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Cutaneous reactions associated with interferon beta in two patients with multiple sclerosis
P1182
P1184
Funny objects emerging from the skin Cristina Martı´nez-Mora´n, MD, Dermatology, Hospital Universitario de Fuenlabrada, Madrid, Spain; Carmen Garcia-Donoso, MD, Dermatology, Hospital Universitario de Fuenlabrada, Madrid, Spain; Dolores Arias-Palomo, MD, Dermatology, Hospital Universiterio de Fuenlabrada, Madrid, Spain; Jesu ´s Borbujo, MD, PhD, Dermatology, Hospital Universitario de Fuenlabrada, Madrid, Spain
Yellow nail syndrome associated with asthma Priya Sivanesan, MD, MBBS, University of Pittsburgh, Pittsburgh, PA, United States; Joseph English, MD, University of Pittsburgh, Pittsburgh, PA, United States; Pooja Khera, MD, University of Pittsburgh, Pittsburgh, PA, United States A 45-year-old white male presented to the clinic complaining of yellowing of his fingernails and toenails. He reported having the discoloration of his nails for 4 to 5 months. He also reported a 9-month history of asthma. The physical examination was significant for yellow discoloration of the entire nail plate of all fingernails and toenails. There were no cuticles or lunulae on exam. There was no onychodystrophy or lymphedema on exam. Based on the history and clinical evaluation, the patient was diagnosed with yellow nail syndrome. Consideration of underlying malignancy is important, because malignancy has been associated with yellow nail syndrome. Pulmonary disease associated with yellow nail syndrome is usually bronchiectasis or recurrent pleural effusions; however, any pulmonary disease can be present. It is important to identify and diagnose this disorder so that appropriate treatment and evaluation can be initiated, including pulmonary evaluation and evaluation of underlying malignancy.
It is a frequent consultation to physician: a foreign body sensation referred for some patients in a variety of anatomic places after suffering a traumatic event, eating some kind of food, and usually after combat injuries in military conflict zones. Depending on where the foreign body sensation is, different doctors are asked for help: otorhinolaryngologists, gynecologists, general surgeons, ophthalmologists, or dermatologists. Sometimes we find nothing in those places; however, strange objects have been removed from the referred areas. Here, we report three male patients that presented with apparently banal cutaneous lesions with a history that made us think of foreign bodies in different body sites. The first patient was a 35-year-old male that presented to us after a traumatic event with a palm thorn on his left leg. After surgical excision, we removed a 2-cm palm thorn. The second patient, an 11-year-old child, presented with a nodule on his left hand and related a traumatic event with a splinter. After surgical excision, a 15-mm splinter was obtained. Our third patient was a 34-year-old male that presented with nodular lesions over a laparotomy scar. A 20-cm long nylon suture was removed with a simple surgical procedure from one of the nodules.
Commercial support: None identified.
Commercial support: None identified.
P1185 P1183 ¨ ebner phenomenon occurring in polymorphic eruption of pregnancy Ko Victoria Brown, MD, Oxford Dermatology Department, Oxford, Oxfordshire, United Kingdom; Aoife Lally, MBChB, Oxford Dermatology Department, Oxford, Oxfordshire, United Kingdom; Susan Burge, MBChB, Oxford Dermatology Department, Oxford, Oxfordshire, United Kingdom Ko¨ebner phenomenon refers to the development of isomorphic pathologic lesions in traumatized, previously normal skin. It was first reported by Heinrich Ko¨ebner in 1872. Ko¨ebner phenomenon has never previously been described in association with any pregnancy dermatosis. A 28-year-old female developed a pruritic rash within 24 hours of delivering her first child. The skin lesions were initially limited to her abdominal striae but quickly spread to the site of a recent burn on her right wrist. She had not had any previous dermatologic problems either before or during her pregnancy, and there was no history of atopy. A physical examination revealed erythema, papules, and vesicles over the abdomen, predominantly within the abdominal striae. Notably, the eruption had also Ko¨ebnerized into the burn scar on her right wrist. There was periumbilical sparing. Skin biopsy histology from abdominal skin showed epidermal spongiotic vesicle formation and a dense superficial dermal perivascular lymphocytic and eosinophilic inflammatory infiltrate. Both direct and indirect immunofluorescence was negative, excluding pemphigoid gestationis. The clinical and histologic findings were consistent with a diagnosis of polymorphic eruption of pregnancy (PEP). Our patient was treated with topical corticosteroids and emollients. Her symptoms initially worsened and the eruption progressed to other areas of her trunk and upper and lower limbs. It fully resolved within 2 weeks of onset with no further treatment. This is the first reported case of Ko¨ebner phenomenon occurring in a pregnancy dermatosis. It is difficult to explain why this association has developed in our patient, because the pathogenesis of both Ko¨ebner phenomenon and PEP are incompletely understood. The most popular theory for Ko¨ebner phenomenon is the localization of a circulating microbial antigen or inflammatory mediators to sites of increased vasculature caused by trauma. Increased abdominal distension is a factor in the development of PEP, and it has been postulated that this causes inflammation in abdominal striae. Alternatively, it has been hypothesized that fetal cells may migrate to maternal skin provoking an inflammatory reaction. The development of PEP via Ko¨ebner phenomenon on our patients arm lends support to the later hypothesis. Commercial support: None identified.
AB60
J AM ACAD DERMATOL
Cutaneous reactions associated with interferon beta in two patients with multiple sclerosis Nuria Pe´rez-Robayna, MD, PhD, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain; Antonio Martı´n-Herrera, MD, Hospital Universitario de Canrias, La Laguna, Santa Cruz de Tenerife, Spain; Francisco Guimera´-Martı´n Neda, MD, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain; Rosalba Sa´nchez-Gonza´lez, MD, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain; Sorahaya Gonza´lezHerna´ndez, PhD, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain Introduction: Multiple sclerosis is a demyelinating chronic disease of the central nervous system that is also the main cause of disability in adults. Since 1993, interferon beta-1b is one of the treatment options of this neurologic disease. We report on two patients with multiple sclerosis who presented with cutaneous lesions at injections sites during treatment with subcutaneous interferon beta-1b. Case 1: Our first patient was a 36-year-old male who suffered from multiple sclerosis who had been taking subcutaneous interferon beta-1b since 2001. He showed cutaneous lesions of 3 weeks’ duration, consisting of several erythematous, hard, painful plaques localized at both arms and thighs, precisely at those areas where he injected interferon beta-1b. Case 2: Our second patient was a 32-year-old female with multiple sclerosis, who had been taking subcutaneous interferon beta-1b since 2003. She showed cutaneous lesions of 10 days’ duration consisting of multiple erythematous and purple hard plaques, badly delimited with aspect of livedo in some areas. The physical examination also revealed some cutaneous ulcerations at injection sites, such as the abdomen and thighs. A skin biopsy was also performed and we could observe lymphoid vasculitis in both cases. Discussion: Skin damage has been reported in association with interferon beta treatment, such as cutaneous necrosis and even panniculitis or vasculitis in some cases. The etiology of these lesions is unknown. Some authors have suggested a vasospastic effect by the interferon beta. Orlow and Friedman-Kien attributed the presence of cutaneous necrosis to the repeated injections at the same site. Finally, we want to highlight that is important to bear this diagnosis in mind in patients with multiple sclerosis and interferon beta. Commercial support: None identified.
MARCH 2009
P1184
Funny objects emerging from the skin Cristina Martı´nez-Mora´n, MD, Dermatology, Hospital Universitario de Fuenlabrada, Madrid, Spain; Carmen Garcia-Donoso, MD, Dermatology, Hospital Universitario de Fuenlabrada, Madrid, Spain; Dolores Arias-Palomo, MD, Dermatology, Hospital Universiterio de Fuenlabrada, Madrid, Spain; Jesu ´s Borbujo, MD, PhD, Dermatology, Hospital Universitario de Fuenlabrada, Madrid, Spain
Yellow nail syndrome associated with asthma Priya Sivanesan, MD, MBBS, University of Pittsburgh, Pittsburgh, PA, United States; Joseph English, MD, University of Pittsburgh, Pittsburgh, PA, United States; Pooja Khera, MD, University of Pittsburgh, Pittsburgh, PA, United States A 45-year-old white male presented to the clinic complaining of yellowing of his fingernails and toenails. He reported having the discoloration of his nails for 4 to 5 months. He also reported a 9-month history of asthma. The physical examination was significant for yellow discoloration of the entire nail plate of all fingernails and toenails. There were no cuticles or lunulae on exam. There was no onychodystrophy or lymphedema on exam. Based on the history and clinical evaluation, the patient was diagnosed with yellow nail syndrome. Consideration of underlying malignancy is important, because malignancy has been associated with yellow nail syndrome. Pulmonary disease associated with yellow nail syndrome is usually bronchiectasis or recurrent pleural effusions; however, any pulmonary disease can be present. It is important to identify and diagnose this disorder so that appropriate treatment and evaluation can be initiated, including pulmonary evaluation and evaluation of underlying malignancy.
It is a frequent consultation to physician: a foreign body sensation referred for some patients in a variety of anatomic places after suffering a traumatic event, eating some kind of food, and usually after combat injuries in military conflict zones. Depending on where the foreign body sensation is, different doctors are asked for help: otorhinolaryngologists, gynecologists, general surgeons, ophthalmologists, or dermatologists. Sometimes we find nothing in those places; however, strange objects have been removed from the referred areas. Here, we report three male patients that presented with apparently banal cutaneous lesions with a history that made us think of foreign bodies in different body sites. The first patient was a 35-year-old male that presented to us after a traumatic event with a palm thorn on his left leg. After surgical excision, we removed a 2-cm palm thorn. The second patient, an 11-year-old child, presented with a nodule on his left hand and related a traumatic event with a splinter. After surgical excision, a 15-mm splinter was obtained. Our third patient was a 34-year-old male that presented with nodular lesions over a laparotomy scar. A 20-cm long nylon suture was removed with a simple surgical procedure from one of the nodules.
Commercial support: None identified.
Commercial support: None identified.
P1185 P1183 ¨ ebner phenomenon occurring in polymorphic eruption of pregnancy Ko Victoria Brown, MD, Oxford Dermatology Department, Oxford, Oxfordshire, United Kingdom; Aoife Lally, MBChB, Oxford Dermatology Department, Oxford, Oxfordshire, United Kingdom; Susan Burge, MBChB, Oxford Dermatology Department, Oxford, Oxfordshire, United Kingdom Ko¨ebner phenomenon refers to the development of isomorphic pathologic lesions in traumatized, previously normal skin. It was first reported by Heinrich Ko¨ebner in 1872. Ko¨ebner phenomenon has never previously been described in association with any pregnancy dermatosis. A 28-year-old female developed a pruritic rash within 24 hours of delivering her first child. The skin lesions were initially limited to her abdominal striae but quickly spread to the site of a recent burn on her right wrist. She had not had any previous dermatologic problems either before or during her pregnancy, and there was no history of atopy. A physical examination revealed erythema, papules, and vesicles over the abdomen, predominantly within the abdominal striae. Notably, the eruption had also Ko¨ebnerized into the burn scar on her right wrist. There was periumbilical sparing. Skin biopsy histology from abdominal skin showed epidermal spongiotic vesicle formation and a dense superficial dermal perivascular lymphocytic and eosinophilic inflammatory infiltrate. Both direct and indirect immunofluorescence was negative, excluding pemphigoid gestationis. The clinical and histologic findings were consistent with a diagnosis of polymorphic eruption of pregnancy (PEP). Our patient was treated with topical corticosteroids and emollients. Her symptoms initially worsened and the eruption progressed to other areas of her trunk and upper and lower limbs. It fully resolved within 2 weeks of onset with no further treatment. This is the first reported case of Ko¨ebner phenomenon occurring in a pregnancy dermatosis. It is difficult to explain why this association has developed in our patient, because the pathogenesis of both Ko¨ebner phenomenon and PEP are incompletely understood. The most popular theory for Ko¨ebner phenomenon is the localization of a circulating microbial antigen or inflammatory mediators to sites of increased vasculature caused by trauma. Increased abdominal distension is a factor in the development of PEP, and it has been postulated that this causes inflammation in abdominal striae. Alternatively, it has been hypothesized that fetal cells may migrate to maternal skin provoking an inflammatory reaction. The development of PEP via Ko¨ebner phenomenon on our patients arm lends support to the later hypothesis. Commercial support: None identified.
AB60
J AM ACAD DERMATOL
Cutaneous reactions associated with interferon beta in two patients with multiple sclerosis Nuria Pe´rez-Robayna, MD, PhD, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain; Antonio Martı´n-Herrera, MD, Hospital Universitario de Canrias, La Laguna, Santa Cruz de Tenerife, Spain; Francisco Guimera´-Martı´n Neda, MD, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain; Rosalba Sa´nchez-Gonza´lez, MD, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain; Sorahaya Gonza´lezHerna´ndez, PhD, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain Introduction: Multiple sclerosis is a demyelinating chronic disease of the central nervous system that is also the main cause of disability in adults. Since 1993, interferon beta-1b is one of the treatment options of this neurologic disease. We report on two patients with multiple sclerosis who presented with cutaneous lesions at injections sites during treatment with subcutaneous interferon beta-1b. Case 1: Our first patient was a 36-year-old male who suffered from multiple sclerosis who had been taking subcutaneous interferon beta-1b since 2001. He showed cutaneous lesions of 3 weeks’ duration, consisting of several erythematous, hard, painful plaques localized at both arms and thighs, precisely at those areas where he injected interferon beta-1b. Case 2: Our second patient was a 32-year-old female with multiple sclerosis, who had been taking subcutaneous interferon beta-1b since 2003. She showed cutaneous lesions of 10 days’ duration consisting of multiple erythematous and purple hard plaques, badly delimited with aspect of livedo in some areas. The physical examination also revealed some cutaneous ulcerations at injection sites, such as the abdomen and thighs. A skin biopsy was also performed and we could observe lymphoid vasculitis in both cases. Discussion: Skin damage has been reported in association with interferon beta treatment, such as cutaneous necrosis and even panniculitis or vasculitis in some cases. The etiology of these lesions is unknown. Some authors have suggested a vasospastic effect by the interferon beta. Orlow and Friedman-Kien attributed the presence of cutaneous necrosis to the repeated injections at the same site. Finally, we want to highlight that is important to bear this diagnosis in mind in patients with multiple sclerosis and interferon beta. Commercial support: None identified.
MARCH 2009