Euthyroid pretibial myxedema.

OBJECTIVE: To describe a case of biopsy-proven pretibial myxedema in a man with normal thyroid function. METHODS: We present the pertinent clinical and laboratory data for the current case and review previously published information on pretibial myxedema. RESULTS: Our patient, a 53-year-old man, had the characteristic lesions of pretibial myxedema on the anterolateral aspects of his calves. Laboratory tests showed normal thyroid function. The thyroid-stimulating immunoglobulin value was above normal. No exophthalmos or goiter was present. This uncommon dermopathy is typically associated with Graves' disease, accompanied by clinical hyperthyroidism, ophthalmopathy, and goiter. CONCLUSION: The pathogenesis of pretibial myxedema remains elusive. It is presumed to be an autoimmune phenomenon attributable to the presence of serum thyroid-stimulating immunoglobulin, although immunofluorescence studies have failed to demonstrate a direct role for such an immunoglobulin. Only two other cases of biopsy-proven pretibial myxedema in a euthyroid patient were found in the literature.

Measurement of suberythema UVA radiation effects on skin by 31P magnetic resonance spectroscopy.

31P magnetic resonance spectroscopy (MRS) scans were obtained from the same anatomical location in four healthy Caucasian individuals before and after 1/2 MED UVA radiation. Suberythema UVA radiation induced in skin production of phosphomonoesters, phosphodiesters, and also depleted phosphocreatine and adenosine triphosphate (ATP). This data seems to indicate that 31P MRS is a sensitive enough technique to detect UVA induced changes in skin phosphometabolites. Furthermore, this data also appears to indicate that suberythema UVA radiation and dexamethasone induce in skin nearly identical pharmacodynamic effect.

Monitoring wound healing of venous stasis leg ulcers by in vivo (31) P magnetic resonance spectroscopy.

BACKGROUND/AIMS: Venous stasis ulcers is a frequent clinical problem. Objective techniques for characterization and monitoring of wound healing are needed including noninvasive study of biochemical changes associated with the healing process. (31) P magnetic resonance spectroscopy was not used in the past to study human wound healing in vivo. METHODS: (31) P magnetic resonance spectroscopy with study of intracellular pH, phosphocreatine, and the phosphocreatine/inor-ganic phosphate ratio was used. Six patients with venous leg ulcer and three controls were studied. RESULTS: Both intracellular pH, phosphocreatine and the phos-phocreatine/inorganic phosphate ratio were found sensitive indicators of wound healing. Surprisingly the intracellular pH in healing ulcers was in the alkali range. CONCLUSION: (31) P magnetic resonance spectroscopy was found useful for the study of biochemical changes associated with wound healing. pH in the alkali range was an unexpected observation.

Identification and activity of cytosol creatine phosphokinase enzymes in normal and diseased skin.

Phosphocreatine molecules (PCR) in skin regenerate adenosine triphosphate and help cutaneous tissue survive ischemia associated with skin flaps, grafts, and hair transplantation procedures. In addition, PCR concentration in psoriasis is elevated many times above normal, indicating either overproduction of PCR by mitochondrial creatine phosphokinase (CPK) enzymes or a defect in cytosol CPK enzymatic activity. Skin CPK isoenzymes, before this study, have not been identified. Herein, for the first time, cytosol CPK enzymatic activity was measured in normal and psoriatic, involved and uninvolved skin, skin tumors, and mouse skin and keratinocyte cell cultures. Creatine phosphokinase MM is the major isoenzyme in normal, uninvolved psoriatic and mouse skin. Total CPK enzymatic activity was increased in psoriasis and skin tumors. These data clearly indicate that increased PCR concentration in a psoriatic skin is not a result of decreased cytosol CPK enzymatic activity.

Human in vivo phosphorus 31 magnetic resonance spectroscopy of psoriasis. A noninvasive tool to monitor response to treatment and to study pathophysiology of the disease.

BACKGROUND: There is no objective laboratory technique to measure and to monitor disease activity in psoriasis. OBJECTIVE: We assessed the effectiveness of using phosphorus 31 (31P) magnetic resonance spectroscopy (MRS) to noninvasively monitor metabolism in psoriasis and to compare these spectroscopic data with chromatographic analysis. METHODS: Fourteen persons were enrolled in the study. 31P magnetic resonance spectra were obtained from skin of persons without skin disease, uninvolved psoriatic skin, nonpsoriatic erythroderma, and from skin of patients with psoriasis. In three patients with psoriasis 31P magnetic resonance spectra were repeated after treatment with methotrexate, UVB, etretinate, and topical steroids. Finally, shave biopsy specimens were obtained from two patients with psoriasis and submitted for chromatographic evaluation. RESULTS: In patients with severe psoriasis, in comparison with the control group, elevations in phosphomonoester concentrations and in the phosphomonoester/phosphodiester ratio were observed. These appear to be useful markers to monitor treatment response in patients with psoriasis. Finally, 31P MRS data in conjunction with chromatographic analysis indicated a defect in phosphometabolism in psoriatic skin. However, it is unclear whether this defect is a cause or an epiphenomenon of the disease. CONCLUSION: 31P MRS appears to be a sensitive, noninvasive technique to monitor disease activity in psoriasis. Further studies to characterize the defect in phosphometabolism in psoriatic skin are warranted.

Acquired purpura fulminans induced by alcohol and acetaminophen. Successful treatment with heparin and vitamin K.

Purpura fulminans is a rare syndrome of progressive hemorrhagic necrosis of the skin that may present as a dermatologic emergency. It most commonly affects children during the convalescent phase of a streptococcal infection or a viral exanthem. In adults, it may be associated with sepsis or acquired causes. Its pathogenesis has challenged physicians for decades. It has been discovered that purpura fulminans is almost always associated with disseminated intravascular coagulation and can occur in subjects with inherited or acquired deficiencies of the protein C anticoagulant pathway. Patients with liver compromise may also be potential candidates for coagulopathies secondary to hepatic dysfunction and impaired protein synthesis. It is widely recognized that individuals who consume alcohol on a long-term basis may develop severe hepatotoxicity from ingestion of therapeutic doses of acetaminophen (500 to 1000 mg every 4 to 6 hours). We have observed a patient with chronic alcoholism in whom hepatotoxicity and purpura fulminans developed secondary to the ingestion of acetaminophen.

Pityriasis rubra pilaris presenting as subacute cutaneous lupus erythematosus.

Diseases of a very different nature may occasionally present in a similar manner. Differentiating among several possible diagnoses may be complicated by confusing and conflicting laboratory data. Our recent evaluation and treatment of a patient confirmed the need for thorough testing, particularly in patients suspected of having a connective tissue disorder.