Rapidly fatal metastatic cutaneous angiosarcoma initially mimicking a furuncle in a middle-aged male.

Cutaneous angiosarcomas are rare but typically occur in three distinct clinical settings and are most commonly found on the scalp or face of elderly men. Positive prognostic factors include tumor size less than 5 cm, primary tumor location below the head, negative margins after excision, resectability, and younger age. Metastases drastically reduce survival and the most common metastatic site is lung. We present a 43-year-old man who had primary cutaneous angiosarcoma that initially mimicked a furuncle and eventuated in multiple metastases. The metastatic disease included brain involvement, which has rarely been reported, especially in a relatively young person without known predisposing conditions. This unique case also highlights the need for early diagnosis followed by advanced imaging, given the limitations of current therapies and high metastatic potential of angiosarcoma.

Primary Cutaneous Coccidioidomycosis Presenting as a Recurrent Preauricular Cyst.

A 31-year-old Filipino active duty marine presented with a 2-year history of a waxing and waning nodule on his left cheek that had been incised and drained on multiple occasions. The patient had no significant medical history other than a positive purified protein derivative test with negative chest x-ray finding treated with a 9-month course of isoniazid in 2010. He denied cough, fever, chills, night sweats, weight loss, joint/bone pain, or prior trauma to the area. On initial examination, there was a 1×1-cm erythematous indurated nodule associated with an overlying violaceous scar on his left preauricular cheek. Since the lesion was presumed to be an inflamed epidermal cyst, it was initially treated with 0.1 cc of interlesional triamcinolone acetonide (10 mg/cc). At 1-month follow-up, the lesion was slightly less indurated, but an excisional biopsy was performed to remove the residual nodule. The biopsy showed an essentially normal epidermis with focal dermal fibrosis below which were multiple collections of histiocytes and multinucleated giant cells surrounded by a dense lymphoplasmacytic infiltrate with numerous eosinophils (Figure 1). A few multinucleated giant cells contained large thick-walled spherules, some with endospores, consistent with Coccidioides immitis (Figure 2). Serological tests showed positive serum for C immitis IgG antibodies with low levels of complement-fixing antibodies (1:2). IgM antibodies were negative. Findings from chest x-ray and bone scan failed to reveal evidence of systemic disease. Although the infectious disease physician felt that the patient most likely had primary cutaneous coccidioidomycosis (PCC), since the duration of the infection was unknown and the patient was Filipino, thereby increasing his risk of dissemination, he was placed on a daily regimen of 400 mg of oral fluconazole until his complement fixation titers became undetectable.

Intradermal proliferative fasciitis on the finger.

Intradermal nodular fasciitis is a rare but not extraordinary pathological finding with approximately 100 cases reported since originally described in 1990. Intradermal proliferative fasciitis, however, has only been reported twice and both arose in the postauricular region. Herein, we report a third case of intradermal proliferative fasciitis and the first to occur on the finger. This case was also unusual in its slow growth, and complete lack of smooth muscle actin expression that has only been reported once before.

Cutaneous metastasis of a transitional cell carcinoma.

Cutaneous metastases are infrequently encountered in dermatology. We describe a rare case of a urolethial carcinoma metastatic to the skin in an elderly female. The metastasis expanded rapidly and was thought to possibly be infectious on her initial evaluation by her primary team. We were called in as consultants and biopsied this mass to confirm our concern for metastatic disease. In this case there was an unknown primary tumor. Histologic staining patterns were used to suggest that the tumor may have originated from her urinary bladder.

Syringocystadenocarcinoma papilliferum with locoregional metastases.

Syringocystadenocarcinoma papilliferum (SCACP) is a rare malignant counterpart of syringocystadenoma papilliferum (SCAP). To date, less than 30 cases have been reported, and of those, only three had locoregional metastases [1,2]. Herein, we report a case of a 42-year-old man with a rapidly growing nodule on his right parietal scalp ultimately diagnosed as SCACP arising in association with a preexisting SCAP and nevus sebaceus. This case differs from prior reports in the tumor's rapid growth and aggressive course with the development of locoregional metastases within 5-weeks from initial presentation.

Multiple clustered and focally atrophic dermatofibromas (DF).

Multiple clustered dermatofibromas describes a confluence of dermatofibromas in one anatomic location. We describe a 32-year-old man who presented for evaluation owing to skin papules and plaques and concerns about malignancy. Repeat histopathological evaluation found no evidence for dermatofibrosarcoma protuberans. Our case presents this relatively rare condition and discusses observation along with potential treatment options.

Congenital cutaneous candidiasis in two full-term infants.

We describe two full-term infants who presented with congenital cutaneous candidiasis (CCC) and compare their clinical presentation and outcome with that of neonatal candidiasis and chronic mucocutaneous candidiasis. Although candidal vulvovaginitis occurs in up to one-third of pregnancies, CCC is uncommon and can be confused with more-serious pustular disorders that present in neonates. Greater awareness of CCC is essential to make an early diagnosis and distinguish it from other infections.

Hereditary hidradenitis suppurativa restricted to the auricular region.

Hidradenitis suppurativa (HS) is part of the follicular occlusion tetrad, which typically presents as recurrent deep-seated nodules, abscesses, and communicating sinus tracts with a predilection for the axilla and genital region. There is only one prior report of HS restricted to the auricular region. Herein the first familial case of HS restricted to the auricular region is reported.

Metastatic atypical fibroxanthoma.

Atypical fibroxanthoma (AFX) is an undifferentiated pleomorphic sarcoma that typically has low-grade malignant potential. Although recurrences do occur, only approximately 25 cases of metastasizing AFX have been reported. Herein a patient with an AFX that metastasized and eventuated in death is described. Although AFX remains a diagnosis of exclusion, through this pedagogic case, the clinical, immunohistochemical, and genetic features that can assist in diagnosis are discussed.

Signet ring-like cells: no longer a "signature" of glandular differentiation.

The term "signet ring" is used to describe a cell with an eccentric nucleus that is compressed to the periphery of the cell by a large cytoplasmic vacuole or by a substance accumulated within the cytoplasm. In pathology, these cells have been traditionally associated with adenocarcinomas. We describe two cases of cutaneous tumors that contained signet ring-like cells. Because of the morphology of the cells and the fact that one patient had a past history of lung cancer, the possibility of metastatic adenocarcinoma was considered. Upon further investigation, the tumors proved to be a primary cutaneous squamous cell carcinoma and a basal cell carcinoma; surgical management was curative. Because signet ring changes may pose a diagnostic challenge, we review the various benign and malignant cutaneous lesions that have been reported to contain signet ring cells and we explore the possible causative mechanisms of this phenomenon.

Depth of tissue ablation and residual thermal damage caused by a pixilated 2,940 nm laser in a swine skin model.

BACKGROUND/OBJECTIVE: The purpose of this study was to assess the effects of fluence, pulse stacking, and multiple passes on the depth of injury caused by a fractionated Er:YAG laser in an in vivo farm pig model. DESIGN/MATERIAL/METHODS: A fractionated 2,940 nm Er:YAG laser (Pixel, Alma Lasers, Caesarea, Israel) was applied to the flank skin of a Yorkshire cross pig. The 11 mmx11 mm handpiece was comprised of either 49 or 81 microbeams (200 microm diameter), depending on the tip configuration. There were six different parameter sets divided according to total energy per pulse (150, 285, and 500 mJ) and tip type (81 or 49 microbeams per 11 mmx11 mm macrospot). Each of these six groups was subdivided according to number of stacked pulses (1, 3, and 6) and number of passes (1, 3, and 6). This resulted in a total of 36 treatment parameters. RESULTS: With the 49 microbeam configuration, a single pulse resulted in partial epidermal ablation at 150 mJ, complete epidermal ablation at 285 mJ and partial dermal ablation at 500 mJ to a depth of 90 microm. Stacking the pulses resulted in a significant increase in ablation with each fluence with the maximal depth of ablation measured at 140 microm after six stacked pulses at 500 mJ. Increasing the number of passes did not result in a significant increase in ablative depth, but did create a larger surface area of ablation. Residual thermal damage (RTD) was minimal and remained between 10 and 20 microm. CONCLUSIONS: The fractionated Er:YAG laser exhibited some of the same tissue interactions as its fully ablative counterparts. An increase in fluence resulted in an increase in ablative depth with minimal RTD. Additionally, RTD was unaffected by pulse stacking or by additional passes. Differences were that pulse stacking appeared to yield a more rapid decrease in ablation efficiency and additional passes did not seem to increase the depth of ablation.

Secondary yaws: an endemic treponemal infection.

Although yaws is rare in developed countries, as worldwide travel has become commonplace, it is essential to recognize this condition when evaluating patients who traveled from endemic regions. Herein, we discuss a case of secondary yaws presenting as extensive expanding annular lesions to raise awareness of this condition.

The role of a dermatologist on military humanitarian missions.

The US military in conjunction with allied military services and nongovernmental organizations have embarked on various humanitarian missions to underserved areas worldwide. These missions illustrate what interoperability between nations can accomplish. Dermatologists involved with humanitarian missions encounter many conditions rarely seen in developed countries and learn to practice general dermatology with limited resources in austere environments.

Inoculation bartonellosis in an adult: a case report.

Cat-scratch disease (CSD) and bacillary angiomatosis (BA) are caused by a gram-negative bacilli classified under the genus Bartonella (formerly Rochalimaea). Patient history, symptoms, and histopathology often fall along a continuum; therefore, both conditions should be considered in the differential diagnosis. We report a case of an 83-year-old immunocompetent woman who presented with a pyogenic granuloma-like lesion on her dorsal left wrist. The histologic differential diagnosis included an inoculation site from a cat scratch infected with Bartonella and BA. Because the patient had only 1 lesion at the site of a prior cat scratch, the lesion was diagnosed as inoculation bartonellosis. We also review the epidemiologic, clinical, and histopathologic features of CSD and BA.

Diffuse xanthogranulomatous dermatitis and systemic Langerhans cell histiocytosis: A novel case that demonstrates bridging between non-Langerhans cell histiocytosis and Langerhans cell histiocytosis.

The advent of electron microscopy and immunohistochemical stains allowed for reclassification of the histiocytoses based on the predominant cell in the infiltrate. Although the current schema simplicity provides a good foundation, some patients display overlapping clinical and immunohistochemical features that defy classification. The patient herein illustrates bridging between histiocytic disorders. Through this case we review the various conditions classified under the non-Langerhans cell histiocytosis and Langerhans cell histiocytosis rubric.

Solitary superficial angiomyxoma: an infrequent but distinct soft tissue tumor.

Superficial angiomyxoma (SA) is a distinct soft tissue tumor characterized by a circumscribed collection of spindled and stellate fibroblasts that are admixed with thin-walled blood vessels and embedded in a mucinous stroma. Because of its relative infrequent occurrence, the purpose of this article was to present a classical example of an isolated superficial angiomyxoma and discuss the differential diagnosis.

Tumors composed of malignant epithelial and melanocytic populations: a case series and review of the literature.

Over the last 30 years, there have been approximately 49 case reports of tumors composed of both malignant epithelial and malignant melanocytic populations. Herein, we present four additional cases of combined tumors that consist of two phenotypically distinct but intermingled populations of malignant cells. Each tumor was composed of an invasive melanoma closely associated with either a basal cell carcinoma or a squamous cell carcinoma. We review all previous case reports in the English literature and attempt to clarify the terminology and summarize what is currently known about these unique tumors.