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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: 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.

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: Atrophia maculosa varioliformis cutis is a rare disease characterized by spontaneously formed facial scars in young adults. Its etiology is unknown; there may be an underlying defect of dermal elastin. We discuss a patient with this unusual disorder and review its literature.

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: Background Fixed drug eruption (FDE) is a common cutaneous disorder which develops within hours of taking the offending drug and recurs at the same site with subsequent exposure to the same drug. Non-steroidal anti-inflammatory drugs (NSAIDs) are common offending drugs.Methods A 14-year-old girl initially presented with a 1-year history of a recurrent reddish-brown plaque around her right areola. The lesion became pruritic and raised during menses, and subsided during the remainder of her menstrual cycle with the exception of persistent residual hyperpigmentation. The patient had a pattern of naproxen use during menses for dysmenorrhea.Results The skin biopsy specimen revealed focal bullae formation and scattered necrotic keratinocytes in epidermis, hydropic degeneration of the basal cell layer, pigmentary incontinence and a perivascular infiltrate composed of lymphocytes and eosinophils. These changes confirmed the diagnosis of fixed drug eruption.Conclusion Fixed drug eruption to nonsteroidal anti-inflammatory drugs is common. However, FDE due to naproxen, one of the NSAIDs, is rarely reported. We describe an unusual case of FDE, which recurred at each menses.

Notes: A 12-year-old girl from Kastoria, Greece, was referred to the University Hospital Xeroderma Pigmentosum Clinic (UHXPC, University Hospital, Newark, NJ) in March 1999, after previously being followed in Greece and France. Unscheduled DNA synthesis testing revealed normal unscheduled DNA synthesis and subsequent testing placed this patient in the XP-variant group. Complementation studies were not performed. She had a history of multiple excisions and biopsies in France, but no malignancies were discovered. The patient was a product of a normal full-term pregnancy, with no complications noted. The patient's pediatric records from Greece showed no abnormalities in growth and development or mental function. Neurologic assessment was normal. At the time of presentation, the patient was an excellent student in the fourth grade of a Greek public grammar school. The patient had no further history of previous hospitalizations or systemic diseases. Her family history was positive for type II diabetes mellitus, hypertension, and coronary artery disease. The patient had a 16-year-old brother who was otherwise healthy; she was the only XP patient in her family. Both parents were from the surrounding Kastoria area, and there was no family history of consanguinity.Initial examination revealed diffuse macules on the face and forehead, generalized xerosis most pronounced in the nasolabial folds, prominent cheilitis, a scar on the left eyelid from a previous excision, and an elevated, erythematous 1 × 2 mm firm papule noted on the medial portion of the right lower eyelid (〈link href="#f1"〉Fig. 1). Histologic assessment of this lesion revealed a basal cell carcinoma, which was subsequently curetted. Examination of the oral cavity showed no abnormalities. Ophthalmologic examination revealed lid freckles and conjunctival congestion. Slit lamp examination was normal.〈figure xml:id="f1"〉1〈mediaResource alt="image" href="urn:x-wiley:00119059:IJD1215:IJD_1215_f1"/〉Close-up view of the face of a 13-year-old XP-variant from Greece. Left profile view demonstrating diffuse macular mottling on the face and nose; generalized xerosis and prominent cheilitis are also seenThe patient's arms were covered with diffuse macular mottling, consistent clinically with nevocellular nevi and lentigines (〈link href="#f2"〉Fig. 2). A 3 × 2 mm darkly pigmented, asymmetric macule was noted on the dorsal base of the right thumb. Histologic evaluation revealed a lentigo with focal cytologic atypia.〈figure xml:id="f2"〉2〈mediaResource alt="image" href="urn:x-wiley:00119059:IJD1215:IJD_1215_f2"/〉Close-up view of the left shoulder. Diffuse macular freckling and xerosis are seenThe patient's anterior thorax, abdomen, and upper and lower back also revealed a similar pattern of macular mottling, although less diffuse than on the arms and legs (〈link href="#f3"〉Fig. 3). A 4 × 3 mm slightly asymmetric, deeply pigmented macule on the right upper back and a 4 × 2 mm macule on the upper chest were biopsied, revealing junctional nevocellular nevi with focal cytologic atypia. A biopsy of a 3 × 3 mm deeply pigmented macule on the right lower back showed a lentigo with atypical cells.〈figure xml:id="f3"〉3〈mediaResource alt="image" href="urn:x-wiley:00119059:IJD1215:IJD_1215_f3"/〉Frontal view of neck, shoulders, and chest. Diffuse macular mottling is seen; numerous suspicious hyperpigmented macules, with irregular borders, are also evidentExamination of the legs revealed a similar pattern of macular mottling to that seen on the arms and chest. Of concern was an 8 × 5 mm irregularly pigmented, asymmetric lesion on the right posterior thigh and a 3 × 2 mm asymmetric macule on the left upper thigh. A 4-mm punch biopsy was taken of the macule on the left upper thigh, revealing a nevocellular nevus with atypical melanocytic hyperplasia (melanoma in situ). The right posterior thigh lesion was a malignant melanoma, Clark–Mihm level III, Breslow depth 0.60 mm.At this time, the patient was instructed to return to the UHXPC in 3 months for follow-up, skin examination, and clinical photographs for documentation and monitoring of suspicious lesions. The patient and her parents were instructed on the need for strict avoidance of UV photoexposure. Sunscreens, UV-absorbing sunglasses, sun-blocking headwear, and protective clothing were to be used when photoexposure was unavoidable. Eucerin facial moisturizing lotion [sun protection factor (SPF) 25] (lactic acid emollient) was to be used twice daily for the patient's facial xerosis; areas of xerosis on the trunk or extremities could be treated, as needed, with Eucerin Plus creme (2.5% lactic acid/10% urea). A multivitamin, zinc and vitamin E were to be taken daily. The parents were also instructed to periodically examine the child for the development of suspicious lesions. The patient was added to the Xeroderma Pigmentosum Registry, and will be followed up on a long-term basis in our clinic.Over almost 2 years of follow-up, multiple excisions of newly arising, suspicious lesions have been performed as necessary on each visit. Histologic examination was significant for numerous intraepidermal, atypical, melanocytic hyperplasias (melanoma in situ), a number of dysplastic nevi, and two basal cell carcinomas (upper lip, right lumbar area). Re-excision of the melanoma site on the right posterior thigh revealed no evidence of recurrence. The patient's most recent visit was in July, 2001.The patient continues to use photoprotective precautions. Multivitamin, zinc and vitamin E tablets are taken daily. We have also recommended the use of 5-fluorouracil 1% cream (Fluoroplex) nightly for 6 weeks applied to the nose and nasolabial folds. The patient has also been followed up by a child psychiatrist in Greece on a regular basis.