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Notes: Although there are nemerous ways in which physicians evaluate one naother and themselves, the multiple choice examination has become the key method for evaluating the scientific data base of both medical students and postgraduate phisicans. Knowledge of the mechanisms at work in such examinations is thus important for both giving and taking these examinations. Analysis of these mechanisms is now provided.

Notes: : Onchocerciasis was diagnosed when a skin biopsy specimen immersed in saline revealed microfiliariae. The patient was a 22-year-old student from Cameroon, West Africa, complaining of small, recurrent, pruritic papules on his thighs. Chemotherapy with ivermectin, an established anti-parasitic agent with newly recognized anti-onchocercal potential, was well tolerated, and microfilariae were not detected in post-therapy skin biopsy specimens. The diagnosis of Onchocerciasis should be entertained in individuals returning or emigrating from endemic areas.

Notes: A 62-year-old man was evaluated for chronic recurrent pyoderma gangrenosum (PG) of 8 years’ duration. He had a long history of acne conglobata beginning in his early twenties. Although periods of inactivity lasted for months, renewed cyst formation recurred on the face, trunk, and groin. Minocycline, 100 mg twice daily, was useful for the control of acne.Severe periodontal disease developed 25 years prior to presentation. He had coronary bypass surgery 12 years ago. His family history was noncontributory and negative for PG, acne conglobata, or follicular occlusion (FO) triad.The patient presented with an 8-year history of small hemorrhagic pustules on the legs, progressing over the subsequent few months to large ulcers with raised borders. Spikes in temperature and general malaise for 3 or 4 days sometimes heralded new PG eruptions.On examination, large inflammatory, scarring cysts were present, predominantly on the face, lateral neck, back, and inguinal areas. Both lower legs showed small hemorrhagic pustules and scattered ulcers with raised, irregular borders (〈link href="#f1 #f2 #f3"〉Figs 1–3). The larger ulcers often began as painful nodules, with central necrosis; peripheral expansion led to the formation of a central mucopurulent base surrounded by an undermined, ragged, erythematous or dusky, edematous ulcer rim. A vague, serpiginous halo of erythema surrounded these lesions.〈figure xml:id="f1"〉1〈mediaResource alt="image" href="urn:x-wiley:00119059:IJD1682:IJD_1682_f1"/〉Multiple necrotic ulcerations of pyoderma gangrenosum on the leg, demonstrating raised, inflammatory borders, a mucopurulent base, and a surrounding halo of erythema. Cribriform scarring is also apparent〈figure xml:id="f2"〉2〈mediaResource alt="image" href="urn:x-wiley:00119059:IJD1682:IJD_1682_f2"/〉Characteristic ulcer of pyoderma gangrenosum consists of a boggy, necrotic base with ragged, undetermined, violaceous edges surrounded by a halo of erythema〈figure xml:id="f3"〉3〈mediaResource alt="image" href="urn:x-wiley:00119059:IJD1682:IJD_1682_f3"/〉Close up of leg ulcer in 〈link href="#f2"〉Fig. 2 A biopsy specimen taken from the erythematous border of a leg ulcer showed a massive neutrophilic infiltrate with necrotizing suppurative inflammation and limited necrotizing vasculitis; direct immunofluorescence examination gave nonspecific results. Thrombosis of the small vessels, edema, and extravasation of erythrocytes were also noted. These histologic findings support the clinical diagnosis of PG.Serum protein electrophoresis revealed a monoclonal, immunoglobulin A (lgA) kappa-type gammopathy. Bone marrow evaluation showed a slight elevation of plasma cells, suggesting a benign monoclonal gammopathy; urine analysis did not demonstrate Bence-Jones protein. Evaluation for gastrointestinal, liver, and hematologic disease was negative. A complete blood cell count and blood chemistries gave results within normal limits.Oral prednisone, 60 mg daily, dapsone, 200 mg daily, and trimethoprim/sulfamethoxazole DS, twice daily, were administered. Prednisone was reduced to 30 mg every other day when the large ulcers of the legs ceased to expand, and regression was noted. Cribriform scarring was seen in areas of healing. Systemic prednisone eventually produced noticeable side-effects, including bilateral cataract formation and the development of tachycardia. Isotretinoin was begun with excellent initial results, but the patient had to discontinue therapy due to frontal headaches, scleral hemorrhage, the development of painful heel pads, and elevated hepatic function tests. The patient remained on minocycline, 100 mg twice daily, with relatively good control of the acne. Pustules were treated adequately with topical corticosteroids; larger ulcers were well controlled with intralesional corticosteroids and short courses of oral prednisone. Colchicine, 0.6 mg twice daily, and dapsone, 100 mg twice daily, were continued at maintenance levels for several years, and topical clobetasol propionate was applied to new lesions as they appeared.

Notes: : Histoid lepromas are a rare eruption in patients with lepromatous leprosy. A 59-year-old man from India with lepromatious leprosy who developed histoid lepromas and who was dapsone resistant was studied. These tumors resembled cutaneous metastases. This Indian man is to our knowledge the first patient to be reported with this rare disorder in the continental United States.

Notes: A 45-year-old male cook was seen for the evaluation and removal of a “mole on my eye” of steady growth during the previous 6 months. The patient stated that he had had a “brown spot” above his left eye for 17 years prior to its recent enlargement; it was now partly blocking the vision in his left eye. He denied a history or family history of cutaneous tumors, including skin cancer. On examination, a 2.5-cm × 0.5-cm × 0.8-cm, horn-like, darkly pigmented, cutaneous nodule was evident extending from the left upper eyelid downwards to below the lower eyelid (〈link href="#f1 #f2"〉Figs 1 and 2). He also had scattered, skin-colored, 2–3-mm cystic papules on his anterior mid-chest. A shave excision specimen was obtained from the eyelid nodule.〈figure xml:id="f1"〉1〈mediaResource alt="image" href="urn:x-wiley:00119059:IJD1848:IJD_1848_f1"/〉Horn-like, cutaneous nodule extending from the left upper eyelid downwards to below the lower eyelid〈figure xml:id="f2"〉2〈mediaResource alt="image" href="urn:x-wiley:00119059:IJD1848:IJD_1848_f2"/〉Close up, demonstrating the morphologic features to better advantageMicroscopic examination demonstrated acanthosis, hyperkeratosis, and papillomatosis (〈link href="#f3"〉Fig. 3). Large dendritic cells with abundant melanin granules were spread throughout the epidermis. In addition, small basaloid or spinous keratinocytes were present in the malpighian layer.〈figure xml:id="f3"〉3〈mediaResource alt="image" href="urn:x-wiley:00119059:IJD1848:IJD_1848_f3"/〉Histology of the nodule, showing an epidermis with acanthosis, hyperkeratosis, papillomatosis, and large dendritic cells with abundant melanin granules spread throughout the epidermis (hematoxylin and eosin; original magnification, × 100)

Notes: An acute dermatitis overlying an immunologic granuloma was noted at the site of purple “dye” injection in a man with multiple multicolored tattoos. The skin reaction was observed 3 weeks after the injection, which proved to contain manganese, the usual metallic salt used for purple colored tattoos. Atomic absorption spectrometry showed a large amount of manganese in the biopsy specimen. Neither the dermatitis nor an immunologic granuloma could be reproduced with manganese salts or the alleged tattoo pigment. In addition, his peripheral blood lymphocytes were shown to be normal both in subset distribution and in their function, but these cells did not respond by blastogenesis to dilutions of the alleged pigment or to 2 manganese salts tested.

Notes: Abstract: A 72-year-old man had florid cutaneous papillomatosis (FCP), which is an obligatory paraneoplastic syndrome always associated with an internal malignancy. The cancer, which is usually intraabdominal and most often gastric in origin, evolves parallel to the FCP. This patient is the first case of FCP occurring in association with a lung malignancy. An association of FCP with other signs of internal cancer is common, with malignant acanthosis nigricans usually appearing many times with the sign of Leser-Trélat. FCP, malignant acanthosis nigricans, and the sign of Leser-Trélat are part of a continuum, developing by a common or similar pathogenic pathway due to an underlying malignancy producing a factor possibly similar to human epidermal growth factor.