A Case of Malignant Melanoma with In-Transit Metastasis That Responded to Intravenous Infusion of Interferon-β

Late recurrence, defined as that occurring 10 or more years after diagnosis, is an unusual event in cutaneous malignant melanoma (MM). A 59-year-old woman presented with a black nodule measuring 10 mm x 9 mm on the sole of her right foot. She was diagnosed with MM and the tumor was totally excised with 5 cm of the normal surrounding skin. Eleven years after the operation, five in-transit metastases were found in her right limb. They were all excised and beta-interferon (IFN-beta) was injected into the skin around the postoperative scars. However, numerous new in-transit skin metastases have been emerging every year in her right limb. Fifty-four in-transit skin metastases have so far been found. Recently, there have been few in-transit metastases. All in-transit metastatic lesions were excised and local IFN-beta injections were conducted continuously. There is no evidence of metastases to the internal organs or lymph nodes. This report describes this case with a brief review of the published work concerning the rare late recurrences of MM.

Nevus trichilemmocysticus (NTC) constitutes a broader group of epidermal nevi that are commonly present at birth or during early childhood and marked by hamartomatous lesions with epidermal hyperplasia.1, 2 Epidermal nevi lesions often begin as a linear tan patch or thin plaque presenting along Blaschko lines and typically progress over time, especially with puberty. NTC is an uncommon form of epidermal nevi that was first recognized as a distinct entity in 2007.2 There are not many reports in literature identifying this condition. We describe the case of a 38-year-old female with nodules on the leg and scalp consistent with NTC. A 38-year-old female with no significant past medical history presented with a several-year history of slowly enlarging nodules on her scalp and left lower leg. These nodules were occasionally tender and red. The patient reports having similar nodules on her left knee that were surgically removed and thought they contained “calcium deposits.” The left leg nodules were spread over a rash that had been present since birth. Her family history was non-contributory. She denied fevers, chills, headaches, joint pains, or muscle aches. On physical examination, there were two 5 cm soft, nontender, and mobile nodules on the bilateral parietal scalp. A thin, scaly plaque covered the left posterior upper and lower leg in a blaschkoid pattern along with scattered firm, erythematous nodules and hyperkeratotic papules (Figure 1). Punch biopsies were obtained for the nodules on the proximal and distal left leg. Histopathology of the proximal lesion revealed filiform hyperkeratosis with sections of the skin that demonstrated compact orthokeratosis, mild papillomatosis, and epidermal hyperplasia (Figure 2a). A hyperparakeratotic plug in a dilated follicle showed trichilemmal differentiation. The tissue sample of the distal left leg showed sections with squamous-lined cysts with abrupt trichilemmal type keratinization and a lack of granular cell layer within the cyst lining (Figure 2b). Given the history, physical exam, and histopathological findings, a diagnosis of nevus trichilemmocysticus (NTC) was made. The patient underwent excision of two leg nodules and two pilar cysts on the scalp. Epidermal nevi evolve from genetic mutations or epigenetic changes that alter gene expression in the early postzygotic embryo, resulting in somatic mosaicism that follows the lines of Blaschko.1, 3 Based on a report of 38 Danish family members, trichilemmal cysts may be associated with the TRICY1 gene as an autosomal dominant trait.4 However, solely indicating this gene may oversimplify the more complex disease findings found in NTC.2 Extracutaneous manifestations may further accompany NTC. One patient reported headaches, arthritis during childhood and adolescence, and severe bone deformities due to osteomalacia.2 However, it is uncertain if these bone deformities were affected by NTC or due to her vitamin D deficiency. Mild frontal bossing was also observed in a 10-year-old female.5 They suspect that the facial abnormalities observed in their case do have a connection to NTC given that CNS deformities can be associated with several types of epidermal nevi. Clinicians should be aware of these systemic findings and their association with epidermal nevi syndromes. NTC treatment involves excision of bothersome nodules. CO2 ablation and radiofrequency treatment have been used in some cases to improve cosmetic outcomes.3 Overall, epidermal nevi treatment can be challenging. Topical therapies including cryotherapy, dermabrasion, and electrodessication may allow temporary improvement but are prone to recurrence.1 Emerging research involves identifying genotypes and elucidating the pathogenesis of epidermal nevi; this may provide greater insight into targeted therapies and individualized treatment modalities.

Background: Microsoft Kinect is used in the field of anthropometry (Sameijma et al., 2012 ; Xu et al., 2013 ; Clarkson et al., 2016 ; Zhang et al., 2015), gait analysis (Springer & Seligman, 2016 ; Pfister et al., 2014 ; Motiian et al., 2015 ; Prochazka et al., 2015 ; Cippitelli et al., 2015), motor performance (Lim et al., 2015 ; Sevick et al., 2016 ; Taha et. al., 2016), posture/balance evaluation (Dutta et al., 2014 ; Metiplay et al., 2013 ; Oh et al., 2014 ; Saenz-de-Urturi & Garcia- Zapirain Soto, 2016) and rehabilitation (Galna et al., 2014 ; Mobini et al., 2015 ; De Rosario et al., 2014 ; Shapi’i et al., 2015). Reliability of instruments in clinical and sport application differ, therefore the goal of this research was to initially determine the protocol of validation of a new measuring instrument for digital measurement of anthropometric dimensions of the body structural and metric). Reliability of results in this paper was tested on three classically and digitally measured anthropometric variables, i.e. height, left forearm length and left lower leg length. Methods: Male and female employees of the Technology Park Zagreb (N=52) volunteered for this research. Subjects were wearing their everyday clothes. Among 471 assessed variables (3 + ((26 * 6)) * 3) three variables from a set of classically measured anthropometric dimensions were extracted - height, length of left forearm and length of left lower leg. Classical measurements were conducted through standard IBP protocols, a Standardized protocol for digital measurement (DM- I) was produced. Data were analyzed by Statistica 12 for Windows operating system. Mean, standard deviation, range, variability coefficient, skewness and kurtosis were used as descriptive parameters, as well as Pearson correlation coefficient, Spearman-Brown alpha, Cronbach`s alpha and Spearman-Brown (standardized) alpha. Results: Classically and digitally measured height in average results do not differ significantly, while for lengths of the left forearm and the left lower leg do indicate significant differences (lower values). The differences could be attributed to different reference points used in two measurement methods. Measures of internal consistency (reliability) for digitally measured variables:height of the body, length of left forearm and length of left lower leg demonstrate high reliability (Cronbach alpha, the standardized alpha 0.995 to 0.997) and the average inter-item correlation (0.973 to 0.985), indicates a high internal consistency between items related to digitally measured height. Reliability was slightly lower for digitally measured length of the left forearm and lower leg due to greater differentiation in average interitem correlations coefficients. Conclusions: Digital measurements with Kinect are not appropriate for clinical trials demanding high precision. There is no statistical evidence that could differentiate distances of examinee from Kinect sensor in order to define optimal distance (as long as subject stands within Kinects range. Small errors occur due to clothing, possibly due to illumination, and sensor height and distance, which is in line with previous research.

Mrs. J. G. W., white female, housewife, aged 49, was admitted to the Wisconsin General Hospital on February 20, 1931, complaining of pain and swelling in the left leg. She stated that on October 29, 1930, she had sustained an injury to the fingers of her left hand and to the left lower leg in an automobile accident. A superficial laceration from scraping of the skin marked the place of injury to the left leg, which might have escaped attention had it not been for the adherence of the stocking to the abraded area by reason of exuded serum. Varicose veins had been noticed in both legs since the last pregnancy, 11 years before, and these varicosities had been more marked on the left lower leg. The morning following the injury the left leg was quite painful, but she was able to walk. There was no swelling at this time, but the second day after the injury the patient was unable to walk by reason of the pain and swelling in the left lower leg. There were also a number of circular red spots on the left lower leg about three inches in diameter, which felt like burns and were painful to the touch. Since that time, the patient had remained in bed, experiencing irregular exacerbations and remissions of the local condition. The history by systems was interesting in two details, namely, a cough, usually non-productive since the time of injury and particularly marked when lying on the left side, and constipation. The patient had had hemorrhoids over a period of three years and there had been bleeding up to the time of admission. The past medical history was important because of the details of typhoid fever at 15 years of age and pleurisy at 19 years of age. A hemorrhoidectomy had been performed four years before and a herniotomy twenty years before. Her social history was without bearing on the present conditions, as was the family history, except for the occurrence of epithelioma in the paternal grandfather. Physical examination revealed the following pertinent findings: pigmented nevi on the right cheek and beneath the left angle of the jaw; small, firm cervical lymph nodes about the left clavicle; retraction of the left chest close to the sternum in the first and second interspaces, over which area there was decreased tactile fremitus and dullness to percussion, the area of dullness extending 5 cm. from the left border of the sternum in the first interspace, whereas posteriorly the dullness was noted off the spine of the left scapula toward the vertebral column. The breath sounds were bronchial to amphoric over the area of dullness, with marked increase in the spoken voice and definite whispering pectoriloquy. The entire remaining left chest showed a decreased resonance, the breath sounds were somewhat suppressed, and there were abundant medium and fine moist rales throughout the left, with a few fine crepitant rales at the right base. The heart was widened in the transverse diameter, measuring 16 cm. at the maximum width.

The study assesses the effects of a six-week plyometric training program (PT) on muscle stiffness in the dominant and non-dominant leg in male collegiate volleyball players. The study group comprised 16 volleyball players who had played collegiate volleyball for at least four years. For six consecutive weeks, twice a week, the players undertook a plyometric program of 60-min training sessions, each preceded with a specialist warm-up. The analysis of the anterior muscles of the right and the left lower leg revealed a significant increase in stiffness in the muscles of the right leg and the left leg. No significant differences were found between the anterior muscles of the left lower leg and the right lower leg in particular weeks of the training program. The analysis of the posterior lower leg muscles revealed no significant differences, either in the consecutive weekly training microcycles or between the left leg and the right leg. The measurement of muscle tone and biomechanical properties of muscles can be used as a fast and direct assessment of plyometric training-related muscle fatigue. A similar level of muscle stiffness in both lower legs (symmetry) is a reflection of the appropriate selection of plyometric training loads.

Difficult Femoral Arteriovenous Fistula in a Child

Background:Although lower extremity pain and fatigue are important conditions for hairdressers, such occupational issues are poorly documented. This study aimed to determine lower extremity fatigue and related factors in hairdressers.Methods:The study population consisted of at least 18 years old individuals working as hairdressers. Lower Extremity Fatigue was assessed with 2 questions containing a 5-point Likert scale. A numerical fatigue rating scale was used to assess general fatigue level, a visual analog scale was used to assess occupational satisfaction, Nottingham Health Profile (NHP) was used to assess health profile, and Cornell Musculoskeletal Discomfort Questionnaire (CMDQ) was used to assess lower quadrant pain profile.Results:In the assessment of lower extremity pain, a statistically significant difference was found between Fatigue and Non-fatigue groups in the lower back (p=0.011), left knee (p=0.012), right (p=0.017) and left (p=0.012) lower leg parameters. In the lower extremity Weighted Scores, there was no significant difference between the fatigue and non-fatigue groups in the pelvis (p=0.365), right upper leg (p=0.153), left upper leg (p=0.156), right knee (p=0.054) but there were significant differences in the lower back (p=0.002), left knee (p=0.023), right lower leg (p=0.006) and left lower leg (p=0.017). The difference in the Energy, Pain, and Physical Mobility sub-dimensions of the Nottingham Health Profile of the hairdressers in the ‘Fatigue Group’ was at a significant level.Conclusions:In conclusion, the rate of lower extremity fatigue found in hairdressers in the present study was quite high, and lower extremity fatigue was associated with lower extremity pain and health profile.

Persistent Generalized Cutis Marmorata Telangiectatica Congenita with Venectasia.

Mycetoma is a chronic granulomatous infection of the subcutaneous tissue, usually involving extremities and rarely the other parts of body. It is most commonly caused by fungi and actinomycetes. Botryomycosis is a mycetoma-like lesion most commonly caused by Staphylococcus aureus and less commonly by Pseudomonas aeruginosa, Escherichia coli, Proteus spp., and Streptococcus spp. Clinically, it presents as localised, painless swelling with chronic multiple sinuses discharging viscid sero-purulent fluid containing granules/grains of different colours, sizes, and shapes based on aetiological agents.1, 2 The correct aetiological diagnosis of mycetoma or mycetoma-like lesion plays an important role in the initiation of rational therapy because of its varied aetiology of fungal, actinomycotic, or bacterial origin. We recently came across a case of multiple discharging sinuses over the left lower leg, typically mimicking a mycetoma-like lesion. A 40-year-old male with a 2-year history of deep vein thrombosis of the left leg presented with multiple discharging sinuses over the left lower leg, typically mimicking a mycetoma-like lesion. There was no history of any previous surgeries. He was apparently in good health about 15 days ago, after which he began complaining of multiple swellings over the inner side of the left lower limb, which burst open to form multiple discharging sinuses. On physical examination, his left leg was found swollen, with dark pigmentation over the left foot and lower half of the calf and multiple punched out lesions over the medial side of the lower part of the left leg (Figure 1). The physical examination also revealed raised local temperature and tenderness (1+). The remaining systemic and general findings were normal. Based on typical clinical presentation, a provisional clinical diagnosis of maduramycosis was considered. His haematological parameters were within the normal limits, urine routine examination was also normal, and he was negative for HBsAg and HIV. The random blood glucose level tests, kidney function tests, and liver function tests were within normal limits. Venous colour Doppler of the left lower limb was suggestive of old deep vein thrombosis. Careful macroscopic examination of a pus sample collected from the deep infection site showed the absence of grains/granules. The culture of pus yielded methicillin-resistant Staphylococcus aureus (MRSA) resistant to cotrimoxazole, cefoxitin, and penicillin G and susceptible to ciprofloxacin, gentamicin, and erythromycin. Direct microscopy and culture were negative for fungal elements. The patient was advised to keep the leg elevated and was administered intravenous 500 mg ciprofloxacin BD for 7 days, with daily cleaning and dressing of the wound. The patient showed significant improvement after 7 days of treatment. Further oral administration of 500 mg ciprofloxacin BD for 5 further days resulted in complete healing of lesions (Figure 2). Skin and soft-tissue infections (SSTIs) are the most frequent forms of the diseases caused by Staph. aureus. Methicillin resistance in Staph. aureus makes it a pathogen of growing concern in hospitalised patients. In recent years, MRSA has also become a significant cause of community-acquired infections.3 Staph. aureus is the most common cause of botryomycosis (a mycetoma-like lesion), in which the formation of grains/granules resembling sulphur granules of actinomycosis is the typical feature.4-7 In this case, the clinical presentation was typically like a mycetoma, with culture positive for Staph. aureus, which favoured a diagnosis of botryomycosis, but the absence of grains/granules helped to rule out this diagnosis. The result shows that Staph. aureus may cause lesions clinically mimicking mycetoma-like lesions, especially in patients with underlying diseases, and also suggests the importance of careful examination of clinical specimen and investigations in the final confirmation of the diagnosis and initiation of rational therapy.

Dear Editor: The lack of reliable pathological criteria for distinguishing between benign and malignant melanocytic lesions makes it very difficult for clinicians and pathologists to diagnosis melanoma. Here, we describe a rare case of a young patient affected by Spitzoid melanoma of the left leg with left superficial inguinal lymph node metastasis. A 13-year-old boy was referred to our hospital for a 19×9-mm cutaneous dome-shaped pigmented nodule on his left lower leg (Fig. 1A). The nodule appeared 3 months prior and was asymptomatic. No lymphadenopathy was found on physical examination. Under the suspicion of Spitz nevus, the tumor was excised with a 2-mm free margin. Histological analysis demonstrated that it was a symmetrical melanocytic tumor; it exhibited prominent pleomorphism and definitely showed changes of maturation (Fig. 1B~D). We detected hemorrhage crusts on the horny layer, but these were caused by the patient's scratching. There was no bleeding in his clinical course. Atypical epithelioid and spindle-shaped melanocytes with large hyperchromatic pleomorphic nuclei were observed. No ulceration was present. These findings were discordant with pigmented epithelioid melanocytoma1. His immunologic profile was consistent with a melanocytic tumor: S-100, Melan-A, and HMB-45 positivity, and CD34 negativity. The presence of diffuse HMB-45 positivity, even deeper in a nest, was considered unusual in a Spitz nevus. The extremely controversial nature of the lesion led to a diagnosis of atypical Spitz neoplasm of indeterminate biologic potential or Spitzoid-type minimal deviation melanoma. After receiving informed consent from the patient's parents, we performed careful observation, considering the possibility of malignant tumor. He had a huge palpable inguinal lymph node on physical examination 4 months postoperatively. Magnetic resonance imaging and positron emission tomography scans showed a large metastatic superficial inguinal lymph node (Fig. 2). Under a diagnosis of Spitzoid melanoma with subsequent lymph node metastasis, we performed wide local excision (2-cm margin including the periosteum) of the lower leg and resurfaced the defect with a local flap procedure. Left inguinal lymph nodes including the superficial and deep node groups were completely dissected. Three of the nine harvested lymph nodes including the large lymph node exhibited metastasis. Atypical melanocytes similar to those in the leg lesion were found within the lymph node parenchyma. The patient was treated with adjuvant dacarbazine, nimustine, and vincristine chemotherapy 5 times over 6 months. At a recent follow-up 2 years later, he did not have any evidence of recurrence or metastasis. The 5-year survival rate of children between 11 and 17 years old with metastatic Spitzoid melanoma is 49%2. Recent studies suggest the prognosis of children with Spitzoid melanoma is better than that in adults even local metastases or positive sentinel lymph nodes are present3,4,5. However, some cases of incomplete excision of Spitzoid melanoma leading to systemic metastasis and death have been reported5. Therefore, in cases in which the diagnosis is uncertain despite further evaluations, it is necessary perform careful observation to prevent recurrence and metastasis as early as possible. Fig. 1 (A) A 10-mm dome-shaped pigmented nodule on the left lower leg. (B) Histopathology of the skin lesion; Breslow's thickness clearly exceeded 4 mm. No ulceration was present (H&E, ×10). (C) Abundant irregular nests of varying size and shape, ... Fig. 2 Magnetic resonance imaging (left panel) and anterior projection images from the positron emission tomography-computed tomography scan (right panel). Note the extensive left inguinal lymph node uptake (arrows). This sentinel lymph node was larger than ...

Introduction: Hereditary multiple exostosis (HME) is a hereditary disorder characterized by multiple osteochondromas. Clinical symptoms can result from compression of adjacent structures such as peripheral nerves. In Indonesia, HME with nerve compression cases have rarely reported. Presentation of Case: An eleven-year-old female with complaining of left knee joint pain and progressive masses in left lower leg since 6 years ago. This complains followed by numbness and difficulty to dorso flexion motion on left ankle joint since four months ago. Physical examination showed of the bony masses was detected at the left lateral upper third lower leg with measuring about six into eight centimeters. Range of motion of left ankle joint patient had difficult to dorso flexion. X-ray imaging viewed demonstrates multiple exostosis appearance involving distal femoral, proximal fibula, proximal tibia and distal fibula bone. MR Imaging revealed cartilage cap of head fibula is thin less 1.5 cm and the axially specimen showed peroneal nerve compression. The patient underwent left head fibula wide resection. Intraoperative findings peripheral nerve peroneal compression and was decompression. Medical rehabilitation for physiotherapy was advised. The results of the follow-up after 2 years, no pain feels and the patient was able to dorso flexion of left ankle joint and no additional bumps in other areas of the body. These lesions may arise from any bone which was pre-formed in the cartilage. Nerve compression syndromes are the neurological complex symptom caused by the mechanical or dynamic compression of a specific single segment. MRI was excellent demonstration of blood vessels compromise and represents choices with peripheral nerves structures and to measuring cartilage cap thickness for criterion of osteochondromas differentiation and exostotic grade. Complete resection was importance of the cartilaginous cap to prevent recurrence. The decompressing the peroneal nerve that pressured by the masses and vascular problems occured. Conclusion: Hereditary multiple exostosis is an inherited disorder characterized by multiple osteochondromas. It is important to monitor all cases of HME especially if the patient complains of pain or growth of an osteochondroma. The surgical excision, with complete resection of the cartilaginous cap of the tumor, is important in preventing recurrence.

Tumors arising from burn scars are not rare but sometimes cause the rare co-existence of different tumors. However, detailed information on this topic remains largely unknown. We present a case of the co-occurrence of malignant melanoma and squamous cell carcinoma in a patient with a history of burn scars. A 73-year-old man presented with an erythematous plaque on his left lower leg that gradually turned into a tumor with ulceration. He also presented with scaly tumors at other sites within the same burn scar lesion. He had a history of burns on the left leg at the age of 20 years. After surgical resection of the tumors, histological analysis revealed that the posterior aspect of the largest tumor was malignant melanoma, and the remaining two tumors were squamous cell carcinomas, indicating the co-existence of different types of malignant skin cancers. Based on a literature review of previously published case reports, this is the first report to highlight the importance of complete skin grafts in reducing this risk.

Background - Post thrombotic syndrome (PTS) is a complication of deep vein thrombosis (DVT) with limited treatment options.Venous ulceration is the ultimate and most severe presentation of PTS, although not all symptoms and signs are irreversible once PTS is diagnosed, this diagnosis is deemed permanent. Treatment options are limited therefore emphasis is placed on its prevention. Objective – Management of the Post thrombotic syndrome associated with chronic ulcer by Ayurvedic approach Materials and Methods–Here we report a case of non-healing ulcer on left foot associated with pain, itching, swelling and blackish discoloration on left lower leg since 2 years.The case was diagnosed and treated as PTS complicated with venous ulcer. In Ayurvedathese clinical features are co-related with GambhirVatarakta and treatment principles include Raktamokshana Virechana, Basti. The case was treated with Jaloukavacharana (Leech therapy), Virechana (Purgation) and Vrana Chikitsa (Shodhana and Ropana). Results– Clinical improvements were seen in parameters like pain, swelling, itching and wound. The time taken for complete healing of the ulcer was two months. Conclusion - The adopted Ayurvedic treatment has given promising results in the management of PTS associated with chronic venous ulcer.

Cutaneous atypical mycobacterial infection with Mycobacterium fortuitum arising after endovenous radiofrequency ablation

Pancreatic or gastric metastases from other primary malignancies are rare, especially from leiomyosarcoma. We report a case of leiomyosarcoma in the left lower leg with metastases to the pancreas and stomach. A 61-year-old man had liver cirrhosis caused by hepatitis C virus infection and was followed up by his primary physician. Two years before presentation at our hospital, he had undergone surgical resection of leiomyosarcoma in the left lower leg and systemic chemotherapy for multiple metastatic tumors in the lung. On admission, endoscopic examination and computed tomography were performed for a routine checkup to exclude esophageal varices and liver tumor. Although the patient had no specific symptoms, multiple gastric and pancreatic metastases were identified by endoscopy and computed tomography, respectively. In general, metastases to the pancreas and stomach are rare. We discuss the clinical and diagnostic findings of pancreatic and gastric metastases by reviewing previously reported cases.