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Thrombotic nodules secondary to bevacizumab in a patient with glioblastoma multiforme
P1108
P1110
Thrombotic nodules secondary to bevacizumab in a patient with glioblastoma multiforme Christopher Burnett, MD, Henry Ford Hospital, Detroit, MI, United States; Dakara Wright, MD, Henry Ford Hospital, Detroit, MI, United States; Ethan Nydorf, MD, Henry Ford Hospital, Detroit, MI, United States; Pranita Vemulapalli, Henry Ford Hospital, Detroit, MI, United States
Unusual self-inducted paraffinoma of the face in an old woman Cristina Rodriguez-Garcia, MD, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain; Francisco Guimera, MD, PhD, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain; Maria-Jose Gonzalez-de-Mesa, MD, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain; Nuria Perez-Robayna, MD, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain; Sorahaya Gonzalez-Hernandez, MD, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain Dermatitis artefacta is an uncommon condition that is difficult to diagnose and treat. Clinical presentation of the skin lesions does not conform to those of known dermatoses and are located on easily reached parts of the skin. Typically, patients deny having inflicted the lesions on themselves, and reports of self-introduction of foreign material, such as feces, sand, oily materials, or silicone into the skin are rare. We report 74-year-old woman with symmetric indurated periocular erythematous plaques. Biopsy specimens taken had disclosed a granulomatous foreign-body reaction, possibly related to silicone injection. The self-induced nature of the lesions was not admitted when the patient was directly confronted with the biopsy results. She was diagnosed as having a borderline personality disorder. Onset of dermatitis artefacta may occur at any age, although the highest incidence of onset is in late adolescence to early adult life. Most patients are young women who have a personality disorder; borderline features are common and the patient’s denial of psychologic distress makes management and treatment difficult.
Bevacizumab, a recombinant humanized monoclonal antibody directed against vascular endothelial growth factor (VEGF), is currently FDA-approved in treatment of several human malignancies. We present a case of a 75-year-old white male who suffered recurrent glioblastoma multiforme following initial chemotherapy and radiation. His oncologists began a second-line therapy of bevacizumab and irinotectan. Ten weeks into this treatment course, he developed violaceous nodules and tumors scattered over the upper and lower extremities. Shortly thereafter, he developed pulmonary embolism and began treatment with enoxaparin with subsequent worsening of the cutaneous eruption. Partial thromboplastin time, prothrombin time, and platelets were within normal limits. A biopsy specimen revealed focal vascular proliferation and red blood cell extravasation in the dermis. A second, deeper saucerization biopsy demonstrated adherent blood clot on the epidermal surface. The lesions improved with reduction of the bevacizumab dose. Paradoxically, bevacizumab can simultaneously predispose to both thrombosis and hemorrhage. These side effects are well described on a systemic level, but appear to only rarely involve the skin, because only one previously reported case exists, in which a patient on bevacizumab developed widespread ecchymoses. As bevacizumab becomes more popular in general oncology practice, it will be important for dermatologists to be aware of potential cutaneous side effects. Moreover, in the present case, the thrombotic cutaneous nodules preceded development of pulmonary embolism. Perhaps the development of cutaneous thrombosis or hemorrhage may be an easily identifiable warning sign of impending systemic thrombosis or hemorrhage.
Commercial support: None identified.
Commercial support: None identified.
P1109 A rare case of cutaneous and nasal extranodal RosaieDorfman disease Suzanne Cheng, MBBS, Queen’s Medical Centre, Nottingham, United Kingdom; Iain Leach, Queen’s Medical Centre, Nottingham, United Kingdom; William Perkins, Queen’s Medical Centre, Nottingham, United Kingdom RosaieDorfman disease (RDD) is a rare, usually benign systemic histiocytic disease characterized by massive painless lymphadenopathy, particularly in the head and neck region. Extranodal sites are involved simultaneously in 43% of cases, while isolated extranodal RDD occurs in only 23% of cases. Common extranodal sites include the skin (10%), paranasal sinuses, bone, eye, and soft tissues. RDD is most common in adolescents and young adults. Typically RDD is associated with pyrexia, anemia, leukocytosis, an elevated erythrocyte sedimentation rate, and hypergammaglobulinemia. We report a rare case presenting in middle age with extranodal manifestations which made the diagnosis of RDD challenging. A 61-year-old white male initially presented in 2004 with pigmentation around both ankles, bilateral tender nonpitting leg edema, left inguinal lymphadenopathy, and profuse night sweats. He underwent extensive investigations including magnetic resonance imaging (MRI) of his legs which showed abnormal marrow signals in the left tibia and a lymphoscintigraphy which showed functioning lymphatics in the left leg. No definite diagnosis could be made, but parasitic infections, such as filiariasis or leishmaniasis, low-grade chronic osteomyelitis, and cutaneous lymphoma, were considered. His symptoms improved spontaneously. Three years later he developed nasal symptoms. A large nasal septal mass with swelling of the right middle turbinate was detected on MRI. This mass was excised and histology showed a heavy cellular infiltrate rich in plasma cells with stromal scarring and bone erosion. Immunohistochemistry showed the plasma cells to be polyclonal, indicating an inflammatory infiltrate. At this stage, he was referred to dermatology with multiple asymptomatic nodules on his posterior calves and thighs. An excision biopsy showed sheets of large histiocytes with large vesicular nuclei, prominent nucleoli, and abundant pale cytoplasm with focal emperipolesis and a peripheral mixed inflammatory infiltrate with fibrosis. Immunohistochemistry showed positive staining of histiocytes with S100 protein but not CD1a, which is a characteristic of RDD. The histology of the nasal septal mass was reviewed and showed similar features consistent with nasal RDD. It is likely that his unexplained symptoms since 2004 are all related to RDD. Because of the benign course of his disease so far, our patient received no treatment. His skin lesions have improved spontaneously and his nasal septum has healed well postsurgery. Commercial support: None identified.
AB28
J AM ACAD DERMATOL
P1111 Treatment of keratoacanthoma arising from hypertrophic lichen planus Rachel Epstein, DO, HCA/Largo Medical/Sun Coast Hospital Osteopathic Dermatology Residency Program, Largo, FL, United States Hypertrophic lichen planus is a variant of lichen planus that has the potential to undergo malignant transformation. We report an 86-year-old white female who presented with multiple squamous cell carcinomas of the keratoacanthoma type arising from hypertrophic lichen planus on the anterior shins. Because of the numerous amount of lesions in this challenging anatomic location, a unique treatment approach was attempted. Four weeks after her initial treatment, there was marked clinical improvement of the squamous cell carcinomas, in addition to the underlying hypertrophic lichen planus. An overall decline in new lesions was also observed. Our findings suggest that intralesional triamcinolone acetonide is a valuable treatment option for keratoacanthomas arising from hypertrophic lichen planus on the lower extremities. Commercial support: None identified.
MARCH 2010
P1110
Thrombotic nodules secondary to bevacizumab in a patient with glioblastoma multiforme Christopher Burnett, MD, Henry Ford Hospital, Detroit, MI, United States; Dakara Wright, MD, Henry Ford Hospital, Detroit, MI, United States; Ethan Nydorf, MD, Henry Ford Hospital, Detroit, MI, United States; Pranita Vemulapalli, Henry Ford Hospital, Detroit, MI, United States
Unusual self-inducted paraffinoma of the face in an old woman Cristina Rodriguez-Garcia, MD, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain; Francisco Guimera, MD, PhD, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain; Maria-Jose Gonzalez-de-Mesa, MD, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain; Nuria Perez-Robayna, MD, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain; Sorahaya Gonzalez-Hernandez, MD, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain Dermatitis artefacta is an uncommon condition that is difficult to diagnose and treat. Clinical presentation of the skin lesions does not conform to those of known dermatoses and are located on easily reached parts of the skin. Typically, patients deny having inflicted the lesions on themselves, and reports of self-introduction of foreign material, such as feces, sand, oily materials, or silicone into the skin are rare. We report 74-year-old woman with symmetric indurated periocular erythematous plaques. Biopsy specimens taken had disclosed a granulomatous foreign-body reaction, possibly related to silicone injection. The self-induced nature of the lesions was not admitted when the patient was directly confronted with the biopsy results. She was diagnosed as having a borderline personality disorder. Onset of dermatitis artefacta may occur at any age, although the highest incidence of onset is in late adolescence to early adult life. Most patients are young women who have a personality disorder; borderline features are common and the patient’s denial of psychologic distress makes management and treatment difficult.
Bevacizumab, a recombinant humanized monoclonal antibody directed against vascular endothelial growth factor (VEGF), is currently FDA-approved in treatment of several human malignancies. We present a case of a 75-year-old white male who suffered recurrent glioblastoma multiforme following initial chemotherapy and radiation. His oncologists began a second-line therapy of bevacizumab and irinotectan. Ten weeks into this treatment course, he developed violaceous nodules and tumors scattered over the upper and lower extremities. Shortly thereafter, he developed pulmonary embolism and began treatment with enoxaparin with subsequent worsening of the cutaneous eruption. Partial thromboplastin time, prothrombin time, and platelets were within normal limits. A biopsy specimen revealed focal vascular proliferation and red blood cell extravasation in the dermis. A second, deeper saucerization biopsy demonstrated adherent blood clot on the epidermal surface. The lesions improved with reduction of the bevacizumab dose. Paradoxically, bevacizumab can simultaneously predispose to both thrombosis and hemorrhage. These side effects are well described on a systemic level, but appear to only rarely involve the skin, because only one previously reported case exists, in which a patient on bevacizumab developed widespread ecchymoses. As bevacizumab becomes more popular in general oncology practice, it will be important for dermatologists to be aware of potential cutaneous side effects. Moreover, in the present case, the thrombotic cutaneous nodules preceded development of pulmonary embolism. Perhaps the development of cutaneous thrombosis or hemorrhage may be an easily identifiable warning sign of impending systemic thrombosis or hemorrhage.
Commercial support: None identified.
Commercial support: None identified.
P1109 A rare case of cutaneous and nasal extranodal RosaieDorfman disease Suzanne Cheng, MBBS, Queen’s Medical Centre, Nottingham, United Kingdom; Iain Leach, Queen’s Medical Centre, Nottingham, United Kingdom; William Perkins, Queen’s Medical Centre, Nottingham, United Kingdom RosaieDorfman disease (RDD) is a rare, usually benign systemic histiocytic disease characterized by massive painless lymphadenopathy, particularly in the head and neck region. Extranodal sites are involved simultaneously in 43% of cases, while isolated extranodal RDD occurs in only 23% of cases. Common extranodal sites include the skin (10%), paranasal sinuses, bone, eye, and soft tissues. RDD is most common in adolescents and young adults. Typically RDD is associated with pyrexia, anemia, leukocytosis, an elevated erythrocyte sedimentation rate, and hypergammaglobulinemia. We report a rare case presenting in middle age with extranodal manifestations which made the diagnosis of RDD challenging. A 61-year-old white male initially presented in 2004 with pigmentation around both ankles, bilateral tender nonpitting leg edema, left inguinal lymphadenopathy, and profuse night sweats. He underwent extensive investigations including magnetic resonance imaging (MRI) of his legs which showed abnormal marrow signals in the left tibia and a lymphoscintigraphy which showed functioning lymphatics in the left leg. No definite diagnosis could be made, but parasitic infections, such as filiariasis or leishmaniasis, low-grade chronic osteomyelitis, and cutaneous lymphoma, were considered. His symptoms improved spontaneously. Three years later he developed nasal symptoms. A large nasal septal mass with swelling of the right middle turbinate was detected on MRI. This mass was excised and histology showed a heavy cellular infiltrate rich in plasma cells with stromal scarring and bone erosion. Immunohistochemistry showed the plasma cells to be polyclonal, indicating an inflammatory infiltrate. At this stage, he was referred to dermatology with multiple asymptomatic nodules on his posterior calves and thighs. An excision biopsy showed sheets of large histiocytes with large vesicular nuclei, prominent nucleoli, and abundant pale cytoplasm with focal emperipolesis and a peripheral mixed inflammatory infiltrate with fibrosis. Immunohistochemistry showed positive staining of histiocytes with S100 protein but not CD1a, which is a characteristic of RDD. The histology of the nasal septal mass was reviewed and showed similar features consistent with nasal RDD. It is likely that his unexplained symptoms since 2004 are all related to RDD. Because of the benign course of his disease so far, our patient received no treatment. His skin lesions have improved spontaneously and his nasal septum has healed well postsurgery. Commercial support: None identified.
AB28
J AM ACAD DERMATOL
P1111 Treatment of keratoacanthoma arising from hypertrophic lichen planus Rachel Epstein, DO, HCA/Largo Medical/Sun Coast Hospital Osteopathic Dermatology Residency Program, Largo, FL, United States Hypertrophic lichen planus is a variant of lichen planus that has the potential to undergo malignant transformation. We report an 86-year-old white female who presented with multiple squamous cell carcinomas of the keratoacanthoma type arising from hypertrophic lichen planus on the anterior shins. Because of the numerous amount of lesions in this challenging anatomic location, a unique treatment approach was attempted. Four weeks after her initial treatment, there was marked clinical improvement of the squamous cell carcinomas, in addition to the underlying hypertrophic lichen planus. An overall decline in new lesions was also observed. Our findings suggest that intralesional triamcinolone acetonide is a valuable treatment option for keratoacanthomas arising from hypertrophic lichen planus on the lower extremities. Commercial support: None identified.
MARCH 2010