Orbital Cellulitis in a Psoriatic Patient Treated With Adalimumab.

INTRODUCTION: Psoriatic patients on tumor necrosis factor alpha inhibitors (TNFi) may be at increased risk for upper respiratory tract infections, including chronic rhino-sinusitis (CRS). Rarely, CRS can progress to orbital cellulitis (OC), an emergent ophthalmic complication wherein respiratory flora from paranasal sinus disease intrude the retro-orbital space. MATERIALS AND METHODS: Single case report. RESULTS: We report the first case, to our knowledge, of an invasive sinusitis that rapidly evolved into OC in a patient receiving adalimumab treatment for plaque psoriasis and psoriatic arthritis. After TNFi withdrawal and appropriate medical and surgical intervention, the patient fully recovered. However, on resumption of TNFi therapy, symptoms of recalcitrant CRS returned. CONCLUSION: More investigation is needed to explore how TNFi might predispose to chronic, refractory rhino-sinusitis and subsequent progression to OC. Military physicians and other medical providers should be aware of this proposed new disease entity and the potential for rapidly evolving and invasive infections in immunocompromised patients. Screening and monitoring for chronic infectious disease, such as CRS before initiating and during TNFi therapy is warranted.

Atypical fibroxanthoma-a diagnosis of exclusion!

Fibrohistiocytic tumors of the skin comprise a large range of lesions. One such tumor is the atypical fibroxanthoma (AFX), which is widely considered as a "pseudomalignant" tumor. It is derived from fibroblasts and expresses a variety of histiocytic markers. We present a case of AFX, localized in the right temporal region of the scalp, successfully treated with surgical excision. Immunohistochemical staining helps differentiate this tumor from others in the clinical differential diagnosis, including malignant melanoma, squamous cell carcinoma, and other nonmelanocytic spindle cell tumors such as leiomyosarcoma, rhabdomyosarcoma, angiosarcoma, liposarcoma, and dermatofibrosarcoma protuberans. Historically, AFX was believed to be a superficial variant of malignant fibrous histiocytoma (MFH). However, MFH is now considered a more generalized term for a sarcomatous neoplasm of the subcutaneous tissue. The histopathology of MFH shares features with some malignant mesenchymal neoplasms such as liposarcoma, leiomyosarcoma, rhabdomyosarcoma, and angiosarcoma, but can be differentiated using immunohistochemistry and/or electron microscopy. More recently, the examples of MFH that do not exhibit a more specific line of differentiation have been reclassified as undifferentiated pleomorphic sarcoma (UPS). Many authors currently cannot draw a distinction between AFX and UPS. The clinical and histopathological differences between AFX and UPS are often difficult to delineate. It is probable that they represent two poles of the same disease. Surgical excision in the patient we describe resulted in excellent aesthetic results with lack of recurrence in the 7-month postoperative period.

Use of a variable long-pulse alexandrite laser in the treatment of facial telangiectasia.

BACKGROUND: The alexandrite laser selectively targets melanin and hemoglobin. We used the alexandrite laser with variable pulse widths to treat facial telangiectasia. METHODS: Nineteen patients were enrolled in this study, which consisted of two parts: a series of test spots over a range of pulse durations (3-80 ms) and treatment over a larger area based on the pulse width-specific outcomes from the test spots. The final follow-up visit was 12 weeks after irradiation. RESULTS: The 40-ms pulse width achieved the optimal balance of pain tolerance, epidermal tolerance, and vessel reduction. Mean fluence was 88 J/cm(2), with a 6-mm spot. Overall, a 48% reduction in vessels was noted after one treatment. Side effects were minimal. CONCLUSIONS: In fair-skinned patients with large telangiectasia, the alexandrite laser is a good option for vessel reduction.

Hand dermatitis: review of etiology, diagnosis, and treatment.

Hand dermatitis is a common condition seen in the primary care setting. Occupational exposures and frequent hand washing often lead to symptoms that are irritating and may cause discomfort. Irritant dermatitis, atopic hand dermatitis and contact hand dermatitis account for at least 70% of all diagnoses. A unifying feature in most cases is an underlying disruption in the stratum corneum, altering its barrier function. Transepidermal water loss increases with barrier disruption and is exacerbated by additional exposure to water. Precise diagnosis and subsequent treatment present a considerable challenge, and hand dermatitis often becomes chronic. Initial treatment should be aimed at controlling inflammation and restoring the skin's natural barrier. Common management recommendations include the avoidance of irritants and potential allergens along with the use of emollients and topical corticosteroids to decrease inflammation. Simple petroleum-based emollients are very effective at restoring hydration and repairing the stratum corneum. Referral to a Dermatologist or an Allergist may be necessary for patients who require patch testing or those with refractory symptoms.

Delayed autoimmune hemolytic anemia in efalizumab-treated psoriasis.

Efalizumab, a humanized anti-CD11a monoclonal antibody, has been shown to treat plaque psoriasis. A known association between this drug and autoimmune thrombocytopenia has already been established. More recently publicized, however, is efalizumab's ability to affect another cell line--that of the erythrocyte--and cause an autoimmune hemolytic anemia that typically occurs 4 to 6 months after initiating therapy. In this article, we report the case of a patient who developed autoimmune hemolytic anemia after 8 months of successful treatment with efalizumab. His delayed presentation suggests that monitoring of blood cell counts longer than 6 months may be warranted.

Atypical cutaneous myeloid infiltrate in myelodysplastic syndrome: a case report.

We report the case of a 31-year-old man with an atypical myeloid dermal infiltrate manifested by a 1.5-year history of recurrent erythematous plaques over his body that previously were shown to be culture positive for Staphylococcus aureus and had responded well to oral antibiotic treatment. The ultimate diagnosis was refractory anemia with excess blasts-2 (RAEB-2), a myelodysplastic syndrome (MDS). Whether it is a specific or nonspecific lesion, cutaneous involvement in MDS is a poor prognostic factor. Leukemia cutis (LC), a specific dermal infiltrate of malignant hematopoietic cells, particularly is associated with progression to acute leukemia. However, the pathology of our patient's lesions revealed a more sparse sprinkling of atypical mononuclear cells indicative of an inflammatory recruitment of leukemic cells to the dermis. Nonetheless, the guarded prognosis of this high-risk subtype of MDS mandates continued monitoring for development of LC and progression to leukemia.