Advanced Pretibial Melanoma (APM): Clinicians Behaviour As Triggering Factor?

BACKGROUND: Pigmented lesions represent a broad spectrum of clinical conditions, both benign and malignant. The precise diagnosis is often a challenge, while the clinical diagnostic criteria could be misleading, as a result of the frequently atypical presentation of otherwise completely benign in nature lesions. The variety of therapeutic options for benign pigmented lesions including shave curettage, local laser destruction, electrocoagulation removal could sound enticingly both for the physician and patient, but they destroy the possibility for histological examination and provide a deceptively feeling of calm, that the problem is solved. If there is even a minimum chance for misdiagnosis, the risk could be a human life. Furthermore, a simple surgical excision could provide total resolution of the problem, with correct histological verification and further therapeutic measurements, if needed. CASE REPORT: We present a case of a patient, with advanced pretibial melanoma with multiple lung metastases, misdiagnosed as a seborrheic keratosis, treated with shave-curettage 6 months earlier, as we want to emphasize the importance of the correct therapeutic method in all cases with pigmented lesions with unknown origin, in order to minimize the risk of dramatic consequences of misdiagnosis of melanoma. So, we want to ask you- is this risk justified? CONCLUSION: So, we want to ask you - is this risk justified?

Neurofibromatosis Type 1 with Massive Ventricular Polyposis: First Report in the Medical Literature.

BACKGROUND: Neurofibromatosis type 1 (NF1) is a multisystemic disorder with genetic background, characterised by specific cutaneous findings, skeletal dysplasias, and growth of both benign and malignant nervous system tumours. NF1 is caused by mutations in the NF1 gene, situated in chromosome 17q11.2, with an autosomal dominant pattern of inheritance and clinical manifestation of neurofibromas, malignant peripheral nerve sheath tumour, optic and non-optic nerve gliomas, congenital heart disease, cardiovascular and cerebrovascular disease and orthopaedic disorders. The incidence of gastrointestinal manifestations of NF1 is relatively low, compared to neurological disorders, presenting approximately in 5 to 25% of the patient, but later in life. CASE REPORT: We present a patient with NF1, ventricular polyposis and attentional disorders with cognitive phenotype, while both of her daughters also present with cutaneous manifestations of NF1. CONCLUSION: To the best of our knowledge, this is the first reported case of NF1 with ventricular polyposis as a gastrointestinal manifestation in the mother and NF1 with no signs of inner organ involvement in both of her daughters.

Para - And Intraurethral Penile Tumor - Like Condilomatosis.

Condyloma acuminata represents an epidermal manifestation, associated with the epidermotropic human papillomavirus (HPV). They have been reported as the most common sexually transmitted disease, with prevalence exceeding 50%, increased up to 4 times, within the last two decades, as the most common side of affection are the penis, vulva, vagina, cervix, perineum, and perianal area, with increased prevalence in young, sexually active individuals. Increased attention should be focused on lesions, caused by types, with moderate (33, 35, 39, 40, 43, 45, 51-56, 58) or high risk potential (types 16, 18) for malignant transformation, leading to further development of cancers of anus, vagina, vulva and penis, as well as cancers of the head and neck. A provident of coexistence of many of these types in the same patient could be seen in approximately 10-15% of patients, as the lack of adequate information on the oncogenic potential of many other types complicated the treatment and the further outcome. Although the variety of treatment options, genital condylomata acuminata still show high recurrent rate to destructive topical regiments, because of the activation of the viruses at some point, which emphasise the importance of virus- eradication, instead only of the topical destruction of the lesions. Despite decreasing the recurrent rate, the most important goal of immunisation is the reduction of the incidence of HPV-associated squamous cell carcinomas using either the quadrivalent (Silgard/Gardasil) or the bivalent (Cervarix) HPV (human papillomavirus) vaccine. We present a patient with periurethral condylomata acuminate, who refused performing of a biopsy for determining the virus type, as we want to emphasize the importance of the virus - treatment in all cases of genital warts, instead only of topical destruction of the lesions, not only because of the recurrence incidence rate, but also because of the well - known oncogenic potential of some HPV - types, as well as the unknown potential of various underestimated types, in contrast.

Another Case of Interdigital Located "Metastasing Hematoma"?

Interdigital spaces could be an area of affection of a various cutaneous conditions, most of them with benign origin. The spectrum of differential diagnosis of pigmented interdigital lesions with a recent occurrence is not so wide, in contrast. When considering pigmented lesions in the interdigital area, the most harmless differential diagnosis is a traumatic hematoma. But what would happen if we based our therapeutic behaviour or suspicious and unconfirmed harmless diagnosis, instead of considering the real life-threatening once with priority, if we kept in mind that acral lentiginous melanoma has rather an aggressive course and is the main cause of death in skin cancer patients? We present a case of misdiagnosed interdigital melanoma, treated as a hemangioma with curettage, with almost fatal consequences, in regard to uncontrolled tumor progression as a result of the wrong traumatic procedure in one hand, and the lack of adequate screening and follow up, leading to progress of the disease with lymph node metastasis and poor prognosis in general. We want to emphasise the importance of acral lentiginous melanoma with an unusual location in the differential diagnostic plan because, despite the early detection, early eradication with simple excision could save a life, or at least could provide a better prognosis.

Psoriasiform Dermatophytosis in a Bulgarian Child.

Although tinea capitis is the most common fungal infection in children, significant changes have been reported in its epidemiology worldwide, as a result from certain geographic, climatic and cultural differences in one hand, as well as the changes in its etiologic pattern. The clinical manifestation of the infection and the stage of inflammation vary from mild desquamation to severe suppurative indurated plaques in kerion - like the pattern, depending on the nature of the etiologic agent and the host-immune response. We report a case of tinea capitis profunda, caused by Trichophyton verrucosum in a 5 - year - old male patient, presented as a severe scalp and cutaneous desquamation, resembling histopathologically psoriasis, associated with severely indurated ringworm plaque in the temporal area. The performed histological examination revealed a psoriasiform pattern, without the typical Munro abscesses or Kogoj pustules. With the presented case, we want to emphasize the importance of the host's immune reaction to zoophilic dermatophytes, such as Trichophyton verrucosum, resulting in severe and often atypical clinical manifestation, as well as the possible "Id reaction", to avoid or minimise misdiagnosis and delayed therapy. The presented patient was treated with topical oleum acidy salicylic 10% and Terbinafine 125 mg daily with significant resolution of the complaints within the following two months.

A Patient with Multiple Keratinocytic Cancers (MKC): Uncommon Presentation in a Bulgarian Patient.

Keratinocyte skin cancers, including basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), are the most common cancer occurring in people with fair skin, worldwide. Despite all known triggers, several suggested contributors are still investigated. We will focus our attention on the personal history of previous cancers and radiation exposure as occupational risk factors, as in the presented case. We report a patient, with multiple BCCs, and subsequent occurrence of a SCC on photo-exposed area of the face, as we want to emphasize the importance of strict following up of these patients, regarding the risk for developing new tumors in short periods of time, no matter if the triggering exposure factor is known from the history, or not. Although keratinocytes tumours are associated with the low mortality rate, we focus the attention on the fact, that the history of non-melanoma skin cancer is associated with increased mortality.

Seborrheic Pemphigus, Antigen Mimicry and the Subsequent-Wrong Diagnostic and Therapeutic Approach?

It is well-established that drugs could be leading cause of occurrence of numerous diseases, including pemphigus, being either inducer or triggering factor of the autoimmunity. Despite medications, it should be kept in mind that chronic or acute infections are also capable of being a trigger in various types of cutaneous eruptions, including pemphigus. The rapidly obtained and uncompleted history for accompanied medication leads to general mistakes in the subsequent treatment approach, as the first step in such cases is discontinuation of the drug-inductor. The absence of this information guaranties the fail of the treatment. On the other hand, the lack of performed screening for chronic or acute hepatitis and tuberculosis is not the only mistake, regarding the high dosage of immunosuppressors that have been planned as regiment and the possible fatal effect on the infection's spread or exacerbation, but also because of the possible triggering ability of chronic or acute infection, which may play also a key role in the generation of antigen- or molecular- mimicry, as a potential source of antibodies reactive with various tissue antigens. It turns out that although the diagnosis of pemphigus in regular cases is usually not a challenge, the treatment occasionally could be, just because of a simple pitfall in anamnesis and screening, as in the presented case. Herein, we present a case of a patient with seborrheic pemphigus, which is strongly demonstrative for these statements, as we want to emphasise the importance of the first and the most powerful clinician's weapons - the patient's history and thorough examination.

Violet - Colored Inguinal Located Cutaneous Tumour?

Anaplastic large cell lymphoma (ALCL) represents an aggressive CD30 - positive T cell lymphoma, as it is the second most common T cell lymphoma and 2% to 5% of all non - Hodgkin lymphomas. The cutaneous involvement can be primary or secondary within systemic ALCL, resembling inflammatory and other neoplastic lesions both clinically and cytologically. Various pigmented cutaneous tumours with a different origin, cutaneous metastasis and B-cell lymphoma must be carefully considered in the differential diagnostic plan. While simple surgical excision is usually curative, with good prognosis, systemic involvement must also be excluded. We present a case of a patient, with clinically unspecific single violet nodular lesion, as the only clinical manifestation of ALCL. The diagnosis was confirmed histologically, as the surgical excision was enough therapeutic management, regarding the early disease stage. Further following up with the patient is mandatory, because of the high recurrence rate. We want to emphasise the diversity of clinical manifestation of ALCL, regarding the importance of its early diagnosis and treatment.

Disseminated Porokeratosis with Idiopathic Thrombocytopenia - Case Report and Literature Review of Porokeratosis and Related Disorders.

BACKGROUND: Porokeratosis is characterised by one or more atrophic patches surrounded by a distinctive peripheral keratotic ridge, typically found on sun-exposed areas, with several clinical variants and typical histological findings. Despite ultraviolet radiation, varies antibody - related autoimmune disease treated with systemic steroids and other immunosuppressive conditions such as chronic liver disease, HIV and organ transplantations have been implicated in its etiopathology. CASE REPORT: We present a case of porokeratosis, associated with idiopathic thrombocytopenia in 74 - year old, otherwise healthy male patient, as we discuss the previously reported associated disorders. CONCLUSION: Regarding all of the polymorphism of clinical presentation, associated disorders and treatment responses, we could conclude that disseminated porokeratosis is still an unknown well disorder, which will continue to surprise the physicians in future. The screening and follow up of the patients is mandatory in all cases because as we see, porokeratosis has multiple unexpected faces, which require circumstantial clinical and paraclinical behaviour.

Small Dysplastic Congenital Melanocytic Nevi in Childhood as Possible Melanoma Imitators.

Small pigmented lesions in children can represent a significant diagnostic challenge. If the diagnostic features and therapeutic approach are relatively well established in large and giant nevi, there is still much controversy regarding small and intermediate-sized congenital pigmented lesions that can lead to significant diagnostic challenges, both clinically and dermoscopically, and consequently to difficulty in defining the optimal approach in such cases. Although dermoscopy can be useful in the diagnosis of pigmented lesions, the diversity of clinical and dermoscopic features of pigmented nevi in children usually hinder the differentiation between them and melanoma. Histological findings after resection often show surprising results that do not correspond either to the clinical nor the dermoscopic features. With the present case, we want to emphasise the variable natural behaviour of melanocytic lesions in children, which sometimes leads to unnecessary surgical excisions, which should be avoided in pediatric patients.

Penile Melanosis Associated with Lichen Sclerosus et Atrophicus: First Description in the Medical Literature.

We present a 74-year-old male patient with 3-years history of visible discoloration of the glans penis, without subjective complaints. Histopathological examination after incision biopsy revealed a moderate increase in the number of melanocytes in the basal layer with irregular distribution, without melanocytic nests, melanophages in the superficial dermis, and subepidermal sclerosus. No cytologic atypia of melanocytes was detectable. The diagnosis of melanosis of the genitalia in association with lichen sclerosus was made. The importance of the presented cases implicated the unique clinical manifestation of penile melanosis, associated with lichen sclerosus of the penis in one hand, the essential differentiation between malignant melanoma via careful histological examination for diagnosis confirmation in other, in order to optimize the therapeutic behavior.

Khan Krum - "The Fearsome": A Noble Bulgarian with Iris-Fibroma?

A 40-year-old Caucasian, the otherwise healthy male patient, presented with 3-years history of a prominent tumor-like formation, located on his back, without subjective complaints. Initially, the lesion was 1-2 cm in size but gradually increased to a visible-pronounced tumor-like formation. No other dermatologic diseases, neither other known abnormalities were reported for the medical and family history. Softly-elastic on palpation tumor-like formation was established in the left infrascapular area of the back, measuring 8/9 cm in diameter. The lesion was clinically suspected for lipoma or another soft-tissue tumour with benign nature, so the patient underwent planned surgical excision under local anaesthesia. A tumour was excited with deep elliptical excision and furthered for histological evaluation, while the wound edges were sutured with single cutaneous stitches. Additionally, a large black-colored tattoo of the Bulgarian historical noble Khan Krum was also observed within the clinical examination, covering almost the whole upper 1/3 part of the patient's back Within the careful clinical observation of the tattoo, we noticed a fibroma-like lesion, affecting the noble's right iris. Fibromas are common benign tumours in Caucasians, composed of fibrous or connective tissue. They can be seen in all organs from mesenchymal tissue, in varies size. Eyelids are often commonly affected in elderly. Although very commonly seen in every day dermatological practice, fibromas have been never reported, located in the iris. In the presented case, a small "iris-fibroma", hidden within a black-colored tattoo was diagnosed in a patient with lipoma, as a sporadic clinical finding.

New Safety Margins for Melanoma Surgery: Nice Possibility for Drinking of "Just That Cup of Coffee"?

BACKGROUND: The American Joint Committee on Cancer (AJCC's) skin melanoma surgical treatment recommendations from 2011 are characterised by a prima facie "freedom of choice" regarding how extensive should be the excisions for melanomas with tumour thickness up to 2 mm and melanoma in situ. It is unclear why the recommended surgical security margins vary between 0.5 and 1 cm for melanoma in situ, whereas for melanomas with a tumour thickness of up to 1.99 mm, the range of variation is also between 1 and 2 cm, without specifying when the surgical field should be broader and, narrower, accordingly. This "uncertainty or lack of intent" of the guilders often leads to the same surgical approach to melanomas at different stages, or to a different approach in cases of melanomas at the same stage, in contrast. Therefore, this should be defined as wrong, logically. CASE PRESENTATION: We present 3 patients with cutaneous melanomas, treated with similar fields of surgical security. Current issues, generated within the framework of melanoma's surgery guided by the recommendations of the AJCC are also discussed. A new surgical approach in patients with melanoma is recommended, discussed for the first time in world literature. We hypothesize that the introduction of a certain recommendations for a 2 cm surgical field in all directions during the initial excision, combined with the parallel performance of a sentinel lymph node biopsy, will lead in fact to several important advantages: 1) avoiding of the secondary excision in at least 70% - 90% of the patients (depending on the tumor thickness), 2) minimizing the risk of lymphatic effusion change and misinterpretation of the sentinel lymph node biopsy's results in patients with secondary excision; 3) optimization of the surgical team's work; 4) minimizing the possibility of unprepared/uninformed personnel to take part in decisions for treating a specific disease such as skin melanoma, 4) facilitating the appropriate patients' group selection at the appropriate stage when involving them in different studies, leading to equal leveling of the initial positions. CONCLUSION: Whether the proposed approach will be subjected to a detailed discussion of AJCC's expert's remains currently unclear.

Wolf's Panniculitis.

A 28-year-old male patient, presented with a one-week history of pain and itching on the skin of the left upper leg. Erythematous indurated, warm and painful on palpation, subcutaneous plaques and nodules were clinically observed, affecting the skin of the left upper leg, within a recent black-wolf tattoo. The diagnosis of traumatic panniculitis with superposed bacterial infection, provoked by a wolf tattoo was made. The patient underwent 7-days systemic antibiotic treatment regimen and topical application of iodine povidone unguent under occlusion for 7 days. Significant alleviation of the subjective complaints was achieved within the first week, with a total clinical resolution of the symptoms. The role of the procedure as a source of trauma for subcutaneous inflammation (traumatic panniculitis) and the contamination of the equipment or the staff (infective panniculitis) in simultaneously triggering of the pathogenetic chain of the reported Wolf's panniculitis could be present.

Radiation-induced lichen sclerosus of the vulva : First report in the medical literature.

A 67-year-old woman presented with a firm plaque in the perineal region, 16 months after diagnosis of a high-grade basaloid squamous cell carcinoma of the vagina and treatment by external beam radiation therapy and vaginal cuff brachytherapy. The differential diagnosis included radiation-induced morphea, radiation dermatitis, or, possibly, radiation-induced lichen sclerosus. Biopsy findings, including special staining, confirmed the diagnosis of radiation-induced lichen sclerosus. To our knowledge, this is the first report of radiation-induced lichen sclerosus of the vulvar region.