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The value of skin biopsy in inflammatory dermatoses
P1405
P1501
Lupus erythematosus induced by oral fluoropyrimidine Tomohiko Narita, MD, PhD, Department of Dermatology, Kinki University of Medicine, Osaka, Japan We report a rare case of lupus erythematosus (LE) induced by oral fluoroprymidine. A 48-year-old female visited our clinic on December 5, 2006. The chief complaint was erythema on her face and cervical spine. She had been diagnosed with a scirrhous carcinoma in a private clinic in September 2006 and was sent to the tumor internal medicine departmentof Kinki University hospital. She started taking oral fluoroprymidine TS-1, which contained a dihydropyrimidine dehydrogenase inhibitor, on October 6, and thereafter a slight erythema appeared on her face, cervical spine, and the anterior surface of her chest. The erythema lasted 3 weeks and disappeared after one treatment session of TS-1. Two weeks after the second session of TS-1, in November, the erythema was seen on both cheeks and the nose 2 weeks later. She was sent to the dermatology department. The physical examination revealed butterfly-like erythema on her face, and small erythemas were seen on the lip and the lower jaw, but not seen on the hands and feet. The skin biopsy from erythema on the lower jaw showed epidermal atrophy, liquefaction degeneration in the basal layer, and perivascular lymphocytic infiltration in the entire dermis. The antinuclear antibody test was positive, while other autologous antibody tests were negative. From clinical, laboratory, and histopathology findings, this patient was diagnosed as having drug-induced lupus erythematosus related to TS-1.
Epidermal growth factorelike domains of laminin-5 in the tumor microenvironment Kien Tran, MPH, MBBS, University of Texas Southwestern Medical Center, Dallas, TX, United States; Antoanella Bardan, MD, University of Texas Southwestern Medical Center, Dallas, TX, United States; Clay Cockerell, MD, University of Texas Southwestern Medical Center, Dallas, TX, United States
Commercial support: None identified.
Cell migration and proliferation is a crucial process for invasion and metastasis of cancers. The tumor microenvironment secreted and modulated by various cancers such as squamous cell carcinoma has been implicated with this process. With regard to this tumor microenvironment, the extracellular matrix protein laminin-5 (laminin 332) has been associated with increased invasiveness of various malignant neoplasms. Laminin-5 contains epidermal growth factor (EGF)-like repeat subdomains that, after release by matrix metalloproteinases, have been proven to signal via epidermal growth factor receptor in vitro to enhance cell migration. Within this work, we examine the unique properties of this domain and how its expression is correlated with the status of a benign or malignant neoplasm. We examine the expression profile of the laminin-5 EGF-like repeats within various cutaneous cancers, benign tumors, and precancerous lesions via immunohistochemical stains for the EGF-like domain. Our current data suggest that strong focal expression can differentiate between actinic keratosis versus keratoacanthoma, squamous cell carcinoma in situ, and squamous cell carcinoma. Dermal expression can also differentiate between normal scars versus keloids. Finally, little staining is seen within dermatofibromas and dermatofibromasarcoma protuberans. We also examine the profile of MT1-MMP, which can release the EGF-like domain of laminin-5 into the tumor microenvironment. Current data suggest that strong expression of laminin-5 and its corresponding EGF-like domain in tumors capable of expressing laminin-5 is correlated with cancer pathogenesis. Commercial support: None identified.
P1502
A 64-year-old immunosuppressed female with a history of liver transplant for primary biliary cirrhosis was admitted for evaluation of a lower gastrointestinal bleed. Her course in the hospital was complicated by multisystem bacterial infections. The patient developed multiple purpuric lesions with overlying flaccid bullae and erosions on the lower extremities. A skin biopsy demonstrated multiple dematiaceous hyphal elements with epidermal necrosis, vascular thrombosis, and vasculitis. Several blood cultures were positive for Scedosporium prolificans. In spite of systemic antifungal therapy, the patient died. S prolificans is a dematiaceous fungus that was first described in 1984. Fungal spores can infect a patient through inhalation, the gastrointestinal tract, surgical wounds, or trauma. S prolificans can cause infection in three different settings: (1) respiratory tract colonization in patients with cystic fibrosis or solid organ transplants, (2) localized infection in immunocompetent and immunocompromised patients, and (3) disseminated infections in immunocompromised hosts. Frequent clinical manifestations of S prolificans infection in immunocompromised patients include relapsing fever and neutropenia. Skin lesions are typically described as multiple, ulcerated, nonhealing erythematous nodules. Dermatopathology findings have been infrequently reported and include epidermal hyperplasia, granulomatous inflammation, and dermal necrosis. We present a case of disseminated S prolificans infection with distinct clinicopathological findings of purpuric and bullous lesions with underlying vascular thrombosis and vasculitis.
The value of skin biopsy in inflammatory dermatoses Ratna Rajaratnam, MD, University Hospital North Staffordshire NHS Trust, Stoke on Trent, West Midlands, United Kingdom; Andrew Smith, MBBS, University Hospital North Staffordshire NHS Trust, Stoke on Trent, West Midlands, United Kingdom; Mark Stephens, MBBS, University Hospital North Staffordshire NHS Trust, Stoke on Trent, West Midlands, United Kingdom; Milan Mehta, MBChB, University Hospital North Stafforshire NHS Trust, Stoke on Trent, West Midlands, United Kingdom The skin biopsy is considered one of the most important diagnostic tools in dermatology. While histology of a neoplastic lesion (eg, a basal cell carcinoma) can be straightforward, biopsy of an inflammatory dermatosis is more complicated as often several dermatoses appear histologicly similar. This study aims to establish the value of skin biopsy as a diagnostic test for inflammatory dermatoses. Inclusion criteria were any cases where inflammatory dermatoses were recorded in the differential diagnosis. A gold standard test should be sensitive, specific, and provide an answer without relying on other factors (eg, history). Biopsy specimens were therefore initially reviewed ‘‘blind’’ without clinical data to establish what information could be obtained. Authors 1 (resident) and 2 (consultant dermatologist) reviewed 100 consecutive biopsy specimens over a 5-month period. Once the prehistory diagnosis was recorded, the clinical data were provided and a posthistory diagnosis made and compared to the final working diagnosis. The author’s findings were verified by comparison to formal pathology reports. In 98 of 100 cases, there was correlation. Specimens were evaluated for crush artefact, size, and depth. In 55 of 100 cases, histology was able to strongly suggest a prehistory diagnosis. In this category, tumors were most common (n ¼ 11), followed by prurigo nodularis (n ¼ 8), lichen planus (n ¼ 5), vasculitis (n ¼ 5), and pigmented purpuric dermatosis (n ¼ 4). Prehistory ‘‘blind’’ histology precisely identified 2 of 9 bullous dermatoses, 1 of 3 discoid lupus, 0 of 3 psoriasis, 0 of 2 pseudolupus erythematosus and 0 of 2 granuloma annulare. In 31 of 100 cases, histology was able to provide a differential diagnoses. In 21 of 31, a diagnosis was reached posthistory with clinicopathological correlation. In 12 of 100, histology was only able to provide a descriptive pattern analysis, mostly superficial perivascular dermatitis. In 2 of 100, no pattern analysis could be made. The authors found eight cases where histology appeared less useful. The final diagnosis was based primarily on clinical findings; biopsy findings were disregarded by the clinician. Histology provided a new diagnosis which had not been considered clinically and accepted as the final diagnosis in 13 of 100 cases. The approximate mean tissue volume received from a punch biopsy (PB) was 51 mm3 and incisional biopsy (IB) was 289 mm3. The specimen was of poor depth in 13 of 69 PBs and 7 of 24 IBs. We conclude that a biopsy for inflammatory dermatoses is a valuable tool. In 13%, the biopsy provided a working diagnosis which had not been considered clinically. Excluding tumors (inflammatory dermatoses only), histology provided a working diagnosis in 67% of cases. The diagnostic boundaries of dermatopathology are such that in a third of cases, a diagnosis was reached only with aid of clinical data, proving the importance of providing a well thought out differential diagnosis. Twenty-five percent of specimens had inadequate fat, a more evident problem in the PB specimens.
Commercial support: None identified.
Commercial support: None identified.
DERMATOPATHOLOGY P1500 Disseminated Scedosporium prolificans infection Esteban Fernandez-Faith, MD, Cleveland Clinic, Cleveland, OH, United States; David Hamrock, MD, Cleveland Clinic, Cleveland, OH, United States; Najwa Somani, MD, Cleveland Clinic, Cleveland, OH, United States; Steven Billings, MD, Cleveland Clinic, Cleveland, OH, United States
MARCH 2009
J AM ACAD DERMATOL
AB73
P1501
Lupus erythematosus induced by oral fluoropyrimidine Tomohiko Narita, MD, PhD, Department of Dermatology, Kinki University of Medicine, Osaka, Japan We report a rare case of lupus erythematosus (LE) induced by oral fluoroprymidine. A 48-year-old female visited our clinic on December 5, 2006. The chief complaint was erythema on her face and cervical spine. She had been diagnosed with a scirrhous carcinoma in a private clinic in September 2006 and was sent to the tumor internal medicine departmentof Kinki University hospital. She started taking oral fluoroprymidine TS-1, which contained a dihydropyrimidine dehydrogenase inhibitor, on October 6, and thereafter a slight erythema appeared on her face, cervical spine, and the anterior surface of her chest. The erythema lasted 3 weeks and disappeared after one treatment session of TS-1. Two weeks after the second session of TS-1, in November, the erythema was seen on both cheeks and the nose 2 weeks later. She was sent to the dermatology department. The physical examination revealed butterfly-like erythema on her face, and small erythemas were seen on the lip and the lower jaw, but not seen on the hands and feet. The skin biopsy from erythema on the lower jaw showed epidermal atrophy, liquefaction degeneration in the basal layer, and perivascular lymphocytic infiltration in the entire dermis. The antinuclear antibody test was positive, while other autologous antibody tests were negative. From clinical, laboratory, and histopathology findings, this patient was diagnosed as having drug-induced lupus erythematosus related to TS-1.
Epidermal growth factorelike domains of laminin-5 in the tumor microenvironment Kien Tran, MPH, MBBS, University of Texas Southwestern Medical Center, Dallas, TX, United States; Antoanella Bardan, MD, University of Texas Southwestern Medical Center, Dallas, TX, United States; Clay Cockerell, MD, University of Texas Southwestern Medical Center, Dallas, TX, United States
Commercial support: None identified.
Cell migration and proliferation is a crucial process for invasion and metastasis of cancers. The tumor microenvironment secreted and modulated by various cancers such as squamous cell carcinoma has been implicated with this process. With regard to this tumor microenvironment, the extracellular matrix protein laminin-5 (laminin 332) has been associated with increased invasiveness of various malignant neoplasms. Laminin-5 contains epidermal growth factor (EGF)-like repeat subdomains that, after release by matrix metalloproteinases, have been proven to signal via epidermal growth factor receptor in vitro to enhance cell migration. Within this work, we examine the unique properties of this domain and how its expression is correlated with the status of a benign or malignant neoplasm. We examine the expression profile of the laminin-5 EGF-like repeats within various cutaneous cancers, benign tumors, and precancerous lesions via immunohistochemical stains for the EGF-like domain. Our current data suggest that strong focal expression can differentiate between actinic keratosis versus keratoacanthoma, squamous cell carcinoma in situ, and squamous cell carcinoma. Dermal expression can also differentiate between normal scars versus keloids. Finally, little staining is seen within dermatofibromas and dermatofibromasarcoma protuberans. We also examine the profile of MT1-MMP, which can release the EGF-like domain of laminin-5 into the tumor microenvironment. Current data suggest that strong expression of laminin-5 and its corresponding EGF-like domain in tumors capable of expressing laminin-5 is correlated with cancer pathogenesis. Commercial support: None identified.
P1502
A 64-year-old immunosuppressed female with a history of liver transplant for primary biliary cirrhosis was admitted for evaluation of a lower gastrointestinal bleed. Her course in the hospital was complicated by multisystem bacterial infections. The patient developed multiple purpuric lesions with overlying flaccid bullae and erosions on the lower extremities. A skin biopsy demonstrated multiple dematiaceous hyphal elements with epidermal necrosis, vascular thrombosis, and vasculitis. Several blood cultures were positive for Scedosporium prolificans. In spite of systemic antifungal therapy, the patient died. S prolificans is a dematiaceous fungus that was first described in 1984. Fungal spores can infect a patient through inhalation, the gastrointestinal tract, surgical wounds, or trauma. S prolificans can cause infection in three different settings: (1) respiratory tract colonization in patients with cystic fibrosis or solid organ transplants, (2) localized infection in immunocompetent and immunocompromised patients, and (3) disseminated infections in immunocompromised hosts. Frequent clinical manifestations of S prolificans infection in immunocompromised patients include relapsing fever and neutropenia. Skin lesions are typically described as multiple, ulcerated, nonhealing erythematous nodules. Dermatopathology findings have been infrequently reported and include epidermal hyperplasia, granulomatous inflammation, and dermal necrosis. We present a case of disseminated S prolificans infection with distinct clinicopathological findings of purpuric and bullous lesions with underlying vascular thrombosis and vasculitis.
The value of skin biopsy in inflammatory dermatoses Ratna Rajaratnam, MD, University Hospital North Staffordshire NHS Trust, Stoke on Trent, West Midlands, United Kingdom; Andrew Smith, MBBS, University Hospital North Staffordshire NHS Trust, Stoke on Trent, West Midlands, United Kingdom; Mark Stephens, MBBS, University Hospital North Staffordshire NHS Trust, Stoke on Trent, West Midlands, United Kingdom; Milan Mehta, MBChB, University Hospital North Stafforshire NHS Trust, Stoke on Trent, West Midlands, United Kingdom The skin biopsy is considered one of the most important diagnostic tools in dermatology. While histology of a neoplastic lesion (eg, a basal cell carcinoma) can be straightforward, biopsy of an inflammatory dermatosis is more complicated as often several dermatoses appear histologicly similar. This study aims to establish the value of skin biopsy as a diagnostic test for inflammatory dermatoses. Inclusion criteria were any cases where inflammatory dermatoses were recorded in the differential diagnosis. A gold standard test should be sensitive, specific, and provide an answer without relying on other factors (eg, history). Biopsy specimens were therefore initially reviewed ‘‘blind’’ without clinical data to establish what information could be obtained. Authors 1 (resident) and 2 (consultant dermatologist) reviewed 100 consecutive biopsy specimens over a 5-month period. Once the prehistory diagnosis was recorded, the clinical data were provided and a posthistory diagnosis made and compared to the final working diagnosis. The author’s findings were verified by comparison to formal pathology reports. In 98 of 100 cases, there was correlation. Specimens were evaluated for crush artefact, size, and depth. In 55 of 100 cases, histology was able to strongly suggest a prehistory diagnosis. In this category, tumors were most common (n ¼ 11), followed by prurigo nodularis (n ¼ 8), lichen planus (n ¼ 5), vasculitis (n ¼ 5), and pigmented purpuric dermatosis (n ¼ 4). Prehistory ‘‘blind’’ histology precisely identified 2 of 9 bullous dermatoses, 1 of 3 discoid lupus, 0 of 3 psoriasis, 0 of 2 pseudolupus erythematosus and 0 of 2 granuloma annulare. In 31 of 100 cases, histology was able to provide a differential diagnoses. In 21 of 31, a diagnosis was reached posthistory with clinicopathological correlation. In 12 of 100, histology was only able to provide a descriptive pattern analysis, mostly superficial perivascular dermatitis. In 2 of 100, no pattern analysis could be made. The authors found eight cases where histology appeared less useful. The final diagnosis was based primarily on clinical findings; biopsy findings were disregarded by the clinician. Histology provided a new diagnosis which had not been considered clinically and accepted as the final diagnosis in 13 of 100 cases. The approximate mean tissue volume received from a punch biopsy (PB) was 51 mm3 and incisional biopsy (IB) was 289 mm3. The specimen was of poor depth in 13 of 69 PBs and 7 of 24 IBs. We conclude that a biopsy for inflammatory dermatoses is a valuable tool. In 13%, the biopsy provided a working diagnosis which had not been considered clinically. Excluding tumors (inflammatory dermatoses only), histology provided a working diagnosis in 67% of cases. The diagnostic boundaries of dermatopathology are such that in a third of cases, a diagnosis was reached only with aid of clinical data, proving the importance of providing a well thought out differential diagnosis. Twenty-five percent of specimens had inadequate fat, a more evident problem in the PB specimens.
Commercial support: None identified.
Commercial support: None identified.
DERMATOPATHOLOGY P1500 Disseminated Scedosporium prolificans infection Esteban Fernandez-Faith, MD, Cleveland Clinic, Cleveland, OH, United States; David Hamrock, MD, Cleveland Clinic, Cleveland, OH, United States; Najwa Somani, MD, Cleveland Clinic, Cleveland, OH, United States; Steven Billings, MD, Cleveland Clinic, Cleveland, OH, United States
MARCH 2009
J AM ACAD DERMATOL
AB73