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NODULAR FASCIITIS
870
antero-superior division of the left bundle. 28-30 The appearance
of the
R.B.B.B.-L.A.D.
pattern is
now
widely taken as an indication for a prophylactic pacing catheter, in preparation for on-demand pacing. Although many clinicians pace their patients who go into complete heart-block in these circumstances and some patients undoubtedly benefit, the overall mortality remains high, presumably because of the extensive myocardial injury. Problems of conduction are not always restricted the first few weeks after infarction. Atkins and his co-workers 3have drawn attention to the high mortality during the first six months after discharge from hospital among patients who survive transient complete heart-block during infarction but who are left with R.B.B.B.-L.A.D. Several of the deaths appeared to be sudden, and were quite possibly due to a recurrence of complete heart-block or asystole rather than to progressive myocardial failure. Atkins contrasts the fate of six patients in this category, five of whom died within six months of discharge from hospital, with that of a further three patients in whom All three permanent pacemakers were implanted. with pacemakers were still alive, with a mean survivaltime of 33 months. This active policy was supported by results in a further five patients treated in identical fashion, whose course has been uncomplicated for 8-18 months after infarction. Among patients who developed the R.B.B.B.-L.A.D. pattern during infarction but not complete heart-block, the six-month mortalityrate was less than in the complete-heart-block group (only two out of eleven), so the potential role of longIt does seem that term pacing is here less clear. further evaluation among warrants long-term pacing who have mechanical effects of survived the patients extensive infarction but who are left with impairment to
of intraventricular conduction, particularly those with history of transient complete heart-block during the acute phase of infarction.
a
NODULAR FASCIITIS NODULAR fasciitis is
a rare but probably underand co-workers 31 have Dahl condition. reported reviewed 30 cases of their own. Affecting either sex, from infancy on, nodular fasciitis presents as a firm, well-demarcated, often rapidly growing tumour, usually 1-2 cm. in diameter, lying in the subcutaneous tissue or muscular fascia anywhere on the body. Indolent in nature, the tumour may persist for a year or more, producing little pain or tenderness. Occasionally cystic changes may cause umbilication of the overlying skin, mimicking malignant tethering. Indeed, practically speaking, the condition’s importance lies in its similarity to neoplasia. Thus complete primary local excision is required-a relatively easy matter because of the superficial and discrete location. Histological examination may give problems: the predominant cell is a fibroblast; multinucleate giant cells and new capillary vessels are seen, and there may
Scanlon, P. J., Pryor, R., Blount, S. G. Circulation, 1970, 42, 1135. Godman, M. J., Alpert, B. A., Julian, D. G. Lancet, 1971, ii, 345. Atkins, J. M., Leshin, S. J., Blomquist, G., Mullins, C. B. New Engl. J. Med. 1973, 288, 281. 31. Dahl, I., Angervall, L., Magnusson, S., Stener, B. Path. europ. 1972, 7, 211. 28. 29. 30.
be a mild inflammatory reaction. Since mitotic figures tend to be prominent, neoplasia has commonly been diagnosed; but the tumours are not malignant and will eventually resolve spontaneously. Nodular fasciitis can be distinguished on clinical and pathological grounds from the much commoner plantar fasciitis, which is painful and shows inflammatory and degenerative change without hyperplasia. It may be grouped with other conditions such as myositis, panniculitis, and osteitis, where a descriptive title helps to delineate clinical subgroups but where aetiology remains obscure. Effective treatment for such conditions could have far-reaching effects, so wider recognition and investigation is desirable. Among possible causes, trauma is unlikely to be important in view of the distribution of the lesions. Infection is an obvious candidate, but there is no direct evidence for it. Is it possible they represent a forme fruste of the sarcomas they so closely resemble
histologically ? HAZARDS OF POTENT TOPICAL CORTICOSTEROIDS
TOPICALLY administered drugs are just as liable to leave unwanted side-effects as drugs administered by other routes. This is notably true of the fluorinated steroids, and dermatologists are becoming increasingly aware of the drawbacks of these potent preparations. Burry1 has highlighted the problem by describing 8 patients in whom prolonged application of fluorinated corticosteroids proved detrimental. In 3 of them ringworm and candida infections were masked and perpetuated. The 2 with ringworm infection, because of their previous treatment with topical steroids, had rashes that were unlike ordinary tinea-the lesions recalled those in a group described by Ive and Marks2 with ringworm of atypical appearance and extent due to steroid treatment and designated tinea incognito. 1 patient in Burry’s series had a rash on her face resembling rosacea which improved when betamethasone cream was stopped and systemic tetracyclines and local hydrocortisone were substituted. The effects of the potent corticosteroids on rosacea are extraordinary.3 Patients seem to be " addicted" to these agents because in the short term they relieve the discomfort of rosacea and apparently suppress the inflamed papular and pustular lesions. It seems that the dermis of these patients may be particularly prone to the atrophy-producing effects of corticosteroids and that consequent loss of connective tissue leads
to exposure
of the
subpapillary
venous
with increasing erythema and telangiectasia.
plexus,
This both the relief from the inflammatory explain lesions and the increasing redness of complexion. It would not, however, account for the sudden flare of the disease after abrupt withdrawal of steroid treatment. This rebound may explain why patients, once having started topical-corticosteroid treatment, find it so difficult to stop. The fluorinated corticosteroids may possibly play an setiological role in the development of the rosacea-like condition known as
would
1. Burry, J. N. Med. J. Aust. 1973, i, 393. 2. Ive, F. A., Marks, R. Br. med. J. 1968, iii, 149. 3. Sneddon, I. ibid. 1969, i, 671.
antero-superior division of the left bundle. 28-30 The appearance
of the
R.B.B.B.-L.A.D.
pattern is
now
widely taken as an indication for a prophylactic pacing catheter, in preparation for on-demand pacing. Although many clinicians pace their patients who go into complete heart-block in these circumstances and some patients undoubtedly benefit, the overall mortality remains high, presumably because of the extensive myocardial injury. Problems of conduction are not always restricted the first few weeks after infarction. Atkins and his co-workers 3have drawn attention to the high mortality during the first six months after discharge from hospital among patients who survive transient complete heart-block during infarction but who are left with R.B.B.B.-L.A.D. Several of the deaths appeared to be sudden, and were quite possibly due to a recurrence of complete heart-block or asystole rather than to progressive myocardial failure. Atkins contrasts the fate of six patients in this category, five of whom died within six months of discharge from hospital, with that of a further three patients in whom All three permanent pacemakers were implanted. with pacemakers were still alive, with a mean survivaltime of 33 months. This active policy was supported by results in a further five patients treated in identical fashion, whose course has been uncomplicated for 8-18 months after infarction. Among patients who developed the R.B.B.B.-L.A.D. pattern during infarction but not complete heart-block, the six-month mortalityrate was less than in the complete-heart-block group (only two out of eleven), so the potential role of longIt does seem that term pacing is here less clear. further evaluation among warrants long-term pacing who have mechanical effects of survived the patients extensive infarction but who are left with impairment to
of intraventricular conduction, particularly those with history of transient complete heart-block during the acute phase of infarction.
a
NODULAR FASCIITIS NODULAR fasciitis is
a rare but probably underand co-workers 31 have Dahl condition. reported reviewed 30 cases of their own. Affecting either sex, from infancy on, nodular fasciitis presents as a firm, well-demarcated, often rapidly growing tumour, usually 1-2 cm. in diameter, lying in the subcutaneous tissue or muscular fascia anywhere on the body. Indolent in nature, the tumour may persist for a year or more, producing little pain or tenderness. Occasionally cystic changes may cause umbilication of the overlying skin, mimicking malignant tethering. Indeed, practically speaking, the condition’s importance lies in its similarity to neoplasia. Thus complete primary local excision is required-a relatively easy matter because of the superficial and discrete location. Histological examination may give problems: the predominant cell is a fibroblast; multinucleate giant cells and new capillary vessels are seen, and there may
Scanlon, P. J., Pryor, R., Blount, S. G. Circulation, 1970, 42, 1135. Godman, M. J., Alpert, B. A., Julian, D. G. Lancet, 1971, ii, 345. Atkins, J. M., Leshin, S. J., Blomquist, G., Mullins, C. B. New Engl. J. Med. 1973, 288, 281. 31. Dahl, I., Angervall, L., Magnusson, S., Stener, B. Path. europ. 1972, 7, 211. 28. 29. 30.
be a mild inflammatory reaction. Since mitotic figures tend to be prominent, neoplasia has commonly been diagnosed; but the tumours are not malignant and will eventually resolve spontaneously. Nodular fasciitis can be distinguished on clinical and pathological grounds from the much commoner plantar fasciitis, which is painful and shows inflammatory and degenerative change without hyperplasia. It may be grouped with other conditions such as myositis, panniculitis, and osteitis, where a descriptive title helps to delineate clinical subgroups but where aetiology remains obscure. Effective treatment for such conditions could have far-reaching effects, so wider recognition and investigation is desirable. Among possible causes, trauma is unlikely to be important in view of the distribution of the lesions. Infection is an obvious candidate, but there is no direct evidence for it. Is it possible they represent a forme fruste of the sarcomas they so closely resemble
histologically ? HAZARDS OF POTENT TOPICAL CORTICOSTEROIDS
TOPICALLY administered drugs are just as liable to leave unwanted side-effects as drugs administered by other routes. This is notably true of the fluorinated steroids, and dermatologists are becoming increasingly aware of the drawbacks of these potent preparations. Burry1 has highlighted the problem by describing 8 patients in whom prolonged application of fluorinated corticosteroids proved detrimental. In 3 of them ringworm and candida infections were masked and perpetuated. The 2 with ringworm infection, because of their previous treatment with topical steroids, had rashes that were unlike ordinary tinea-the lesions recalled those in a group described by Ive and Marks2 with ringworm of atypical appearance and extent due to steroid treatment and designated tinea incognito. 1 patient in Burry’s series had a rash on her face resembling rosacea which improved when betamethasone cream was stopped and systemic tetracyclines and local hydrocortisone were substituted. The effects of the potent corticosteroids on rosacea are extraordinary.3 Patients seem to be " addicted" to these agents because in the short term they relieve the discomfort of rosacea and apparently suppress the inflamed papular and pustular lesions. It seems that the dermis of these patients may be particularly prone to the atrophy-producing effects of corticosteroids and that consequent loss of connective tissue leads
to exposure
of the
subpapillary
venous
with increasing erythema and telangiectasia.
plexus,
This both the relief from the inflammatory explain lesions and the increasing redness of complexion. It would not, however, account for the sudden flare of the disease after abrupt withdrawal of steroid treatment. This rebound may explain why patients, once having started topical-corticosteroid treatment, find it so difficult to stop. The fluorinated corticosteroids may possibly play an setiological role in the development of the rosacea-like condition known as
would
1. Burry, J. N. Med. J. Aust. 1973, i, 393. 2. Ive, F. A., Marks, R. Br. med. J. 1968, iii, 149. 3. Sneddon, I. ibid. 1969, i, 671.