A case of oral foreign-body granuloma due to diatoms.

Diatoms are photosynthetic algae with a siliceous exoskeleton. Diatoms are utilized by a wide array of industries for applications such as filtration and pest control. Unsubstantiated claims have also propelled their societal reach to trendy oral and topical uses. This case highlights a rare case of an oral granuloma secondary to diatoms. An 80-year-old woman presented with a mobile, firm, asymptomatic submucosal mass on her lower left mandibular vestibular mucosa. Histopathology showed a non-caseating granulomatous reaction to diatoms. Her only verified contact with a diatomaceous earth product was a dental impression using alginate after upper front teeth trauma 5 months before. Although there have been several cases of allergic contact dermatitis attributed to diatoms, there are no reported cases of diatom-induced granuloma formation found in the literature. There are, however, ample data on granulomas initiated by silica. Given the silica-based composition of diatoms, and the broad use of diatoms in industry and alternative medicine, it is unclear why diatom-induced granulomas are not more widely described. This report may alert clinicians to the existence of diatom granulomas and incline them to tailor their history to cover questions about possible exposure when evaluating patients presenting with a localized oral lesion.

High-Velocity Paint Gun Injuries.

Cutaneous injuries due to industrial high-pressure paint guns are well-documented in the literature; however, the histologic characteristics are uncommonly described, and facial involvement has not been previously reported. Histopathologic features of paint gun injuries vary depending on the time since injection and type of material. Early lesions display an acute neutrophilic infiltrate, edema, and thrombosis, with varying degrees of skin, fat, and muscle necrosis. More developed lesions (120-192 hours after injury) have prominent histiocytes and fibrosis around necrotic foci, possibly with the pitfall of muscle regenerative giant cells that could be mistaken for sarcoma. Continuing inflammation, swelling, and resultant vascular compression could explain ongoing necrosis months after the accident. The histopathologic differential diagnosis in the absence of clinical history includes paint in an abrasion, foreign body reaction to tattoo, giant cell tumor of tendon sheath, and various neoplasms. If available, radiologic studies can substitute for clinical photographs to indicate the extent of injury. The radiologic differential, uninformed by history, may include calcific periarthritis, gouty tophus, and tumoral calcinosis. Seven cases of injury due to high-velocity paint guns are presented with 4 additional cases mimicking paint gun injury and with review of the literature.

Cutaneous Balamuthia mandrillaris infection as a precursor to Balamuthia amoebic encephalitis (BAE) in a healthy 84-year-old Californian.

Soil and freshwater-dwelling amoebae may opportunistically infect the skin and evoke a granulomatous dermatitis that camouflages their underlying morphology. Amoebic infestations are incredibly rare in the U.S., predominantly occurring in the young, elderly, and immunocompromised. Sadly, because diagnosis is difficult and unsuspected, most cases are diagnosed at autopsy. The following case is of a healthy 84-year-old man with a non-healing nodulo-ulcerative cutaneous lesion on his left forearm that appeared following a gardening injury. Lesional punch biopsies repeatedly showed non-specific granulomatous inflammation with no pathogens evident histologically or by culture. Histopathologic diagnosis was made five months after initial presentation via identification of amoebic trophozoite forms in tissue from a large excisional specimen. Anti-amoebic therapy was initiated immediately. The patient experienced mental status changes three days following lesion excision, with evidence of a cystic mass in the left medial parieto-occipital lobe by CT. Both intraoperative brain biopsies and cutaneous tissue samples tested positive for Balamuthia mandrillaris by indirect immunofluorescent antibody assay performed at the Centers for Disease Control. The patient achieved a full recovery on a triple antibiotic regimen. Clinical suspicion and thorough histopathologic analysis may determine the difference between survival and death for a patient presenting with a treatment-refractory localized granulomatous lesion.

Ischemic fasciitis: enhanced diagnostic resolution through clinical, histopathologic and radiologic correlation in 17 cases.

Ischemic fasciitis is a pseudosarcomatous nodule or mass resulting from sustained or repeated pressure and consequent ischemia of soft tissue. Fibrin and hemorrhage expand its hypocellular epicenter bordered by enlarged (atypical, ischemic) fibroblasts and reactive vascular prominence resulting in diagnostically important histologic zonation. Although classically in bedridden patients, ischemic fasciitis owing to posture-related intermittent pressure in ambulatory adults is not well characterized; there has not been a thorough review of its presentation in ambulatory patients in the dermatology/dermatopathology literature. This article reviews the clinical, pathologic and radiologic presentation of 17 cases of ischemic fasciitis diagnosed over a 14-year period. Eighty-six percent of the six cases submitted by non-dermatologists were limb girdle/trunk lesions averaging 6.7 cm in greatest diameter while 90% of the eleven lesions submitted by dermatologists were elbow and forearm lesions averaging 2.3 cm. In no case was the diagnosis anticipated pre-biopsy by clinician or radiologist. Dermatologists submitted the majority of cases. Because ischemic fasciitis may simulate soft tissue sarcoma clinically and histologically, diagnosis helps prevent overtreatment. Zonal histopathologic structure may be shown by any form of biopsy and should motivate correlation with available radiologic studies. Importantly, determining a history of postural pressure at the site confirms the histopathologic diagnosis and avoids unnecessary excision.

Pemphigus vulgaris in pregnancy.

We report the case of a 34-year-old woman who was diagnosed with pemphigus vulgaris (PV) during pregnancy. The patient presented with widespread blistering dermatitis and associated burning and pruritus. At 6 weeks' gestation the patient was admitted to the hospital to expedite her diagnosis and initiate treatment. A skin biopsy revealed suprabasal acantholysis, and direct immunofluorescence demonstrated diffuse intercellular IgG in the epidermis and basal intercellular C3, which confirmed the diagnosis of PV. Treatment with corticosteroids was instituted after discussions with the patient about possible adverse effects to the fetus. Pemphigus vulgaris is rare in pregnancy and active PV presents potential threats of fetal spread and transient lesion production, which is associated with increased mortality and morbidity in the fetus. Our patient had active PV and required treatment throughout her pregnancy. The pregnancy progressed to premature delivery of the neonate without skin lesions or apparent complications.

Mixed Pneumocystis and Cryptococcus cutaneous infection histologically mimicking xanthoma.

Cutaneous Pneumocystis jirovecii infection is rare. It is thought that the disease emerges from a latent infection delivered via hematogenous and/or lymphatic dissemination from a primary lung infection in immunocompromised individuals. A 32-year-old human immunodeficiency virus-positive male was admitted for headache and vomiting. He was diagnosed with meningitis due to Cryptococcus neoformans and sputum tested positive for Pneumocystis. Six months later, he presented with a slightly crusted yellowish brown plaque and 2 similar but smaller papules with telangiectasia near the right angle of the mouth. Biopsy of the area featured histiocytes expanded by foamy cytoplasm as in a xanthoma except that the vacuoles were coarser. Special stains ultimately demonstrated the characteristic disks of Pneumocystis accompanied by a minor component of budding yeasts (Cryptococcus) in the same fields. This case illustrates the utility of adequate special stains in recognizing a mixed cutaneous infection, particularly in human immunodeficiency virus-positive patients, when microscopy presents an odd xanthoma-like lesion.

Mucoepidermoid carcinoma of the parotid presenting as periauricular cystic nodules: a series of four cases.

Mucoepidermoid carcinoma is a relatively common neoplasm of the major and minor salivary glands that can secondarily involve skin. In the vicinity of the ear lobe, mimicry of a benign cyst, both clinically and histopathologically is a diagnostic pitfall to avoid. The clinical manifestations, diagnostic histopathology, and clinical course of mucoepidermoid carcinoma of the parotid gland presenting as a clinically benign periauricular cystic nodule in four patients ranging in age from 11 to 63 years, are analyzed in the present report. Illustrating the challenge of accurate diagnosis, three of the four cases were initially misinterpreted on biopsy as benign cystic lesions. Multiple biopsies displayed foamy histiocytes around mucinous extravasations into dermis that mimicked ruptured epithelial cysts in two cases before malignancy was ascertained. This series demonstrates the need to include parotid tumor in the differential diagnosis of odd periauricular cyst-like expansions and adenosquamous proliferations. Mucoepidermoid carcinoma in particular can explain indolent, infra-auricular 'mucinous cysts'. Familiarity with this syndrome should arouse suspicion of parotid carcinoma when a 'cyst' or nodule is located near the earlobe. Delay in diagnosis results in larger surgical procedures than are otherwise necessary.

Unusual teeth in unusual places: Criteria for identifying teratomatous dental elements in archeological contexts.

OBJECTIVE: This paper describes the dental elements (i.e., teeth and incomplete tooth-like structures) formed by mature cystic teratomas and provide some diagnostic criteria to aid in their paleopathological identification and analysis. MATERIALS: Hard tissue structures from 13 clinically-derived mature cystic teratomas excised between 2003 and 2007. All are from female patients (N = 13) between the ages of 17 and 56. METHODS: A dental and osteological inventory identified number of teeth and tooth types present in each specimen. RESULTS: Of the 13 specimens, nine contained dental elements. The number per teratoma ranged from one to seven. A wide variety of tooth types were present in the teratomas with some teeth independent of, and others embedded within, bony matrices. CONCLUSIONS: While some teratoma teeth exhibit distinguishable types and laterality, the majority will exhibit some degree of abnormality in size, form, developmental completion, or association with other irregular bony elements. SIGNIFICANCE: Give the modern clinical prevalence and yet relatively few paleopathological cases reported, it is likely that mature teratomas are under-identified in the archeological record. The diagnostic criteria presented in this paper can aid paleopathologists in their identification and analysis of these neoplasms. LIMITATIONS: Precise paleopathological identification of teratoma elements can be difficult; particularly when they are no longer constrained or contextualized by unmineralized neoplastic borders. As such, there is a risk that such remnants may be mistaken for fetal parts or disassociated elements. SUGGESTIONS FOR FURTHER RESEARCH: Application of these criteria, paired with careful excavation techniques, is advised.

Large neglected ulcerated melanoma mimicking extramedullary plasmacytoma.

Amelanotic melanoma, a renowned impersonator, has taken on a new persona. A 63-year-old woman was seen in the emergency room with a chief complaint of back pain after a fall and was discovered to have a 15-cm fungating mottled gray mass independent of bone on the right elbow. Initial workup discovered lytic calvarial lesions, anemia (Hb 7; Hct 20%), and circulating plasma cells consistent with plasma cell myeloma. Biopsy of the elbow mass displayed sheets of plasmacytoid cells, some reactive for CD138. Flow cytometry revealed a substantial portion of the plasma cells in the tumor that were kappa restricted consistent with cutaneous plasmacytoma. The elbow mass was initially signed out as extramedullary involvement by her myeloma. Reevaluation of the mass after the patient experienced an explosive growth of multinodular jet black malignant melanoma on ipsilateral breast revealed MART-1 and S-100 reactivity of the majority of the cells. In retrospect, the elbow mass was a neglected primary amelanotic malignant melanoma with neoplastic plasma cells participating in its chronic inflammatory infiltrate.

Cutaneous metastasis of osteosarcoma in the scalp.

As a primary malignant bone tumor, osteosarcoma is second only to chondrosarcoma. Although it commonly metastasizes and is aggressive in nature, it rarely colonizes the skin. This is a report of a 22-year-old male with osteosarcoma of the pelvis and metastasis to the lungs and chest wall who developed a clinically unsuspected solitary cutaneous metastasis in the scalp. Instead of the expected cyst, incisional biopsy disclosed a solid tan nodule of chondro-osseous sarcoma. Although rare, cutaneous metastases from osteosarcoma may appear in skin, especially the scalp, or in skin over the primary tumor. New skin lesions in a patient with a history of osteosarcoma warrant investigations including imaging and biopsy.

Digital dermatofibromas--common lesion, uncommon location: a series of 26 cases and review of the literature.

Dermatofibroma (DF), also referred to as cutaneous fibrous histiocytoma (CFH), is a common tumor of the skin presenting as a firm nodule located predominantly on the limbs and shoulder and pelvic girdles that often extends into superficial subcutaneous tissue. This is a retrospective study of 26 DFs located on digits. All case slides were retrieved from saved files for diagnostic verification. One case was rejected after revision of the diagnosis to giant cell tumor of the tendon sheath. The 26 remaining cases constitute this reported series. Digital DFs affected 27 to 70 year-olds in a 2.25:1 male to female ratio. The most common clinical diagnosis submitted was "growth" or wart. In only 6 out of the 26 cases was the pre-biopsy diagnosis of DF ventured. Although lesional tissue went to dermal margins in 14 specimens, only one has been re-excised in follow up ranging from 2 months to 10 years. Because DFs can resemble several entities including leiomyosarcoma and dermatofibrosarcoma protuberans, a lack of familiarity with the occurrence of DF on the digits may result in more aggressive treatment than otherwise necessary. DF should be in the differential diagnosis of circumscribed, firm nodules presenting on the digits.

Expanding the clinicopathologic spectrum of palisaded encapsulated neuroma.

Palisaded encapsulated neuroma (PEN; solitary circumscribed neuroma) is a benign, morphologically characteristic cutaneous or mucosal neuroma. Most are solitary lesions on the face, neck or oral mucosa. Histologically, the majority appears as dermal nodules of Schwann cell-rich fascicles, with or without distinctive encapsulation. To further expand on the existing literature regarding this neuroma, we herein describe three PENs with unique clinical and histopathologic features. All occurred on the acral skin, a rarely described site. Furthermore, one exceptional patient presented with multiple PEN on the bilateral hands, biopsies of which showed a prominent plexiform architecture. Awareness that PEN may occur on acral skin, may rarely present as multiple lesions, and recognition of the plexiform variant is important because PEN may histologically mimic other peripheral nerve sheath tumors. Additionally, misdiagnosis may have significant clinical implications.

Alveolar rhabdomyosarcoma on the external ear: a case report.

Alveolar rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma of childhood. It typically has middle ear/temporal bone and nasopharynx as its most common head and neck sites. In fact, 'middle ear' is what is meant by 'ear' location in the many reports of pediatric RMS. This case report, however, is of RMS occurring on the external ear of a young female. RMS in skin should motivate a search for an occult extremity or visceral tumor, which was not present in this case.

Neoplasm or not? General principles of morphologic analysis of dry bone specimens.

Unlike modern diagnosticians, a paleopathologist will likely have only skeletonized human remains without medical records, radiologic studies over time, microbiologic culture results, etc. Macroscopic and radiologic analyses are usually the most accessible diagnostic methods for the study of ancient skeletal remains. This paper recommends an organized approach to the study of dry bone specimens with reference to specimen radiographs. For circumscribed lesions, the distribution (solitary vs. multifocal), character of margins, details of periosteal reactions, and remnants of mineralized matrix should point to the mechanism(s) producing the bony changes. In turn, this allows selecting a likely category of disease (e.g. neoplastic) within which a differential diagnosis can be elaborated and from which a favored specific diagnosis can be chosen.

Amelanotic melanoma: a unique case study and review of the literature.

Amelanotic melanoma (AM) is a rare form of melanoma which lacks visible pigment. Due to the achromic manifestation of this atypical cutaneous malignancy, it has been difficult to establish clinical criteria for diagnosis. Thus, AM often progresses into an invasive disease due to delayed diagnosis. In this report, we describe the case of a 72-year-old Caucasian woman who had been diagnosed with AM after 3 years of failed treatments for what presented as a periorbital dermatitis. Her Clark's level 4, 1.30 mm thick melanoma required nine surgeries for successful resection and reconstruction. This case exemplifies the diagnostic pitfall of AM and the need for new criteria for early detection and management.

Drug rash with eosinophilia and systemic symptoms (DRESS) caused by phenytoin.

Drug rash with eosinophilia and systemic symptoms (DRESS) is a rare but potentially life-threatening condition with high mortality. Diagnosis is challenging due to variable clinical presentation and a protracted latency period following initiation of the offending drug. DRESS is a complex interplay that starts by introduction of the offending drug, reactivation of viruses and activation of the immune system. Herpes virus reactivation is considered a diagnostic marker and indicator of illness severity. Prompt recognition and the removal of offending agent remain the key to successful treatment. In cases of severe organ involvement, corticosteroids, immunoglobulins, antiviral and specialist consultation may be helpful. Here we present a case of a 36-year-old African-American male who presented with symptoms mimicking sepsis with an associated skin eruption that was diagnosed as DRESS.

Calcific periarthritis: more than a shoulder problem: a series of fifteen cases.

BACKGROUND: Calcific periarthritis, referring to a circumscribed juxta-articular deposit of minute non-birefringent mineral grains, is rarely the clinical diagnosis accompanying a pathologic specimen. Familiarity with the clinical, pathologic, and radiologic manifestations of calcific periarthritis, particularly when encountered adjacent to joints other than the shoulder, facilitates diagnosis and may obviate biopsy, avoid confusion with other entities, and speed appropriate treatment. METHODS: Pathologic specimens that fulfilled the criteria for a diagnosis of calcific periarthritis were prospectively collected. Clinical history and radiologic studies were acquired and analyzed. Well-controlled special stains were employed on two specimens with a neutrophilic infiltrate that excluded fungal and bacterial agents, as corroborated by microbiologic cultures showing no growth. RESULTS: Over a five-year period, fifteen patients between the ages of thirty-one and eighty-eight years (mean age, fifty-nine years) presented to various local healthcare providers for treatment of juxta-articular swelling that was subsequently determined to be calcific periarthritis. In seven patients, deposits were alongside a toe joint; in five, alongside a finger joint; and in three, involving the shoulder. The majority of the patients were female (73%). No patient had a documented recurrence of calcific periarthritis in follow-up periods ranging from eighteen to eighty-seven months (average forty-five months). CONCLUSIONS: Of twelve histologically verified cases of calcific periarthritis adjacent to joints other than the shoulder, in only one patient (toe) was the preoperative clinical diagnosis accurate, which signals the need for greater awareness of this entity as a differential diagnostic option.

Frontal sinus osteoma with osteoblastoma-like histology and associated intracranial pneumatocele.

Osteomas of the cranial sinuses are rare, benign bony tumors that can be complicated by the formation of an intracranial pneumatocele. If not treated promptly, a pneumatocele can lead to abscess formation, meningitis, or ventriculitis. In the present case, an intracerebral pneumatocele was formed when an 18 cm(3) osteoma breached the posterior wall of the frontal sinus creating a one-way valve through which air could enter the intracranial cavity. The patient presented after forceful sneezing with nonspecific symptoms of headache, nausea, and vomiting. CT demonstrated a frontal collection of loculated air with mass effect within the left cerebral hemisphere. A partly mineralized mass occupied the left superior nasal ethmoid sinus and left frontal sinus. Of interest pathologically in this case, the tumor had a substantial osteoblastoma-like component. Surgical repair involved frontal craniotomy to remove the osteoma and debride frontal sinus mucosa, plugging the frontal nasal ducts and sinus with fat and bone wax, and dural restoration using an underwater closed drainage system to vent intracranial air and stabilize the patient.