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Importance of histopathologic diagnosis of acroangiodermatitis
P1516
P1518
Varicella zoster virus brachioplexitis associated with granulomatous vasculopathy John Fleming, MBBS, King’s College Hospital, London, United Kingdom; Abigail Fogo, MBBS, King’s College Hospital, London, United Kingdom; Roderick Hay, MBBS, King’s College Hospital, London, United Kingdom; Salman Haider, MBBS, King’s College Hospital, London, United Kingdom; Saqib Bashir, MD, MBBS, King’s College Hospital, London, United Kingdom Varicella zoster virus (VZV) is well-known to lead to the clinical disease of varicella in primary infection and zoster upon reactivation. However, the manifestations of VZV infection can be altered in the immunocompromised, and our case highlights the potential for motor nerve involvement. We report the case of a 63-year-old man with a prolonged, multidermatomal, nonvesicular rash with VZV PCR positivity on affected skin, limb paresis secondary to brachioplexitis, and histology consistent with granulomatous vasculopathy. Because of the significant motor weakness, nerve conduction studies and electromyography were performed, which revealed absent sensory potentials and biceps denervation, suggesting C5 pathology. In addition, a T2-weighted MRI scan showed root enhancement of the left brachial plexus, supporting the diagnosis of a left brachial radiculoplexitis. No other systemic features of vasculitis developed, a vasculitic screen was negative, and a lumbar puncture excluded the presence of VZV DNA. After 3 months of oral valaciclovir 1 g tds and regular physiotherapy, his motor neuropathy improved with 5/5 power in elbow flexion and extension, but a reduced range of movement and weakness in shoulder abduction persists. His papular red-brown eruption has settled slowly 8 months after the initial presentation. The clinical course of cutaneous zoster in immunocompromised individuals is often recurrent, protracted, and multidermatomal. In such individuals, it can penetrate into deeper tissue and result in a diverse spectrum of disorders, including myelitis, meningoencephalitis, and cerebral or small-vessel vasculopathic or vasculitic changes. This case discusses the unusual finding of disuse muscle wasting secondary to limb paresis from brachioplexitis and the potential role of MRI to investigate cases where a prolonged albeit atypical eruption coincides with motor weakness and pain. The challenges posed by potential central nervous system complications after immunosuppressive treatment are also highlighted. Prolonged oral treatment with valaciclovir improves aciclovir bioavailability and may obviate the need for increasing immunosuppression when these concerns exist.
Importance of histopathologic diagnosis of acroangiodermatitis Ana Maria Mosca de Cerqueira, PhD, Hospital Menino Jesus, Rio de Janeiro, Brazil; Clarissa Caramez, Policlinica Geral do Rio de Janeiro, Rio de JAneiro, Brazil; Joana Orli, Policlinica Geral do Rio de Janeiro, Rio de Janeiro, Brazil; Maria Auxiliadora Jeunon, Hospital Universitario Pedro Ernestro, Rio de Janeiro, Brazil Background: Acroangiodermatitis is a very rare disease. It is characterized by erythematous violaceous cutaneous lesions, localized mainly in the legs and feet, resembling Kaposi sarcoma. Acroangiodermatitis is a disease that is usually associated with different disorders, such as chronic venous insufficiency, arteriovenous malformation, and arteriovenous shunt. This case adds your learning difficulty prenatal. Summary: A 62-year-old white woman who was a resident of Rio de Janeiro presented with lesions that were erythematous, violaceous, painless, and pruritic, with an evolution of approximately 1 year. The physical examination revealed the presence of varicose veins of varying sizes in her legs. Routine laboratory examinations did not reveal alterations. Histopathology revealed hyperplastic epidermis and, in the papillary dermis and the middle reticular dermis, a proliferation of blood vessels amid a moderate interstitial lymphohistiocytic infiltrate and depositing hemosiderin. Immunohistochemistry lookup antigen CD34 was negative, excluding the diagnosis of Kaposi sarcoma, whose cells are 100% positive CD34. Conclusion: Acroangiodermatitis is a disorder that is clinically and histologically similar to Kaposi sarcoma and that is characterized by violaceous papules and nodules grouped into anatomic ends. It seems to be caused by changes in the local circulation, causing a reactive proliferation. This is frequently associated with other vascular disorders. The histopathologic differential diagnosis of Kaposi sarcoma is not always easy; however, in acroangiodermatitis, the vessels are quite regular without the fissures that are very common in Kaposi sarcoma. In the latter, the leakage of red blood cells is not so intense and there is a lesser amount of hemosiderin. There are cases, however, in which the differential diagnosis becomes difficult. In such cases, clinicians should use the CD34 antigen which is expressed in 100% of the cases of Kaposi sarcoma and absent in acroangiodermatitis, according to the work of Kanitakis et al. Commercial support: None identified.
Commercial support: None identified.
DERMATOPHARMACOLOGY/COSMECEUTICALS P1600
Case report: A 45-year-old woman reported that more than 1 year ago, a lesion appeared on her neck after a burn. A physical examination revealed an incomplete annular lesion that was bright, consisted of erythematous papules, and was sometimes itchy. The rest of the skin was normal. The histologic study shows the presence of multiple giant cells, which are not lattice or caseous necrosis, accompanied by few cells located in superficial dermis. Some giant cells had elastic connective tissue debris (elastophagocytosis). Discussion: The etiology is unknown, although cases have been reported on burn scars, after intense sun exposure, and from phototoxicity associated with doxycycline. The clinical course is chronic, and treatment has been effective with topical corticosteroids, intralesional or systemic, chloroquine, acitretin, and cyclosporin. The differential diagnosis must be made with granuloma annulare, erythema annulare centrifugum, necrobiosis lipoidica, sarcoidosis, and granulomatous infections.
Simple vasoconstriction may be a primary antiinflammatory mechanism of topical corticosteroids Christopher Kroodsma, MD, University of Illinois College of Medicine Peoria, Peoria, IL, United States The vasoconstrictor assay is used as a method to measure corticosteroid potency, because their ability to constrict blood vessels has been found to correlate well with antiinflammatory efficacy. Yet this vasoconstriction is generally not considered to be an antiinflammatory mechanism. An experimental model was designed with the purpose of showing the effect that simple diameter differences may have on blood vessel walls. Distensible latex material containing microscopic holes (representing intercellular spaces) was used to create a cylindrical lumen with diameters of 0.5’’ proximally and 1’’ distally. Water was allowed to flow through the lumen and pressure was increased by blocking the distal end. As fluid pressure increased, only the larger diameter segment became visibly distended, although pressure was equal throughout the lumen. No fluid escaped through the luminal wall holes initially, but as the larger diameter segment distended, fluid began to flow rapidly through the holes in this region but not through those in the narrower segment. These phenomena are explained by the LaPlace Law, which holds that T ¼ DPR (where T ¼ wall tension, DP ¼ transmural pressure, and R ¼ radius) for a distensible cylindrical lumen. The term tension (T) represents a force directed along the circumference of the luminal wall that promotes distension and stretch. A narrower vessel, simply as a function of its smaller diameter, is relatively protected from wall tension. Vessels in many inflammatory processes are either temporarily or chronically dilated are therefore exposed to increased wall tension/stretch force. Physical stretch of blood vessel walls and endothelium has been shown experimentally to result in release of numerous proinflammatory cytokines, including VEGF, TNFa, MCP-1, IL-6, and IL-8. Also, as shown in the above experiment, increased wall tension may result in the opening of typically closed gaps in vessel walls, facilitating movement of fluid and/or inflammatory cells into the surrounding tissues. It follows that with corticosteroid-induced decreases in vessel diameter and subsequently decreased wall tension, as defined and predicted by the LaPlace Law, inflammation may be accordingly decreased.
Commercial support: None identified.
Commercial support: None identified.
P1517 Annular elastolytic giant cell granuloma Jose Aneiros-Fernandez, MD, San Cecilio Clinical Hospital, Department of Pathology, Granada, Spain; Husein Husein-ElAhmed, MD, San Cecilio Clinical Hospital, Department of Dermatology, Granada, Spain; Ines Aroca-Siendones, MD, San Cecilio Clinical Hospital, Tumor Bank, Granada, Spain; Jose AneirosCachaza, MD, San Cecilio Clinical Hospital, Department of Pathology, Granada, Spain; Salvador Arias-Santiago, MD, San Cecilio Clinical Hospital, Department of Dermatology, Granada, Spain Background: Annular elastolytic giant cell granuloma is a rare dermatosis of unknown origin that is characterized by a loss of elastic fibers and elastophagocytosis by multinucleated giant cells. It affects photoexposed areas.
FEBRUARY 2011
J AM ACAD DERMATOL
AB69
P1518
Varicella zoster virus brachioplexitis associated with granulomatous vasculopathy John Fleming, MBBS, King’s College Hospital, London, United Kingdom; Abigail Fogo, MBBS, King’s College Hospital, London, United Kingdom; Roderick Hay, MBBS, King’s College Hospital, London, United Kingdom; Salman Haider, MBBS, King’s College Hospital, London, United Kingdom; Saqib Bashir, MD, MBBS, King’s College Hospital, London, United Kingdom Varicella zoster virus (VZV) is well-known to lead to the clinical disease of varicella in primary infection and zoster upon reactivation. However, the manifestations of VZV infection can be altered in the immunocompromised, and our case highlights the potential for motor nerve involvement. We report the case of a 63-year-old man with a prolonged, multidermatomal, nonvesicular rash with VZV PCR positivity on affected skin, limb paresis secondary to brachioplexitis, and histology consistent with granulomatous vasculopathy. Because of the significant motor weakness, nerve conduction studies and electromyography were performed, which revealed absent sensory potentials and biceps denervation, suggesting C5 pathology. In addition, a T2-weighted MRI scan showed root enhancement of the left brachial plexus, supporting the diagnosis of a left brachial radiculoplexitis. No other systemic features of vasculitis developed, a vasculitic screen was negative, and a lumbar puncture excluded the presence of VZV DNA. After 3 months of oral valaciclovir 1 g tds and regular physiotherapy, his motor neuropathy improved with 5/5 power in elbow flexion and extension, but a reduced range of movement and weakness in shoulder abduction persists. His papular red-brown eruption has settled slowly 8 months after the initial presentation. The clinical course of cutaneous zoster in immunocompromised individuals is often recurrent, protracted, and multidermatomal. In such individuals, it can penetrate into deeper tissue and result in a diverse spectrum of disorders, including myelitis, meningoencephalitis, and cerebral or small-vessel vasculopathic or vasculitic changes. This case discusses the unusual finding of disuse muscle wasting secondary to limb paresis from brachioplexitis and the potential role of MRI to investigate cases where a prolonged albeit atypical eruption coincides with motor weakness and pain. The challenges posed by potential central nervous system complications after immunosuppressive treatment are also highlighted. Prolonged oral treatment with valaciclovir improves aciclovir bioavailability and may obviate the need for increasing immunosuppression when these concerns exist.
Importance of histopathologic diagnosis of acroangiodermatitis Ana Maria Mosca de Cerqueira, PhD, Hospital Menino Jesus, Rio de Janeiro, Brazil; Clarissa Caramez, Policlinica Geral do Rio de Janeiro, Rio de JAneiro, Brazil; Joana Orli, Policlinica Geral do Rio de Janeiro, Rio de Janeiro, Brazil; Maria Auxiliadora Jeunon, Hospital Universitario Pedro Ernestro, Rio de Janeiro, Brazil Background: Acroangiodermatitis is a very rare disease. It is characterized by erythematous violaceous cutaneous lesions, localized mainly in the legs and feet, resembling Kaposi sarcoma. Acroangiodermatitis is a disease that is usually associated with different disorders, such as chronic venous insufficiency, arteriovenous malformation, and arteriovenous shunt. This case adds your learning difficulty prenatal. Summary: A 62-year-old white woman who was a resident of Rio de Janeiro presented with lesions that were erythematous, violaceous, painless, and pruritic, with an evolution of approximately 1 year. The physical examination revealed the presence of varicose veins of varying sizes in her legs. Routine laboratory examinations did not reveal alterations. Histopathology revealed hyperplastic epidermis and, in the papillary dermis and the middle reticular dermis, a proliferation of blood vessels amid a moderate interstitial lymphohistiocytic infiltrate and depositing hemosiderin. Immunohistochemistry lookup antigen CD34 was negative, excluding the diagnosis of Kaposi sarcoma, whose cells are 100% positive CD34. Conclusion: Acroangiodermatitis is a disorder that is clinically and histologically similar to Kaposi sarcoma and that is characterized by violaceous papules and nodules grouped into anatomic ends. It seems to be caused by changes in the local circulation, causing a reactive proliferation. This is frequently associated with other vascular disorders. The histopathologic differential diagnosis of Kaposi sarcoma is not always easy; however, in acroangiodermatitis, the vessels are quite regular without the fissures that are very common in Kaposi sarcoma. In the latter, the leakage of red blood cells is not so intense and there is a lesser amount of hemosiderin. There are cases, however, in which the differential diagnosis becomes difficult. In such cases, clinicians should use the CD34 antigen which is expressed in 100% of the cases of Kaposi sarcoma and absent in acroangiodermatitis, according to the work of Kanitakis et al. Commercial support: None identified.
Commercial support: None identified.
DERMATOPHARMACOLOGY/COSMECEUTICALS P1600
Case report: A 45-year-old woman reported that more than 1 year ago, a lesion appeared on her neck after a burn. A physical examination revealed an incomplete annular lesion that was bright, consisted of erythematous papules, and was sometimes itchy. The rest of the skin was normal. The histologic study shows the presence of multiple giant cells, which are not lattice or caseous necrosis, accompanied by few cells located in superficial dermis. Some giant cells had elastic connective tissue debris (elastophagocytosis). Discussion: The etiology is unknown, although cases have been reported on burn scars, after intense sun exposure, and from phototoxicity associated with doxycycline. The clinical course is chronic, and treatment has been effective with topical corticosteroids, intralesional or systemic, chloroquine, acitretin, and cyclosporin. The differential diagnosis must be made with granuloma annulare, erythema annulare centrifugum, necrobiosis lipoidica, sarcoidosis, and granulomatous infections.
Simple vasoconstriction may be a primary antiinflammatory mechanism of topical corticosteroids Christopher Kroodsma, MD, University of Illinois College of Medicine Peoria, Peoria, IL, United States The vasoconstrictor assay is used as a method to measure corticosteroid potency, because their ability to constrict blood vessels has been found to correlate well with antiinflammatory efficacy. Yet this vasoconstriction is generally not considered to be an antiinflammatory mechanism. An experimental model was designed with the purpose of showing the effect that simple diameter differences may have on blood vessel walls. Distensible latex material containing microscopic holes (representing intercellular spaces) was used to create a cylindrical lumen with diameters of 0.5’’ proximally and 1’’ distally. Water was allowed to flow through the lumen and pressure was increased by blocking the distal end. As fluid pressure increased, only the larger diameter segment became visibly distended, although pressure was equal throughout the lumen. No fluid escaped through the luminal wall holes initially, but as the larger diameter segment distended, fluid began to flow rapidly through the holes in this region but not through those in the narrower segment. These phenomena are explained by the LaPlace Law, which holds that T ¼ DPR (where T ¼ wall tension, DP ¼ transmural pressure, and R ¼ radius) for a distensible cylindrical lumen. The term tension (T) represents a force directed along the circumference of the luminal wall that promotes distension and stretch. A narrower vessel, simply as a function of its smaller diameter, is relatively protected from wall tension. Vessels in many inflammatory processes are either temporarily or chronically dilated are therefore exposed to increased wall tension/stretch force. Physical stretch of blood vessel walls and endothelium has been shown experimentally to result in release of numerous proinflammatory cytokines, including VEGF, TNFa, MCP-1, IL-6, and IL-8. Also, as shown in the above experiment, increased wall tension may result in the opening of typically closed gaps in vessel walls, facilitating movement of fluid and/or inflammatory cells into the surrounding tissues. It follows that with corticosteroid-induced decreases in vessel diameter and subsequently decreased wall tension, as defined and predicted by the LaPlace Law, inflammation may be accordingly decreased.
Commercial support: None identified.
Commercial support: None identified.
P1517 Annular elastolytic giant cell granuloma Jose Aneiros-Fernandez, MD, San Cecilio Clinical Hospital, Department of Pathology, Granada, Spain; Husein Husein-ElAhmed, MD, San Cecilio Clinical Hospital, Department of Dermatology, Granada, Spain; Ines Aroca-Siendones, MD, San Cecilio Clinical Hospital, Tumor Bank, Granada, Spain; Jose AneirosCachaza, MD, San Cecilio Clinical Hospital, Department of Pathology, Granada, Spain; Salvador Arias-Santiago, MD, San Cecilio Clinical Hospital, Department of Dermatology, Granada, Spain Background: Annular elastolytic giant cell granuloma is a rare dermatosis of unknown origin that is characterized by a loss of elastic fibers and elastophagocytosis by multinucleated giant cells. It affects photoexposed areas.
FEBRUARY 2011
J AM ACAD DERMATOL
AB69