skin eruption of variable morphology. • DRESS carries considerable morbidity and mortality, usually hepatic in origin, although renal, pulmonary and pericardial involvement can be seen. What does this study add? • The cutaneous phenotype in DRESS can be categorized as an urticated papular exanthem, a morbilliform erythema, exfoliative erythroderma or erythema multiforme-like (EM-like). • An EM-like eruption DRESS may be prognostic of more severe hepatic involvement.

Erythema multiforme following polymorphic light eruption: a report of two cases.

We report two patients in whom episodes of polymorphic light eruption were followed by recurrent erythema multiforme on exposed and nonexposed sites. Treating the polymorphic light eruption with prophylactic PUVA and/or oral prednisolone or cyclosporin prevented the development of erythema multiforme, suggesting that the two events are related. It is possible that erythema multiforme develops as a response to the same causative antigen as polymorphic light eruption.

Scytalidium dimidiatum causing recalcitrant subcutaneous lesions produces melanin.

Scytalidium dimidiatum is a pigmented dematiaceous coelomycete that typically causes chronic superficial skin diseases and onychomycosis, as well as deeper infections, such as subcutaneous abscesses, mycetoma, and even fungemia in immunocompromised patients. A second species, Scytalidium hyalinum, has hyaline hyphae and arthroconidia and is considered by some authors to be an albino mutant of S. dimidiatum. This study aimed to confirm the presence of melanin or melanin-like compounds (which have been previously implicated in the virulence of other fungal pathogens) in S. dimidiatum from a patient with multiple subcutaneous nodules. Treatment of the hyphae and arthroconidia with proteolytic enzymes, denaturant, and concentrated hot acid yielded dark particles, which were stable free radicals, consistent with their identification as melanins. Extracted melanin particles from S. dimidiatum cultures were labeled by melanin-binding monoclonal antibodies (MAbs) from Sporothrix schenckii, Aspergillus fumigatus, and Cryptococcus neoformans. Lesional skin from the patient infected with S. dimidiatum contained fungal cells that were labeled by melanin-binding MAbs, and digestion of the tissue yielded dark particles that were also reactive. S. hyalinum was also subjected to the melanin extraction protocol, but no dark particles were yielded.

Sporotrichosis.

Sporotrichosis is a cutaneous fungal infection with a global distribution. The disease has several clinical forms, primarily cutaneous with associated lymphadenopathy. However, dissemination to osteoarticular structures and viscera may occur, both in healthy and immunosuppressed individuals; such disseminated forms usually follow spread after inhalation of fungal spores. Cutaneous infection is usually associated with trauma during the course of outdoor work, and treatment is required for the majority of patients. Potassium iodide (the treatment of choice in endemic areas) is an effective and inexpensive therapy; however, its adverse effects and complicated dosage regimen often weigh against its use in developed countries, where itraconazole is the antimycotic of choice.

Dermatitis caused by physical irritants.

BACKGROUND: Although physical irritant contact dermatitis (PICD) is a common occupational dermatosis, it is one of the least well understood because of its multiple types, lack of diagnostic test, and the many mechanisms involved in its production. OBJECTIVES: To characterize the materials and mechanisms of physical irritation of the skin. METHODS: We did a retrospective analysis over the past 20 years of all patients with a diagnosis of PICD at St John's Institute of Dermatology Contact Dermatitis Clinic. RESULTS: Of the 29,000 patients who attended the clinic over the study period, 392 patients were diagnosed with PICD and of these, 335 files were analysed. CONCLUSIONS: Our findings show that PICD accounted for 1.15% of all patients attending the contact clinic over the study period. Diverse occupations and materials were implicated. The most common cause of PICD was low humidity due to air-conditioning, which caused dermatitis of the face and neck in office workers due to drying out of the skin.

Mycobacterium abscessus: a cutaneous infection in a patient on renal replacement therapy.

We report a 72-year-old man on haemodialysis who presented with multiple abscesses on his lower legs. Routine bacterial culture of abscess pus was reported as 'sterile' after 48 h, leading to the suspicion of a mycobacterial infection. Skin biopsy taken for mycobacterial microscopy and culture isolated a heavy growth of Mycobacterium abscessus.

Lichen myxoedematosus with associated cardiac abnormalities.

We describe a 42-year-old woman who developed lichen myxoedematosus. Twenty years after the onset of the disease she became breathless and hypertensive, and an echocardiogram showed a mass on the mitral valve, which was thought to be a mucin deposit. Her hypertension was resistant to treatment with combination antihypertensives. To our knowledge, this is the first report to link lichen myxoedematosus with a valvular mucinous mass. This case also demonstrates the slow clinical progression of the disease over 20 years.