Post-traumatic ulcerated and chronic necrobiosis lipoidica of the elbow: A new entity?

BACKGROUND: Necrobiosis lipoidica (NL) is a chronic granulomatous dermatosis usually affecting the lower limbs, although less common sites have been described. Herein we report a series of cases of NL located on the elbow, with an unusual presentation and occurring after trauma or surgery. OBSERVATIONS: Our series includes three men and one woman, with a mean age of 64 years. Three had undergone surgery for elbow bursitis and one had had trauma after a fall from a horse, with exposure of subcutaneous tissue prior to healing. Within 5 years, they had all developed an atrophic erythematous annular plaque with papular and telangiectatic edges, with recurrent episodes of ulceration and scarring. Repeated tests for infectious agents were negative. Histological examinations showed granulomas and necrobiosis with palisading or early-stage palisading. Partial healing was achieved in two patients after 6 months of doxycycline. Treatment with adalimumab resulted in disappearance of the ulcers at 6 months in one patient. DISCUSSION: Unusual sites of NL impose consideration of other types of palisading granuloma or mycobacterial infections, which we were able to rule out. Two other cases of NL of the elbow similar to ours are reported in the literature. These cases, involving multiple ulcerations over a very long period of time, probably constitute a distinct entity because of the very distinct character of these 6 cases. Tetracyclines are partially active and tumour necrosis factor alpha (TNF)-alpha inhibitors may offer an option.

[Clinicopathological study of purpura: Is a skin biopsy necessary for palpable purpura?]. / Étude anatomo-clinique du purpura : y a-t-il un intérêt à biopsier un purpura palpable ?

OBJECTIVE: For many physicians, palpable purpura is synonymous with vasculitis. However, a skin biopsy is almost always performed in common clinical practice in order to confirm the diagnosis. The aim of our study was to assess whether palpable purpura is always indicative of an inflammatory infiltrate in a vessel wall. PATIENTS AND METHODS: Eighty-seven patients were included in this prospective monocentric study, 45 of whom were presenting a palpable purpura. Patients were classified in two categories: "leukocytoclastic vasculitis" or "other diagnosis". The clinical and histopathological features of patients with a palpable purpura were studied. RESULTS: The mean age of patients presenting a palpable purpura was 69 years. There were 26 men and 19 women. Of the 43 patients biopsied, 37 were included in the vasculitis group. The sensitivity, specificity, positive predictive value and negative predictive value for a diagnosis of vasculitis in patients with palpable purpura were respectively 82, 65, 86 and 58 %. The Odds ratio was 8.48 (95 % CI, 2.52-31.80; P<0.05). CONCLUSION: Most of the palpable purpuras examined were indeed related to leukocytoclastic vasculitis. In the remaining cases, biopsy did not contribute to the diagnosis since it only showed purpura without vessel wall inflammation. In our opinion, a skin biopsy is thus not essential where the clinical presentation is typical.

[Measles: a follicular disease]. / La rougeole, une maladie folliculaire.

BACKGROUND: Since the year 2000, measles epidemics have occurred throughout Europe, with a number of severe cases in adults leading to hospitalisation. Herein, we discuss the case of a young adult male with measles presenting clinical and histological features of rash having a follicular nature. PATIENTS AND METHODS: An 18-year-old male consulted for diffuse, febrile morbilliform exanthem consisting chiefly of follicular papules surrounded by erythematosus macules. In the absence of any features suggesting possible contagion or implicated medication, biopsy was performed on one of these elements and showed strictly follicular involvement. Perifollicular lymphocytic inflammation was noted, with necrotic keratinocytes having monster nuclear cells, and above all, multinucleated cells within the outer root sheath and the sebaceous gland. Positive IgM measles serology was noted. DISCUSSION: Follicular involvement is a very common feature in cases of measles that we have seen in recent years. In the present case, histological examination showed a follicular and sebaceous cytopathogenic effect, which while far less well known, has occasionally been seen with measles in the sweat glands or the epidermis, in which viral presence was detected. Thus, the skin rash was accounted for at least in part by the presence of the virus itself within keratinocytes and adnexal cells. This follicular involvement of measles, histologically confirmed in the present case, is frequently seen and can be helpful in differential clinical diagnosis with regard to other viral rashes. It could be caused by special affinity of the virus for body hairs.

[Desmoplastic trichoepithelioma: a clinicopathological study, including a comparison with morpheiform basal cell carcinoma]. / Trichoépithéliome desmoplastique : étude anatomoclinique et comparaison avec le carcinome basocellulaire sclérodermiforme.

BACKGROUND: Desmoplastic trichoepithelioma (DTE) is an uncommon form of adnexal tumour that was described for the first time as a separate clinicopathological entity in 1976. We carried out a retrospective histopathological study of a large series of cases of DTE in order to better characterise this tumour and compare it with sclerodermiform basal cell carcinoma (BCC), which is in fact the most common as well as the most complex type of differential diagnosis. PATIENTS AND METHODS: We included in this study all cases of DTE diagnosed between 1979 and 2001 at our dermatopathology laboratory. The clinical features were taken from the patient files. Diagnosis was confirmed by two different examiners and all microscopic elements were reviewed. The same clinical and demographic data were collected for cases of BCC diagnosed over the same period. RESULTS: We included 68 cases of DTE in 67 patients in our study, of whom 83.5% were women, and the mean age was 42.8 years. Lesions were found primarily on the head (98.5% of cases), mainly on the cheeks (29.2% of cases) and forehead (23.1% of cases). The diagnosis was only made by the clinician in four cases; in 38 cases the diagnosis made was BCC. In all cases, histological examination revealed thin lines of basaloid epithelial cells associated with small keratinising cysts. A common finding was granulomas with foreign bodies and calcifications. In six cases (8.8%), a tumour combining DTE with an intradermal naevus was observed. Mean clinical follow-up of 8 years (1 to 23 years) in 29 patients showed absence of relapse or metastasis. Over the same period, 662 cases of BCC were recorded in 499 patients, 58.9% of whom were women. The mean age was 65.6 years. The principal location was the nose (34% of cases). No cases of associated naevus were recorded. COMMENTS: DTE is a firm plaque-like lesion, flesh coloured or yellowish, and generally with a depressed centre; it is seen primarily in middle-aged women and occurs principally on the cheeks and forehead. There is a significant association with naevus, a singular feature among adnexal tumours. On average, it is 10 times less common than BCC. The size of our study groups shows for the first time distinguishing features with regard to BCC, for which the age of onset is far higher and predominance among women less marked. Further, the sites are different, with BCC being seen predominantly on the nose while DTE is seen mainly on the cheeks. A suggested clinical diagnosis is thus possible.

[Warty dyskeratoma: infundibular histogenesis. Anatomoclinical study of 43 cases]. / Dyskératome verruqueux: une tumeur d'origine infundibulaire.

BACKGROUND: The exact origin and classification of warty dyskeratoma in epithelial tumours are still debated. The purpose of this study was to examine the relationship between this tumour and the pilosebaceous follicles. MATERIALS AND METHODS: This was a retrospective, anatomoclinical study. Expression of cytokeratins 1, 5, 10, 17 and 19 was studied in ten of the samples using Immunohistochemistry techniques. RESULTS: We studied 43 cases of warty dyskeratoma in 42 patients of mean age 61 years. Lesions were described mainly as papular nodules (70%), in most cases keratotic (58%), with frequent central umbilication (30%), and commonly located in the cervicocephalic region (65%). Histological examination frequently revealed a cupuliform aspect (77%), with numerous contiguous invaginated foci in 43% of cases. Less frequently, the lesions were superficial (12%) or nodular cystic (12%). In 72% of cases, at least one instance of follicular differentiation was seen. CK1 and CK10 were expressed in the suprabasal levels of the warty dyskeratoma while CK5 and CK17 were seen in the basal layers. CK19 was not expressed. DISCUSSION: Based on the histological and immunohistochemical findings, we proposed the hypothesis of benign epithelial tumour of follicular type, beginning in the pilar infundibulum.

[Actinomycosis of the buttock]. / Actinomycose fessière.

INTRODUCTION: Cutaneous actinomycosis of the buttocks is a rare granulomatous bacterial infection that usually starts in the perianal area. We present an exceptional case in the form of a pseudo-tumor. CASE REPORT: A 69 year-old woman, in general good health, developed an indurate mass on the supra-external quadrant of the right buttock. The tumor was centered by an ulcerated nodule with a diameter of around 10 centimeters. Imaging showed invasion of the soft tissue of the skin in the internal psoas muscle, the adipose tonality of which was compatible with a liposarcoma. The skin biopsy revealed characteristic bacterial grain in the center of a cholesterol granuloma. Subsequent culture in aerobic milieu identified Actinomyces gerencseriae. Cure was obtained following complete exeresis of the fibrous tissue and 8 months of antibiotic amoxicillin-clavulanic acid therapy. DISCUSSION: Other than the most unusual clinical aspect, the originality of this case of actinomycosis of the buttocks is based on its potential appendix origin, 4 years after acute appendicitis, with slow posterior fistulation. Other cases of actinomycosis of appendix origin have been reported and its delayed onset following the intervention has been documented. The pseudo-sarcomatous aspect was responsible for diagnostic wandering. The histological image and, subsequently, the results of the bacteriological culture confirmed the diagnosis.

[Multiple abscesses induced by self injection of zolpidem]. / Abcès cutanés multiples induits par l'auto-injection de comprimés de zolpidem (Stilnox).

BACKGROUND: Zolpidem, a hypnotic drug, is occasionally taken in high doses by some drug addicts for its hallucinogenic properties. CASE REPORT: We report the original observation of a young female addict who developed aseptic cutaneous abscesses on the forearms and feet induced by self injection of powdered zolpidem. Histopathological analysis revealed birefringent vegetal structures. DISCUSSION: The shape and size of the birefringent structures are those of microcrystalline cellulose, an excipient used in zolpidem pills. The same structures have been identified by microscopic examination of a zolpidem tablet dissolved in water.

Variations of basal cell carcinomas according to gender, age, location and histopathological subtype.

BACKGROUND: Most published series of basal cell carcinomas (BCCs) do not take into account the histopathological subtype. Recent studies suggest that the nodular and superficial types could be induced by different causal factors. OBJECTIVES: To analyse the three major subtypes of BCC with regard to sex, age and anatomical distribution. METHODS: We retrospectively included all cases of BCC diagnosed at a single centre of dermatopathology during 1967-96. The diagnosis and subtype (nodular, superficial, morphoeiform) were confirmed by two dermatopathologists. Gender, age at excision, number of tumours and location were recorded, and analysed by histopathological subtype. RESULTS: We recorded 13 457 cases in 10 245 patients (M/F ratio 0.92) of mean age 65 years. Of the BCCs, 78.7% were nodular, 15.1% superficial and 6.2% morphoeiform. Nodular tumours occurred at a mean age of 66.3 years, whereas superficial tumours were excised earlier (63.0 years) and more frequently in women (M/F ratio 0.96). Patients with morphoeiform BCC had a mean age of 65.8 years and were predominantly women (M/F ratio 0.73). Both nodular and morphoeiform types predominated on the head (89.6% and 94.8%), whereas the trunk was the most common location for the superficial type (45.9%). Superficial carcinomas were predominantly located on the head in women (44.8% vs. 34.7% in men), whereas they predominated on the trunk in men (49.9% vs. 42% in women). Tumours of the trunk were excised earlier than those of the face, whatever their histological subtype, in both men and women. CONCLUSIONS: This is the largest series of BCCs in the literature, and shows striking differences in anatomical distribution, sex and mean age according to histological type. The results suggest that the tumours of the trunk, and not only those of the superficial type, could represent a particular subtype of BCC. The analysis also suggests that the hypothesis of chronic vs. intermittent sun exposure cannot be simply extrapolated to BCC. Other causal factors, such as a genetic predisposition, could be involved in the development of carcinomas located on the trunk.

[Hospitalization criteria for erysipelas: prospective study in 145 cases]. / Motifs d'hospitalisation de l'érysipèle.

INTRODUCTION: Two recent studies conducted in France among general practitioners have shown that they only hospitalized between 20 to 50 percent of patients with erysipelas seen in private practice. We therefore conducted a hospital-based, prospective study designed to determine the hospitalization criteria for erysipelas, since a number of patients are also hospitalized directly through the emergency department. PATIENTS AND METHODS: This prospective, hospital-based study, included patients hospitalized for clinical diagnosis of erysipelas in 9 centres in north-eastern France. Clinical data were recorded using a standard questionnaire filled-in during the first 72 hours of hospitalization. They included: demographic (name and first name initials, age, sex) and clinical (location of erysipelas) characteristics, as well as the origin of the patient (home, emergency department, other department), the reasons for hospitalization (severity of local or systemic signs, suspicion of deep vein thrombosis, location on the face, age over 60 years, associated diseases, absence of improvement after ambulatory treatment, socioeconomic reasons or on principle hospitalization). Patients hospitalized by (or without) a general practitioner were compared using Chi-2 and Student t tests. RESULTS: One hundred forty-five adults (80 women and 65 men; mean age 61 +/- 20 years) were included in the study: 89 patients (61 p. 100) were hospitalized by a general practitioner whereas 56 (39 percent) went directly to the emergency department. In 128/145 cases (88 p. 100), erysipelas was localized on the lower limbs. The mean number of reasons for hospitalization per patient was of 2.2 +/- 1.2. The most frequent reason for hospitalization was an associated disease (diabetes, obesity, alcoholism, immunodeficiency), present in 77 cases (53 p. 100). Patients hospitalized through a general practitioner were older than those hospitalized directly through the emergency department (68 vs 51 years; p<0.001). Patients hospitalized by a general practitioner more frequently had an erysipelas located on the lower limbs (94 p. 100 vs 79 p. 100; p<0.001) and the mean number of reasons for hospitalization was greater (2.4 vs 1.7; p<0.001), especially suspicion of deep vein thrombosis and elevated mean age. The treatment started during hospitalization was intravenous penicillin G in 67 cases (46 p. 100), oral pristinamycin in 28 cases (19 p. 100) and intravenous or oral amoxicillin in 9 cases (6 p. 100). COMMENTS: This study demonstrates the existence of two distinct courses of hospitalization for erysipelas. Patients hospitalized by a general practitioner were older and their erysipelas more frequently located on the lower limbs and deep vein thrombosis was suspected. Our study also shows the emergence of a population of patients younger and without medical supervision, for whom the general practitioner is replaced by the emergency department of the local hospital. Nevertheless, the most frequent reason for hospitalization in both groups is the existence of an associated disease, possibly responsible for further complications.

[Morphology of sweat glands]. / Morphologie des glandes sudorales.

There are two types of sweat glands: eccrine glands, which do not show cytological changes during secretion and apocrine glands, characterised by decapitation secretion, in which part of the cell is pinched off and released into the lumen. Eccrine glands play a major role in thermoregulation and electrolyte balance. They are present everywhere in the human skin and are composed of a secretory portion, an intradermal duct and an upper intraepidermal part, called acrosyringium. The acrosyringium has a unique symmetrical and helicoidal course, which length is correlated to the thickness of the epidermis. Apocrine glands are located only on genital, axillary and mammary areas, where they are always connected to a hair follicle. Their exact role in humans is unknown. A third type of intermediate sweat glands, the apoeccrine glands, was recently described in axillary areas. Sweat glands can be involved in various inflammatory processes and can lead to a large range of both benign and malignant tumors.

[Erythroderma induced by hypercalcitoninemia: two cases]. / Erythrodermie induite par une hypercalcitoninémie.

INTRODUCTION: The most common cause of erythroderma is the extension of a previous cutaneous disease to the entire skin surface, as is the case in mycosis fungoides or drug reactions. Erythroderma related to endocrine disorders has only exceptionally been published. We report two cases of patients suffering from erythroderma probably induced by hypercalcitoninemia. OBSERVATIONS: Case 1. A 69 year-old man had a two year-history of fluctuating erythroderma, resistant to all topical or systemic therapy. After numerous unsuccessful investigations, a high serum calcitonin rate was detected. The pentagastrin test was highly positive, suggesting a medullar carcinoma of the thyroid. Thyroidectomy showed only hyperplasia of C cells. All skin signs disappeared within a few days after surgery. Two years later, there was no recurrence of the erythroderma and the serum calcitonin rate was normal. Case 2. A 58 year-old man suffered from congestive and pruriginous erythroderma for 2 1/2 months, which responded well to topical steroids. Biological investigations done for flushes, showed a raised calcitonin level and highly positive pentagastrin test. Thyroidectomy also revealed simple hyperplasia of the C cells. No recurrence of the erythroderma was noted during the 6 month follow-up. DISCUSSION: These are the first cases of erythroderma associated with hypercalcitoninemia. The causal role of calcitonin is probable in the first case, because of 1) long duration of skin signs before the hypercalcitoninemia; 2) quick post-operative recovery, in parallel with the decrease in calcitonin level; 3) absence of recurrence after thyroidectomy; 4) absence of other proven causes. Erythroderma may have resulted from dilation of the skin vessels, since calcitonin and calcitonin gene related peptide are powerful vasodilators.

Molluscum contagiosum: histologic patterns and associated lesions. A study of 578 cases.

Molluscum contagiosum (MC) is rarely associated with other skin diseases, especially cutaneous neoplasms. Such associations are exceptional and of unknown frequency. The aim of this study was to record the histologic variants and frequency of associated lesions in a large series of consecutive MC cases. We reviewed 578 MC cases from the Laboratory of Dermatopathology of the University Hospitals of Strasbourg, France (1959-1999). The locations of MC were as follows: head and neck (34.7%), trunk (27.1%), lower limbs (20.7%), upper limbs (8.7%), and genitalia (3.8%). Molluscum contagiosum occurred more often in female patients (56.7%). The age range of patients included in this study was 0 to 19 years (34.9%), 20 to 39 years (31.1%), 40 to 59 years (22.8%), and over 60 years (6.5%). Histologic variants of MC were noted in 46 cases (31 pseudocystic, 8 giant, and 7 pedunculated). An underlying abscess was present in 65 cases. Of the 578 cases, 22 were associated with other lesions (3.8%). There were 9 cases of epidermal cysts, 4 of nevocellular nevi, 3 of metaplastic ossifications, 2 of true epidermal nevi, 2 of sebaceous hyperplasias, 2 of soft fibromas, and 1 of Kaposi sarcoma. Except in immunocompromised patients, such associations are likely to be coincidental. The clinical diagnosis was correct in 42.3% of the cases. Clinical accuracy varied according to the age, localization, and histologic pattern of MC. Pseudocystic MC, giant MC, and MC associated with other lesions were responsible for frequent clinical misdiagnosis.