Crystalglobulinemia causing cutaneous vasculopathy and acute nephropathy in a kidney transplant patient.

We present a rare case of crystalglobulinemia causing cutaneous vasculopathy and acute nephropathy in a 66-year-old female kidney transplant recipient. The patient presented with acute kidney injury (AKI), volume overload, anuria, retiform purpura, and blue-black necrosis of her toes. She received a living kidney transplant 7 months earlier with baseline creatinine of 0.6 mg/dl. Transplant kidney biopsy showed massive pseudo-thrombi filling glomerular capillary lumina. Electron microscopy of thrombi revealed an ultrastructural crystalline pattern of linear and curvilinear bundles with ladder-like periodicity typical of crystalglobulin-induced nephropathy. Similar crystalline pseudo-thrombi were detected ultrastructurally in a skin biopsy specimen, indicating systemic involvement. She required several sessions of hemodialysis. Plasmapheresis was initiated to decrease the number of circulating crystalglobulins. In order to treat the underlying paraproteinemia, the patient was started on bortezomib and dexamethasone. After treatment with five cycles of bortezomib, the patient's free kappa to lambda ratio improved to 2.35 from 5.52. Acute kidney injury (AKI) and the cutaneous vasculopathy gradually improved with treatment. This is an extremely rare occurrence of crystalglobulin in a living kidney transplant recipient.

Eosinophilic Dermatosis of Hematologic Malignancy.

Eosinophilic dermatosis of hematologic malignancy (EDHM) is a rare chronic skin condition commonly affecting individuals with underlying hematologic malignancies, most notably chronic lymphocytic leukemia (CLL). EDHM presents as pruritic, insect-like bites, but without patient-reported contact/bites of insects. We present a case of a 44-year-old male who presented to Elkhorn Dermatology with a scaly rash and serpiginous borders on the nasal tip and right cutaneous upper lip. The patient was diagnosed with CLL one year prior and had been on zanubrutinib for 10 days since presenting to the dermatology clinic. Initial treatment with antifungal and antibiotic therapies showed no improvement, leading to a punch biopsy that revealed perivascular and periadnexal lymphocytic dermatitis with eosinophils. This finding, along with the patient's underlying CLL, led to a diagnosis of EDHM. This case highlights the diagnostic challenges and therapeutic complexities associated with EDHM in patients with hematologic malignancies.

Chromhidrosis Linked to Personal Care Products.

Eccrine chromhidrosis (CH) is a rare condition characterized by the excretion of colored sweat from eccrine glands. This case report contributes to the medical literature by highlighting two instances of eccrine CH linked to over-the-counter personal care products, an association not previously documented. These products contained FD&C Blue No. 1, D&C Red No. 33, and Ext. D&C Violet No. 2, which are known colorants in various consumer items. These cases underscore the potential for personal care products containing colored dyes to cause eccrine CH. The medical community and consumers must be vigilant about product ingredients to facilitate an accurate diagnosis and promote informed usage. Healthcare professionals should consider the role of colored personal care products in their differential diagnosis of CH to recognize and address potential risks effectively. These cases emphasize the need to actively include colored personal care products in medical considerations to ensure that healthcare practices and consumer awareness properly recognize and address potential risks associated with these products.

Focal Neurotoxicity Associated With Topical 5-Fluorouracil.

Topical 5-Fluorouracil (5-FU) is an antineoplastic chemotherapy drug used to treat precancerous and cancerous skin growths, such as actinic keratoses (AKs), squamous cell carcinoma in situ, and superficial basal cell carcinoma. The topical agent may rarely cause neurotoxic adverse effects. Multiple cases of systemic 5-FU and capecitabine chemotherapy-induced neuropathies have been reported. However, until now, the topical administration of the drug has not been reported to cause neurotoxicity. We present a case of an 83-year-old male who was prescribed topical 5-FU 5% cream to treat AKs on the left anterior scalp and returned weeks later with the development of focal neurotoxicity in the treatment area. He presented with focal paralysis of the left medial frontalis muscle, with initial loss of sensation followed by intermittent pain and paresthesias, persisting four months after the cessation of therapy. He was referred to a neurologist and received a diagnosis of supraorbital neuralgia. The temporal relationship of symptom onset and the localization of symptoms to the treated area strongly suggests that the medication contributed to the observed neurologic effects. These effects are more likely to be observed in patients with a genetic deficiency of dihydropyrimidine dehydrogenase (DPD), which is responsible for the majority of 5-FU degradation (80%), therefore potentially leading to toxic levels of unmetabolized 5-FU. Providers should be aware of the potentially neurotoxic effects of topical 5-FU in order to properly counsel patients and to consider this as a possible etiology of neurologic deficits in patients using this drug.

Ophiasis Pattern Alopecia Areata in an Infant.

Alopecia areata (AA), an autoimmune inflammatory disorder causing non-scarring hair loss, predominantly affects the adult population and is rarely encountered in young infants and neonates. The etiology of this condition remains multifactorial, involving complex interactions between genetic, autoimmune, and environmental factors. In this report, we present a notable case of a four-month-old infant who presented with distinct band-like hair loss on the right inferior lateral forehead, left inferior lateral forehead, and superior middle forehead following a culturally significant head-shaving ritual known as Chudakarana. This unique presentation of ophiasis AA in an infant is an unusual occurrence and has been associated with a poor prognosis. The patient received topical treatment with triamcinolone 0.1% lotion, resulting in improvement of alopecia at the six-week follow-up, although complete resolution of symptoms was not achieved. This case highlights the significance of recognizing atypical presentations of AA in the pediatric population and underscores the complexities in associated cultural factors.

ChatGPT: A Supplemental Tool for Efficiency and Improved Communication in Rural Dermatology.

In November 2022, OpenAI released version 3.5 of ChatGPT, the first publicly available artificial intelligence (AI) language model designed to engage in natural, human-like dialogue with users. While this groundbreaking technology has been extensively studied in various domains, its potential applications in rural dermatology remain unexplored in the existing literature. Our research investigates the many benefits that ChatGPT could offer in rural dermatology, particularly concerning administrative tasks and communication with communities with lower healthcare literacy. However, we also acknowledge that utilizing ChatGPT without proper caution and discernment may lead to potential drawbacks. This paper examines the opportunities and challenges associated with integrating ChatGPT into rural dermatology practices, ultimately fostering a well-informed and responsible approach to its implementation.

Cutaneous Metastasis of Lung Adenocarcinoma: Initially Mimicking and Misdiagnosed as Keloids.

Cutaneous metastases have distinct morphologic features that can aid in making the diagnosis clinically even prior to biopsy. Lesions often have a nodular appearance and are firm, fixed, and range from flesh-colored to reddish-purple. A 73-year-old female with a history of lung adenocarcinoma status-post neoadjuvant chemotherapy and lobectomy 20 months prior was referred to our dermatology clinic for evaluation and treatment of suspected keloids on the left flank. The lesions were firm, plum-colored, fibrotic nodules, and were diagnosed clinically in the office as cutaneous metastases of internal malignancy. Punch biopsy was performed and revealed a proliferation of atypical epithelial cells arranged in cords and strands, with neoplastic cells positive for CK7 and TTF-1, confirming the diagnosis of metastatic adenocarcinoma. The patient was referred for chemotherapy and is still alive nine months following the prompt clinical diagnosis of cutaneous metastasis. Cutaneous metastasis signifies a poor prognosis, but knowledge of the clinical characteristics of these lesions can lead to earlier detection and more prompt initiation of treatment.

Pathergy of a Medial Heel Schwannoma.

Schwannomas are benign soft-tissue tumors derived from Schwann cells of the peripheral nervous system. They typically appear on the head, neck, or trunk, and are often asymptomatic or present with mild tenderness to palpation and numbness due to nerve compression. A 17-year-old male was referred to our dermatology clinic for evaluation and treatment of an asymptomatic, pink, flesh-colored subcutaneous nodule on the medial right heel. A biopsy was performed to rule out malignancy, with the pathology report consistent with the diagnosis of schwannoma. Following the biopsy, the patient developed a persistent, non-healing red-violaceous ulcerative plaque at the biopsy site, which persisted following additional electrodessication and silver nitrate application. Repeat biopsy showed persistent schwannoma and notably the absence of a pyogenic granuloma. The persistent ulceration following the initial biopsy is consistent with the phenomenon known as pathergy, which refers to exaggerated tissue reactivity in response to trauma. The patient eventually required surgical excision and a keystone flap for definitive treatment of the lesion. Although rare, we have demonstrated that pathergy can occur during surgical procedures on suspected schwannomas. Physicians should be aware of this possible complication so that they can provide anticipatory guidance for patients undergoing surgical procedures on undiagnosed cutaneous neoplasms for which a schwannoma is in the differential diagnosis.

Discrete and Coalescing Pustules Masking Severe Recalcitrant Rosacea Due to Demodex.

CONTEXT: Rosacea is a frequent and often easily treatable condition in dermatological practice. The clinical manifestations of rosacea are hypothesized to be the result of a dysregulation of the innate immune system. The roles played by outside factors, such as the presence of Demodex or localized immunosuppression in the pathogenesis of rosacea, are under considerable debate. OBJECTIVE: The current study intended to examine the contribution of immunosuppression to a case of recalcitrant rosacea and the effects of nutritional status in the resolution of the skin disease. DESIGN: The research team designed a case study. SETTING: The study took place at the dermatology clinic of the Department of Dermatology at Indiana University (Indianapolis, IN, USA). PARTICIPANT: The participant was a 36-y-old male patient at the clinic with a recalcitrant dermatosis of the face and neck. This patient's disease had persisted despite multiple standard treatments for facial dermatitis, rosacea, and granulomatous rosacea with a high Demodex burden. INTERVENTION: The intervention included a tapering course of cyclosporin, 3 mg of ivermectin daily for 3 wk, 500 mg daily of ascorbic acid, 1000 units daily of cholecalciferol, and green smoothies. OUTCOME MEASURES: The study measured the patient's levels of immunoglobulin M (IgM), 25 hydroxyvitamin D, and ascorbic acid. RESULTS: The testing showed isolated IgM deficiency and low levels of 25 hydroxyvitamin D and ascorbic acid. The rash resolved following the tapering course of cyclosporin and vitamin repletion through supplements and dietary alteration. CONCLUSIONS: The case was one with multiple confounding variables: (1) the presence of Demodex, (2) iatrogenic immunosuppression due to prolonged systemic and topical steroid use, and (3) vitamin deficiency. The case demonstrates the multifactorial pathogenesis of a recalcitrant dermatosis of the face and neck, and the research team encourages providers to consider a holistic approach when patients do not respond to standard medical therapy.