Absence Of Cutaneous Lesions Research Articles

When Epilepsy Takes Center Stage in Tuberous Sclerosis Complex: A Case Report from the Dermatology Hospital of Bamako

Tuberous Sclerosis Complex (TSC) is a multi-organ genetic disorder characterized by numerous hamartomas found in several organs, including the brain, heart, skin, eyes, kidneys, lungs, and liver. The responsible genes are TSC1 and TSC2, encoding hamartin and tuberin, respectively. The hamartin-tuberin complex inhibits the mammalian target of rapamycin pathway, which controls cell growth and proliferation. Variations in the distribution, number, size, and location of lesions lead to variations in the clinical syndrome, even among family members. Most features of Tuberous Sclerosis Complex become evident only in childhood, after the age of 3, limiting their usefulness for early diagnosis. Identifying patients at risk of severe manifestations is crucial. We report a case of Tuberous Sclerosis Complex inaugurated by epilepsy. It is a 10-year-old girl, a student, who came for consultation for a black spot on her left cheek evolving continuously for seven years. Two months later, this spot, asymptomatic solid lesions appeared on her face, gradually increasing in size and number. In her medical history, she has had convulsive seizures since the age of three, occurring at least five times a year, confirmed by an electroencephalogram. There is an oblong-shaped skin plaque measuring approximately 7x3 cm, erythematous, on the left cheek. Additionally, there are multiple normochromic angiofibromas affecting the nasal pyramid, nasolabial folds, and cheeks. The rest of the dermatological examination is unremarkable. The diagnosis of Tuberous Sclerosis Complex was made. In the presence or absence of cutaneous lesions, when faced with epilepsy in young children, we must always consider Tuberous Sclerosis Complex before ruling out other causes.

Mpox Pharyngitis

A case of mpox pharyngitis in absence of cutaneous lesions is reported. Usually, clinical presentation is either a cutaneous eruption or a combination of cutaneous and mucosal lesions. In patients with atypical pharyngitis, regardless of the presence of skin lesions, pharyngeal swabs should be collected to rule out mpox.

A cross-sectional observational study of clinical, histopathological, and dermoscopic correlation in patients with nail psoriasis at a tertiary care hospital

Background: Among various nail disorders encountered in dermatology outpatient department, nail psoriasis is not uncommon. Around 80%–90% of patients with psoriasis present with nail involvement at some point in their life. In 1%–5% of patients, alterations compatible with nail psoriasis may also occur in the absence of cutaneous lesions. There is limited literature on nail psoriasis especially in Indian patients. Objective: The present study was undertaken to evaluate clinical, histopathological, and dermoscopic features in nail psoriasis and its impact on quality of life. Materials and Methods: All clinically suspected cases of nail psoriasis were included in the study. Clinical parameters and dermoscopic findings were observed and noted. Nail biopsy was performed to confirm the findings. Impact on quality of life was evaluated by correlating Nail Psoriasis Severity Index (NAPSI) score and nail psoriasis quality of life scale (NPQ10) score. Results: Of 50 patients with clinically suspected nail psoriasis, skin involvement was seen in 45 (90%), and 5 (10%) had only nail involvement. The mean NAPSI score was 34.34 in our study. The most common clinical nail finding was pitting (38 [76%]) followed by onycholysis (31 [62%]). The most common dermoscopic finding was pitting (39 [76%]) followed by onycholysis (32 [64%]). Histopathologically, the most common finding was parakeratosis (41 [82%]) followed by focal hypergranulosis (40 [80%]). The majority of the patients (21 [42%]) had NPQ10 (modified) score between 10 and 20, and moderate positive correlation between NAPSI score and NPQ10 scale score was observed. Limitations: Small sample size and no control group. Conclusion: Nail psoriasis does impact the quality of life of patients especially in females who feel embarrassed in social gatherings and workplace. Nail biopsy, though painful and difficult to perform, is the most efficient method to diagnose nail psoriasis.

RECURRENT ORAL ERYTHEMA MULTIFORME: AN UNUSUAL SUBTYPE OF ERYTHEMA MULTIFORME

Recurrent oral erythema multiforme (ROEM) is an unusual subtype of erythema multiforme, which is characterized by multiple, recurrent, self-limiting, and painful oral ulcers, evidence of herpes simplex virus (HSV) infection, and absence of cutaneous lesions. The diagnosis of ROEM is difficult and challenging, because other similar diseases should be carefully excluded. Acyclovir and/or corticoids are employed but with variable results. A 52-year-old woman presented with recurrent and painful oral ulcers in the buccal mucosa, soft palate, and gingiva in the last 12 months, with 6 to 8 recurrences during this period. The histopathologic analysis revealed an unspecified chronic lymphoplasmacytic infiltrate. Serologic tests were negative, among others, for Veneral Disease Research Laboratory (VDRL) and fluorescent treponemal antibody absorption (FTA-ABS) but positive for HSV 1/2 IgG and IgM. This report emphasizes the importance of identifying the subtypes of erythema multiforme, aiming to deal with its therapeutic and prognostic implications. Recurrent oral erythema multiforme (ROEM) is an unusual subtype of erythema multiforme, which is characterized by multiple, recurrent, self-limiting, and painful oral ulcers, evidence of herpes simplex virus (HSV) infection, and absence of cutaneous lesions. The diagnosis of ROEM is difficult and challenging, because other similar diseases should be carefully excluded. Acyclovir and/or corticoids are employed but with variable results. A 52-year-old woman presented with recurrent and painful oral ulcers in the buccal mucosa, soft palate, and gingiva in the last 12 months, with 6 to 8 recurrences during this period. The histopathologic analysis revealed an unspecified chronic lymphoplasmacytic infiltrate. Serologic tests were negative, among others, for Veneral Disease Research Laboratory (VDRL) and fluorescent treponemal antibody absorption (FTA-ABS) but positive for HSV 1/2 IgG and IgM. This report emphasizes the importance of identifying the subtypes of erythema multiforme, aiming to deal with its therapeutic and prognostic implications.

A Primary Extracutaneous Presentation of Merkel Cell Carcinoma

Merkel cell carcinoma (MCC) is a rare aggressive cutaneous neuroendocrine malignancy with a mortality rate of around 33%. The presence of advanced disease at the time of diagnosis is associated with poor prognosis. Twofold etiologies have been described in the pathogenesis of Merkel cell carcinoma: chronic exposure to ultraviolet (UV) light and Merkel cell polyomavirus (MCPvY). MCC usually affects sun-exposed skin areas, and the presence of cutaneous nodules is the hallmark of the disease. However, there have been case reports in the literature where the diagnosis of MCC was made in the absence of any cutaneous findings. We present a case report of Merkel cell carcinoma that is unique in its presentation because of the presence of pulmonary and hepatic nodules and the absence of cutaneous lesions.

Acute myelitis with multicranial neuritis caused by Varicella zoster virus: a case report

BackgroundVaricella zoster virus (VZV) can remain lifelong in the latent state in ganglionic neurons and adrenal glands after the initial infection. However, it can be reactivated anytime and can trigger several severe neurological manifestations such as encephalitis, meningitis, Ramsay-Hunt syndrome, cerebellitis, myelitis, and stroke. In addition, due to the diversity of clinical manifestations, clinical diagnosis of VZV can be difficult, especially in the absence of varicella. Here, we describe the case of a 52-year-old male who presented with symptoms of acute myelitis as well as polycranial neuritis, and was finally diagnosed with VZV infection through metagenomic next-generation sequencing (mNGS).Case presentationA 52-year-old male came to our hospital with complaint of headache, fever, weakness of right lower limb, abdominal distension, and hearing loss. T2-weighted MRI revealed a hyperintense lesion in the spinal cord extending from T8 to T11. In addition, enhanced MRI showed small patches and strips hyperintensities in both the spinal cord and meninges. Plain abdominal radiographs and abdominal computed tomography (CT) scan displayed air-fluid levels and incomplete bowel obstruction. Moreover, electrophysiological evaluation of the peripheral neuropathy in the extremities was found to be normal. Finally, by using metagenomic next-generation sequencing (mNGS) we found that the copy number of VZV DNA in cerebrospinal fluid (CSF) was significantly increased and IgG antibody against VZV in CSF was also noted to be positive. Hence, VZV infection was identified in patient’s central neuron system. Finally, after a few days of low dose steroid treatment, the patient's symptoms were found to be significantly improved.ConclusionsThe findings indicate that we should pay proper attention to the various symptoms caused by VZV infection due to the clinical heterogeneity, especially in the absence of cutaneous lesions.

Management of Upper Airway Infantile Hemangiomas: Experience of One Italian Multidisciplinary Center.

Airway infantile hemangiomas (IHs) can represent a life-threatening condition since the first months of life. They may be isolated or associated to cutaneous IHs, and/or part of PHACES syndrome. Diagnosis, staging, and indication to treatment are not standardized yet despite the presence in the literature of previous case series and reviews. The diagnosis might be misleading, especially in the absence of cutaneous lesions. Airway endoscopy is the gold standard both for diagnosis and follow-up since it allows evaluation of precise localization and entity of obstruction and/or stricture. Proliferation of IH in the infant airways manifests frequently with stridor and treatment is required as soon as possible to prevent further complications. The first line of therapy is oral propranolol, but duration of treatment is not yet well-defined. All considered, we report the experience of our multidisciplinary center from 2009 to date, on 36 patients affected by airway IHs, and successfully treated with oral propranolol. Thus, the authors propose their experience for the management of airway IHs, specifically early diagnosis, when to perform endoscopy, how to interpret its findings, and when to stop the treatment.

Varicella-Zoster Virus Meningitis and Encephalitis: An Understated Cause of Central Nervous System Infections.

BackgroundVaricella-zoster virus (VZV) and herpes zoster cause infections of the central nervous system (CNS) manifesting as meningitis or encephalitis. As compared to enterovirus (EV) and herpes simplex virus 1 (HSV-1) and 2 (HSV-2), it is not often tested in CNS infections due to VZV and herpes zoster. There is a certain tendency to think that the findings in the cerebrospinal fluid in infections of the CNS by viruses are comparable among themselves. The exact proportion of patients with VZV primary and reactivation infection who present with lesions prior to or concomitant to its involvement in the CNS is unknown. It is also not known about the risk factors that lead to the reactivation of VZV and CNS involvement.ObjectiveTo describe the clinical characteristics and laboratory results of patients with a positive VZV polymerase chain reaction (PCR) and neurological signs and symptoms.MethodsA retrospective and descriptive study was performed at the Hospital Universitario de la Pontificia Universidad Católica de Chile (Hospital Clínico UC CHRISTUS) from September 2012 to July 2014. The following parameters were recorded: neurological signs and symptoms, PCR for VZV in cerebrospinal fluid (CSF), comorbidities, personal medical history, cutaneous lesions, CSF characteristics, CNS imaging, electroencephalography (EEG), treatment, mortality, and neurological sequelae. Adult patients with meningitis, encephalitis, or meningoencephalitis due to VZV diagnosed with PCR were included.ResultsOut of 70 CSF samples analyzed in the previously mentioned period, 21 cases were VZV positive, 16 cases that had clinical information available were included. The mean age with VZV CNS reactivation was 47 years (range 19-80 years). Five patients (31.25%) were immunocompromised: three had human immunodeficiency virus (HIV), one had kidney transplantation, and one had primary immunodeficiency. Clinical presentation was meningitis in 11 patients (68.75%) and encephalitis in five patients (31.25%). Pleocytosis in CSF was observed in all the samples. The five immunocompromised patients had cutaneous lesions. All patients received antiviral treatment. Therapy duration was from 10 up to 21 days. The clinical course was positive in most patients and the mean hospitalization time was 15 days (range 5-60 days). No mortality was observed.ConclusionsVZV is a worldwide virus and a common cause of CNS infection. The rising incidence is probably due to a better diagnostic method and a frequent clinical suspicion even in the absence of cutaneous lesions, except in immunocompromised cases, as it was observed in the present study. CNS infection presented as a wide spectrum of clinical manifestations with possible neurological sequelae. There was a reduction in neurological morbidity with antiviral therapy. Nonetheless, both the incidence and the morbidity of CNS VZV infection are expected to be diminished by varicella and herpes zoster vaccination. Additionally, there was no increase in mortality in these patients.

Acquired immunodeficiency syndrome related Kaposi sarcoma of the rectum in the absence of cutaneous manifestation

Introduction: In developed countries, the incidence of Kaposi sarcoma (KS) has declined substantially with more widespread use of antiretroviral therapy (ART). The initial presentation of KS is usually cutaneous lesions. Uncommonly, KS is discovered in visceral organs without skin involvement. Isolated KS of the rectum is rare. Case Report: A 41-year-old man with history of iron deficiency anemia and external hemorrhoids presented with worsening rectal bleeding over three years with associated tenesmus and weight loss. On exam, no skin lesions were identified. Hemoglobin was 5.4 g/dL. Rapid human immunodeficiency virus (HIV) screen was positive. Absolute CD4 count was 37/uL. HIV-1 viral load was 328,790 copies/mL. Computed tomography (CT) scan revealed an irregular, circumferential 7 cm rectal mass with associated rectal and pelvic lymphadenopathy. Colonoscopy revealed a non-obstructing, circumferential, friable, ulcerated, nodular mass from the dentate line to 14 cm. Biopsy revealed ulcerated tissue and spindle cell proliferation with HHV-8 positive endothelial cells. Conclusion: We describe the case of a 41-year-old man with newly diagnosed HIV/AIDS and latent syphilis who presented with rectal bleeding and was found to have KS of the rectum with no prior history of skin lesion nor any evidence of cutaneous disease seen on thorough physical examination. Although uncommon, KS can present on visceral surfaces, such as the gastrointestinal (GI) tract, in the absence of cutaneous lesions. Isolated anorectal KS in the absence of skin involvement is rarely seen. Despite an endoscopic appearance which mimics adenocarcinoma, rectal KS should remain in the differential for rectal mass in an immunosuppressed patient, even without typical cutaneous lesions.

Gastric Kaposi Sarcoma Discovered in a Immunocompromised Renal Transplant Patient

Kaposi sarcoma (KS) is an angioproliferative tumor associated with human herpesvirus 8. Lesions in the gastrointestinal tract (GI) are the most common extracutaneous location and can even occur in the absence of cutaneous lesions. They are often clinically silent; however, patients can present with abdominal pain, nausea, vomiting, anemia, GI bleeding and, in rare cases, mechanical obstruction, intussusception, and perforation. The purpose of this case study is to share a case of a gastric KS to help illustrate the clinical presentation and endoscopic description of this rare finding. A 61-year-old male post renal transplant for end state renal disease was admitted to the hospital from clinic secondary to worsening anasarca and lethargy. His vitals were stable upon presentation and laboratory evaluation revealed acute kidney injury with a Creatinine of 2.5 (baseline of 1.5) and acute anemia with hemoglobin at 6.8 (baseline of 13). GI was consulted with concern of occult GI bleeding for which an esophagogastroduodenoscopy (EGD) and colonoscopy was performed. On EGD, a large 3x3cm friable mass was found in the gastric antrum thought to be a contributing cause of the patient's anemia. Pathology demonstrated positive CD31 and CD34 staining confirming the vascular origin of the tumor. Further assessment revealed spindle cell proliferation and confirmatory immunohistochemical testing for human herpes virus 8 latent nuclear antigen consistent with a diagnosis of gastric KS. His colonoscopy incidentally demonstrated a diminutive tubular adenoma and a small lipoma. After further work-up, including negative HIV testing, it was felt that the patient's presentation was a result of his immunosuppression from his renal transplant. Oncology was consulted who did not feel chemotherapy was indicated. His tacrolimus was reduced and he was taken off his mycophenolate mofetil. He was discharged home with close follow up with his nephrologist and primary care provider. Although rare, the GI tract is the most common extracutaneous site involved in KS. Endoscopic appearance of KS lesions includes cratered, ulcerated, flat, polypoid/nodular masses. It is usually associated with immunosuppression. Treatment should be focused on reconstitution of the patient's immune system and joint decision making with oncology. Endoscopic examinations are often useful for assisting in therapeutic decision-making and evaluating therapy outcomes.2635 Figure 1. Approximately 3 x 3cm large friable mass in right gastric antrum representing Kaposi sarcoma.

Isolated lip involvement in psoriasis: an uncommon aspect of a common dermatologic condition

Introduction: Psoriasis is a chronic inflammatory skin disease that typically affects the extremities, trunk, scalp, and nails. Psoriatic cheilitis as an exclusive presentation is very rare and to our knowledge, only 6 cases have been reported to date. The absence of cutaneous lesions causes diagnostic difficulties that can result in misdiagnosis and inadequate treatment. Observation: We reported the case of a 21-year-old woman with a seven years history of scaly plaques of the vermillion of the lips as the only disease manifestation. Her cheilitis was associated with significant psychiatric morbidity. Oral biopsy showed a psoriasiform pattern. Local applications of betamethasone was proposed. Discussion: Although lip psoriasis is extremely rare, it can be the sole presentation of psoriasis even in the absence of accompanying skin lesions, other oral manifestations or a family history of psoriasis. Conclusion: Lip psoriasis should be considered in the differential diagnosis of chronic or recurrent treatment-resistant labial lesions.

AIDS-Related Kaposiʼs Sarcoma With Symptomatic Extensive Gastrointestinal Involvement

AIDS-related Kaposi's sarcoma (KS) is the most common tumor arising in HIV-infected persons and is an AIDS-defining illness. Gastrointestinal (GI) involvement can occur in the presence or absence of cutaneous lesions and patients are often asymptomatic. We describe a case of KS with symptomatic extensive GI involvement after initiation of HAART and corticosteroid therapy. A 36 y/o homosexual Hispanic man with AIDS (CD4 of 31) presented to the ED with painful swallowing, fevers, night sweats and 5 lbs. weight loss over two weeks. He reported 6 months of diarrhea averaging 3 loose stools/day. HAART, high dose steroids, and Valganciclovir were started 4 months prior for AIDS, facial swelling and oral ulcers. Vital signs were T103.6 F, BP 102/54, PR 112, RR 20, and SpO2 of 100%. He had facial edema with violaceous plaques and nodules scattered across his face, dorsal tongue, torso and extremities, and oral ulcers. WBC 0.4 K/uL, Hgb 10.3 g/dL, and albumin of 1.4 g/dL. Antibiotics were given for neutropenic fever. Stool studies were negative for infection; positive FOBT. EGD revealed numerous erythematous nodules in the esophagus, stomach, and duodenum. Colonoscopy showed hemorrhagic nodules throughout the colon with multiple large ulcerations in the ascending colon. Biopsies revealed KS confirmed by human herpes virus 8 (HHV-8) immunostudy; CMV negative. Biopsies of skin and tongue were also positive for KS. Liposomal doxorubicin and filgrastim were started. Bone marrow biopsy was negative for HHV-8, infection, or malignancy. PEG tube was placed for malnutrition. Two cycles of Doxorubicin were completed. Odynophagia, diarrhea, and skin lesions resolved. He now tolerates solid food. KS is a vascular tumor associated with HHV-8. KS incidence significantly declined due to widespread use of HAART. KS usually presents with skin disease but can also involve a wide range of visceral organs including the GI and respiratory tract. Patients with GI involvement are often asymptomatic or may experience weight loss, abdominal pain, nausea and vomiting, GI bleeding, malabsorption, intestinal obstruction, or diarrhea. KS appears as hemorrhagic nodules sometimes with ulcerations. Biopsy shows whorls of spindle-shaped cells with leukocytic infiltration and neovascularization. Systemic chemotherapy is indicated for extensive cutaneous disease, symptomatic visceral disease, or cutaneous disease refractory to local therapy. Corticosteroids and infections have been associated with induction and worsening of preexisting KS. The high incidence of KS immediately following HAART may be due to the severe immunosuppression that led to HAART or to uncovering of KS by the immune reconstitution inflammatory syndrome. Chronic diarrhea in AIDS patients warrants endoscopy to evaluate for infectious causes and other diseases such as KS.Figure 1Figure 2Figure 3

Invisible Mycosis Fungoides: Not to be Missed in Chronic Pruritus.

IntroductionPruritus without visible dermatoses may be the first manifestation of hematological malignancies such as Hodgkin disease, chronic lymphocytic leukemia and mycosis fungoides (MF) and may precede the definitive diagnosis by weeks to years.Case ReportWe present a case of ‘invisible’ MF associated with chronic generalized pruritus in an elderly patient.ConclusionOur case highlights the importance of performing skin biopsies in patients with chronic unexplained pruritus, especially in the absence of cutaneous lesions. This can prompt the clinician to consider possible underlying malignancy, such as ‘invisible’ MF.Electronic supplementary materialThe online version of this article (doi:10.1007/s13555-015-0083-4) contains supplementary material, which is available to authorized users.

Clinical manifestations and genetic variation of Leishmania infantum and Leishmania tropica in Southern Turkey

L. infantum was isolated from cutaneous leishmaniasis (CL) skin lesions in patients having no signs and symptoms of visceral leishmaniasis (VL). Similarly, L. tropica had previously been isolated from patients with VL in the absence of cutaneous lesions. It was not certain how visceralization occurred. Smears (207) and bone marrow samples (135) were taken from CL and VL-suspected patients, respectively. Microscopic examination, ITS1-PCR, RFLP and DNA sequencing for all samples were analyzed. The microscopic examination of smears was found to be 61.3% (127/207) in CL-suspected cases and bone marrow samples were found to be positive 8.8% (12/135) in VL-suspected cases. L. tropica 48.6% (72/148), L. infantum 35.8% (53/148), L. major 15.6% (23/148) in CL, and L. infantum 56.3% (18/32), L. donovani 31.2% (10/32), L. tropica 12.5% (4/32) in VL were found with PCR-RFLP. In addition, the DNA sequencing revealed a genetic variation in L. infantum (variants 1–3) and L. tropica (variants 1–5). We assume that the increased disease occurrence may have resulted from geographical expansion of disease, changing patterns of international travel, population migrations, non-immune people into endemic regions of infected people into non-endemic regions. In this study, L. infantum (variant 3) only in CL-patients and L. tropica (variant 2) only in VL-patients were identified. We hypothesize that genetic variation might play a role in the causation of CL and VL in southern Turkey and the genetic variants may differ according to the geographical location among Leishmania strains.

Three Leishmania/L. species – L. infantum, L. major, L. tropica – as causative agents of mucosal leishmaniasis in Iran

Cases of human oro-mucosal leishmaniasis are mainly reported in areas where Leishmania (Viannia) braziliensis perpetuates and the damages are mainly located at the cartilaginous nasal septum and frontal portions of the nasal fossa. In Iran, an area free of any L.(V) braziliensis, three Leishmania species are known to perpetuate through distinct (i) blood-feeding sand flies and (ii) rodents or (iii) canidae. Thus while establishing the diagnosis of any human oro-mucosal lesions, three Leishmania species – L. infantum, L. major, and L. tropica – must be considered as potential etiological agents of these damages.With these objectives in mind, features such as localization, extent, severity of oro-mucosal lesions, and duration of symptoms at the time of diagnosis were recorded from 11 patients with respect to the presence or absence of cutaneous lesions in other body parts. The biopsy samples were collected from the oro-mucosal and cutaneous lesions and were processed for further identification of the Leishmania species.The lesions ranged from mucosal nodules without ulceration, nodules with erosion, and shallow to deep ulcerations. Leishmania major was isolated from six (55%) cases showing lesions or scars. The scars were restricted to upper and lower extremities. For the other five patients who did not display any signs of former or active cutaneous leishmaniasis, L. major, L. tropica, and L. infantum were isolated from their lesions.In conclusion L. major, L. infantum, and L. tropica, regardless of common tropism, can be seen in mucosal tissues. However, L. major was the predominant species detected from the lesions in the nasal, gingival, and hard and soft palates, and L. tropica was isolated from the gingival and lower lip lesions. Leishmania infantum was isolated from two severe cases of deep mucosal damage displayed by the epiglottis, cricoarytenoid muscle, and laryngeal mucosa. One important finding was the association of L. major with active or scarred skin lesions.

Geographic stomatitis: an oral manifestation of psoriasis?

Geographic stomatitis is an uncommon oral lesion that presents similar clinical, histopathological and genetic features as those of psoriasis. These findings suggest that this lesion may actually represent an oral manifestation of psoriasis. We report one case of geographic stomatitis and discuss a possible connection between this condition and psoriasis. A 37-year-old woman presented with red patches, surrounded by a white border on the labial mucosa and a positive family history of psoriasis. Histopathological examination, immunohistochemical analysis with antibodies against CD4, CD8, CD20, CD68, CD31, and Ki-67 and HLA-A*, -B*, -C*, -DRB1*, -DQA1* and -DQB1* genotyping were performed. Histopathological examination revealed parakeratosis, marked elongation of rete ridges with acanthosis and clubbing, exocytosis, Munro microabscesses, pustule of Kogoj, dilated tortuous vessels at the tip of dermal papillae, and predominant superficial and perivascular lymphocytic chronic inflammatory cell infiltrate. Immunohistochemistry analysis revealed a predominant T-cell subepithelial infiltrate. Based on the referred clinicopathological findings and in the absence of cutaneous lesions, the diagnosis of geographic stomatitiswas confirmed. This case and theoretical data indicate that geographic stomatitis may be an oral manifestation of psoriasis. Moreover, to improve our understanding, psoriatic patients should routinely undergo a detailed oral examination and patients with geographic stomatitis should routinely be submitted to a cutaneous routine examination.

Paracoccidioidomicose sistêmica multifocal: desafio diagnóstico por manifestação cutânea tardia

Paracoccidioidomycosis is an endemic systemic mycosis in Brazil, frequent in the rural areas and often in adult men. It is reported the case of a farmer, who is an illicit drugs' user, with insidious manifestations affecting kidneys, lungs, lymphonodes, bones and lately, the skin, with a delay of more than one year in the diagnosis and effective therapy It is important to include paracoccidioidomycosis as differential diagnosis, even in the absence of cutaneous lesions, for early recognition and treatment, given the high mortality of this entity.

Atypical Case of Mucosal Malignant Melanoma

Purpose: Malignant melanoma of the gastrointestinal mucosa in the absence of cutaneous lesions is very rare. We report an unusual case of primary malignant melanoma of the duodenal mucosa. A 38-year-old diabetic male presented with nausea, bilious vomiting and severe, colicky, epigastric pain for 3 days associated with worsening jaundice for 7 days. Proton pump inhibitors were started 3 months earlier for “heart burn”. Review of systems was positive for decreased appetite. Rest of the history was non contributory. Physical exam revealed stable vitals; scleral icterus and epigastric tenderness. Initial laboratory work up was significant for elevated total bilirubin, transaminases and alkaline phosphatase suggestive of obstructive jaundice. Computed Tomography scan of abdomen with contrast showed hepatic hilar lymphadenopathy and biliary obstruction. Endoscopic Retrograde Cholangiopancreatogram revealed ulcerated proximal duodenal mass with common bile duct (CBD) stricture. Pathology confirmed duodenal malignant melanoma with involvement of CBD. Comprehensive physical exam to rule out any cutaneous or retinal melanoma was negative. Extensive imaging with whole body positron emission tomography and magnetic resonance imaging of the brain did not reveal any other foci. Despite being on chemotherapy and radiotherapy patient rapidly deteriorated with extensive metastasis and expired within 8 months of diagnosis. This case illustrates that a high index of suspicion is warranted to diagnose mucosal malignant melanoma in a timely manner which can originate in esoteric locations and progress rapidly with significant mortality.

Prolonged Diarrhea, Protein Losing Enteropathy, and Intestinal Perforation: An Illustrative Case of HIV-Associated Kaposi Sarcoma

A 24 year-old male with AIDS, chronic non-bloody diarrhea, abdominal pain, and anasarca, developed a jejunal perforation. This case highlights a constellation of rare findings associated with Kaposi's sarcoma – GI lesions in the absence of cutaneous lesions, protein losing enteropathy with anasarca, and intestinal perforation.

Contact heat evoked potentials in normal subjects.

Laser-evoked potentials are widely used to investigate nociceptive pathways. The newly developed contact heat stimulator for evoking brain response has the advantages of obtaining reliable scalp potentials and absence of cutaneous lesions. This study aimed to identify the most appropriate stimulation site with consistent cortical responses, and to correlate several parameters of the contact heat evoked potentials (CHEPs) with age, gender, and body height in normal subjects. CHEPs were recorded at Cz with a contact heat stimulator (Medoc, Israel) in 35 normal controls. The subjects were asked to keep eyes open and remain alert. The baseline temperature was 32 degrees C, and stimulation peak heat intensity of 51 degrees C was applied to five body sites: bilateral forearm, right dorsum hand, right peroneal area, and right dorsum foot. Reproducible CHEPs were recorded more frequently when stimulated at volar forearm (62.5%) than at the lower limbs (around 40%). The first negative peak latency (N1) was 370.1 +/- 20.3 ms, first positive peak latency (P1) was 502.4 +/- 33.0 ms, and peak to peak amplitude was 10.2 +/- 4.9 microV with stimulation of the forearm. Perceived pain intensity was not correlated with the presence or amplitude of CHEPs. No gender or inter-side differences were observed for N1 latency and N1-P1 amplitude. Also, no correlation was noted between N1 and age or body height. These results support future clinical access of CHEPs as a diagnostic tool.