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A peculiar annular eruption in a child with AIDS
BRIEFCOMMUNICATIONS A peculiar annular eruption in a child with AIDS Barry A. Solomon, MD, and Teresita A. Laude, MD Brooklyn,
New York
Child abuse is a term that has no accepted definiit is agreed that its incidence is increasing, especially among vulnerable children. We report a case that demonstrates the necessity to examine all patients, especially HIV-infected children, with an expanded differential diagnosis that includes child abuse.
tion. However,
CASE REPORT A ‘I-year-old black girl had a 2-week history of painful “blisters” on the right hip and thigh. The patient’s birth mother died of AIDS shortly after the patient was born. The patient’s CD4 cell count was 63. She was adopted at 13 months of age by her aunt, a pediatric nurse. The patient was in relatively good health until approximately 1% years before presentation when she began experiencing neurologic deficits. Medical history revealed similar cutaneous lesions on two occasions beginning approximately 1 year before presentation. One of these lesions was on the left hip/thigh area and the other on the right lower extremity. Topical antifungal and antibiotic treatment was given, which cleared the lesions. Examination revealed eight tender annular and halfmoon-shaped hyperpigmented crusted patches and plaques, measuring 2 to 3 cm (Fig. 1). Several had areas of central clearing. No blisters or bullae were evident. An umsual findiug was that the orientation of the crescents were in both gravity- and anti-gravitydepcndent directions. A punch biopsy specimen revealed degenerated keratinocytes in the cornified layer (Fig. 2). This was in-
terpreted as complete reepithelialization of prior necrosis of the epidermis, most probably caused by trauma. At the next visit the adoptive parent and the child were separated momentarily. Without prompting of causation, subtle questioning of the child as to the cause of the lesions revealed that the adoptive parent had been using a belt to discipline the child. The buckle on the belt was From the Department of Dermatology, Health Science Center at Brooklyn.
State University
Reprint requests: Barry A. Solomon, MD, SUNY Center at Brooklyn, Department of Dermatology, Ave., Brooklyn, NY 11203. J AM ACAD DERMATOL Copyright 0190-9622.95
0
York
Health Science 450 Clarkson
19!95;33:5 13-4.
1995 by the American $3.00 + 0
of New
16lS4l654Xi
Academy
of Dermatology,
Inc.
1 Fig. 1. Annular
and half-moon-shaped hyperpigmented patches and plaques of the right thigh.
causing the lesions on the patient’s body. Appropriate regulatory agencies for child abuse and maltreatment were contacted.
DISCUSSION In 1974, the Federal Child Abuse Prevention and Treatment Act’ was enacted. This act established uniform operating standards regarding the identification and management of child abuse cases. Further legislation protecting children from neglect was enacted with the Child Abuse Amendments of 1984.2 Individual states, however, continue to grapple with their own definitions of maltreatment. The magnitude of abuse, especially in the HIV-infected population, is not well defmed. The lack of epidemiologic data limits the extent to which public health and social welfare policies and interventional programs could be evaluated, developed, and implemented. The data that are available are alarming. In 1993, nationally, more than 2.9 million child abuse or neglect cases were repomd3 Fifteen of 1000 children in the United States were substantiated as victims of abuse.3 Neglect represents the most common type. Physical abuse is second with a 30% rate of frequency.3 Furthermore, an estimated 1299 children died of abuse or neglect in 1993.3 Such rates have risen 14% from 1990 to 1993. However, sev513
Journal
of the American
514 Brief communications
degenerated keratinocytes in comified layerrepresents completereepithelialization of prior necrosisof epidermis.
Fig. 2. Stratum of
eral studiessuggestthat thesenumbers underestimate the actual incidenceof maltreatment.In New York State,only 2.2% of child abuseandmaltmatment caseswere reportedby physiciansin 1992.4 Several factors are involved in determining the likelihood of adults engagingin abusivebehavior. Identifying thesesignsis a first steptoward pmvention. Substanceabuse,domesticviolence,economic stress,age,lack of parentingskills, sex (in physical abusecases),and ethnicity are acknowledgedpmdictors of abuse?We suggestthat a “need for sup port services” shouldbe anotherconsideration,es-
Academy
of Dermatology September 1995
p&ally with a compromised child. For example, parentsof HIV-infected childrenrequirethe support of social, educational,and medical serviceslest the emotional, financial, and medical burden lead to abuse.In addition, we have noted that in HIVseropositivechildren,the incidenceof maltreatment increasesastheirCD4 cell countdeclines,especially below 200.In our patient,the abusebeganwhenher CD4 count was 173.Furthermore,the patentwas a singleworking mother whosesisterdied shortlybefore the lesions appeared. The World Health organization predictsthat by the year2000,lO million childrenworldwide will be infected with HIV.6 In the United States,in 1994, approximately 20,000 children had been infected with HIV.6 REFERENCES 1. PL 93-2487. 2. 42 USCA Section 5101-5117d (west supp. 1990). 3. McCmdy K, Dam D. Current trends in child abuse reporting and fatalities: the results of the 1993 annual fifty state survey. Chicago: National Committee to Prevent Child Abuse, 1994: 808:1-22. 4. Facts on pediatric AIDS. Cutis 1994,53:288B. 5. New York State Central Registry Statistics. New York: Federation on Child Abuse and Neglect, 1994. 6. Cappelleri JC, Eckenrode J, Powers JL. The epidemiology of child abuse: findings from the second national incidence and prevalence study of child abuse and neglect. Am J Pub lit Health 1993;83:1622-4.
The significance of mast cells in basal cell carcinoma Michael S. Cohen,MD, and Gary S. Rogers,MD Boston, Massachusetts
The purposeof our study was to assessmore accuratelythe significanceof mast cells in the stroma surrounding basal cell carcinomas (BCCs). We Fnnn the Departments of Dermatology sity School
and Surgery,
Boston
Univer-
of Medicine.
Resented in part at the annual meeting of the American College Mohs Surgery and Cutaneous Oncology, May 14,1994.
of
Reprint requests: Gary S. Rogers, MD, Department of Dermatology, Boston University School of Medicine, 80 E. Concord St., Boston, MA CL2118-2393. J AM ACAD Copyright
DERMAToL
1995;33:514-7.
0 1995 by the American
01!40-%22/95$3.00+0
Academy
16/54/64668
of Dermatology,
Inc.
quantitativelycomparedthe mast cell density surroundingthe tumor islandsto the normal adjacent tissues.We alsostudiedthe histologicfeaturesof the tumor and the type of collagensurroundingthe tumor islandsandwe collatedthesefindings with several clinical parameters. Mast cells are bone marrow-derived circulating cells found in andaroundalmostall tissues;thosein the skin, gastsointestinaltract,andlung arethemost studied.’ Mast cells are effecters of IgBmediated immune reactions2but haverecentlybeenshownto participatein a variety of physiologicandpathologic reactions.Mast cells containin their cytoplasmnu-
New York
Child abuse is a term that has no accepted definiit is agreed that its incidence is increasing, especially among vulnerable children. We report a case that demonstrates the necessity to examine all patients, especially HIV-infected children, with an expanded differential diagnosis that includes child abuse.
tion. However,
CASE REPORT A ‘I-year-old black girl had a 2-week history of painful “blisters” on the right hip and thigh. The patient’s birth mother died of AIDS shortly after the patient was born. The patient’s CD4 cell count was 63. She was adopted at 13 months of age by her aunt, a pediatric nurse. The patient was in relatively good health until approximately 1% years before presentation when she began experiencing neurologic deficits. Medical history revealed similar cutaneous lesions on two occasions beginning approximately 1 year before presentation. One of these lesions was on the left hip/thigh area and the other on the right lower extremity. Topical antifungal and antibiotic treatment was given, which cleared the lesions. Examination revealed eight tender annular and halfmoon-shaped hyperpigmented crusted patches and plaques, measuring 2 to 3 cm (Fig. 1). Several had areas of central clearing. No blisters or bullae were evident. An umsual findiug was that the orientation of the crescents were in both gravity- and anti-gravitydepcndent directions. A punch biopsy specimen revealed degenerated keratinocytes in the cornified layer (Fig. 2). This was in-
terpreted as complete reepithelialization of prior necrosis of the epidermis, most probably caused by trauma. At the next visit the adoptive parent and the child were separated momentarily. Without prompting of causation, subtle questioning of the child as to the cause of the lesions revealed that the adoptive parent had been using a belt to discipline the child. The buckle on the belt was From the Department of Dermatology, Health Science Center at Brooklyn.
State University
Reprint requests: Barry A. Solomon, MD, SUNY Center at Brooklyn, Department of Dermatology, Ave., Brooklyn, NY 11203. J AM ACAD DERMATOL Copyright 0190-9622.95
0
York
Health Science 450 Clarkson
19!95;33:5 13-4.
1995 by the American $3.00 + 0
of New
16lS4l654Xi
Academy
of Dermatology,
Inc.
1 Fig. 1. Annular
and half-moon-shaped hyperpigmented patches and plaques of the right thigh.
causing the lesions on the patient’s body. Appropriate regulatory agencies for child abuse and maltreatment were contacted.
DISCUSSION In 1974, the Federal Child Abuse Prevention and Treatment Act’ was enacted. This act established uniform operating standards regarding the identification and management of child abuse cases. Further legislation protecting children from neglect was enacted with the Child Abuse Amendments of 1984.2 Individual states, however, continue to grapple with their own definitions of maltreatment. The magnitude of abuse, especially in the HIV-infected population, is not well defmed. The lack of epidemiologic data limits the extent to which public health and social welfare policies and interventional programs could be evaluated, developed, and implemented. The data that are available are alarming. In 1993, nationally, more than 2.9 million child abuse or neglect cases were repomd3 Fifteen of 1000 children in the United States were substantiated as victims of abuse.3 Neglect represents the most common type. Physical abuse is second with a 30% rate of frequency.3 Furthermore, an estimated 1299 children died of abuse or neglect in 1993.3 Such rates have risen 14% from 1990 to 1993. However, sev513
Journal
of the American
514 Brief communications
degenerated keratinocytes in comified layerrepresents completereepithelialization of prior necrosisof epidermis.
Fig. 2. Stratum of
eral studiessuggestthat thesenumbers underestimate the actual incidenceof maltreatment.In New York State,only 2.2% of child abuseandmaltmatment caseswere reportedby physiciansin 1992.4 Several factors are involved in determining the likelihood of adults engagingin abusivebehavior. Identifying thesesignsis a first steptoward pmvention. Substanceabuse,domesticviolence,economic stress,age,lack of parentingskills, sex (in physical abusecases),and ethnicity are acknowledgedpmdictors of abuse?We suggestthat a “need for sup port services” shouldbe anotherconsideration,es-
Academy
of Dermatology September 1995
p&ally with a compromised child. For example, parentsof HIV-infected childrenrequirethe support of social, educational,and medical serviceslest the emotional, financial, and medical burden lead to abuse.In addition, we have noted that in HIVseropositivechildren,the incidenceof maltreatment increasesastheirCD4 cell countdeclines,especially below 200.In our patient,the abusebeganwhenher CD4 count was 173.Furthermore,the patentwas a singleworking mother whosesisterdied shortlybefore the lesions appeared. The World Health organization predictsthat by the year2000,lO million childrenworldwide will be infected with HIV.6 In the United States,in 1994, approximately 20,000 children had been infected with HIV.6 REFERENCES 1. PL 93-2487. 2. 42 USCA Section 5101-5117d (west supp. 1990). 3. McCmdy K, Dam D. Current trends in child abuse reporting and fatalities: the results of the 1993 annual fifty state survey. Chicago: National Committee to Prevent Child Abuse, 1994: 808:1-22. 4. Facts on pediatric AIDS. Cutis 1994,53:288B. 5. New York State Central Registry Statistics. New York: Federation on Child Abuse and Neglect, 1994. 6. Cappelleri JC, Eckenrode J, Powers JL. The epidemiology of child abuse: findings from the second national incidence and prevalence study of child abuse and neglect. Am J Pub lit Health 1993;83:1622-4.
The significance of mast cells in basal cell carcinoma Michael S. Cohen,MD, and Gary S. Rogers,MD Boston, Massachusetts
The purposeof our study was to assessmore accuratelythe significanceof mast cells in the stroma surrounding basal cell carcinomas (BCCs). We Fnnn the Departments of Dermatology sity School
and Surgery,
Boston
Univer-
of Medicine.
Resented in part at the annual meeting of the American College Mohs Surgery and Cutaneous Oncology, May 14,1994.
of
Reprint requests: Gary S. Rogers, MD, Department of Dermatology, Boston University School of Medicine, 80 E. Concord St., Boston, MA CL2118-2393. J AM ACAD Copyright
DERMAToL
1995;33:514-7.
0 1995 by the American
01!40-%22/95$3.00+0
Academy
16/54/64668
of Dermatology,
Inc.
quantitativelycomparedthe mast cell density surroundingthe tumor islandsto the normal adjacent tissues.We alsostudiedthe histologicfeaturesof the tumor and the type of collagensurroundingthe tumor islandsandwe collatedthesefindings with several clinical parameters. Mast cells are bone marrow-derived circulating cells found in andaroundalmostall tissues;thosein the skin, gastsointestinaltract,andlung arethemost studied.’ Mast cells are effecters of IgBmediated immune reactions2but haverecentlybeenshownto participatein a variety of physiologicandpathologic reactions.Mast cells containin their cytoplasmnu-