Arm Lesions Research Articles

Multislice computed tomography assessment of everolimus-eluting Absorb bioresorbable scaffolds in comparison with metallic drug-eluting stents from the ABSORB Japan randomised trial.

Blooming artefacts limit accurate coronary assessment by multislice computed tomography (MSCT) in metallic stents. We sought to investigate whether bioresorbable vascular scaffolds (BVS) could be better assessed by MSCT. Among 400 patients in the randomised ABSORB Japan trial, a pre-specified MSCT substudy was performed in 98 patients (103 lesions) in the BVS arm and 49 patients (49 lesions) in the cobalt-chromium everolimus-eluting stent (CoCr-EES) arm at 13 months prior to follow-up angiography. The assessability of BVS by MSCT was superior to that of CoCr-EES (94% versus 67%, p<0.001). Blooming artefacts were the main reason CoCr-EES could not be analysed (29%), while marker artefacts precluded analysis in 1.1% of BVS. In the CoCr-EES arm, non-assessable lesions were more prevalent in segments with 2.5 mm stents compared to 3.0 or 3.5 mm stents (75.0% versus 23.5%, p=0.01), while in the BVS arm image quality was good regardless of the diameter. The in-device minimal lumen diameter by MSCT was smaller than that by QCA with a difference of 0.61 mm in the CoCr-EES arm, vs. only 0.026 mm in the BVS arm. The feasibility of MSCT assessment of BVS-treated lesions was greater than that for lesions with CoCr-EES.

Oral Manifestation of Stevens-Johnson Syndrome: a Case Report

Stevens-Johnson syndrome (SJS), a rare dermatological condition, affects the skin and mucosa, and is usually triggered by medications and rarely by infections. A 17-year-old boy presented with oral and ocular mucosal pain. Clinical examination revealed erosive areas with epithelial detachment in the oral cavity, lip ulceration, conjunctival hyperemia, and fever. The patient reported tetracycline use for 30 days to treat acne. The diagnostic hypotheses were SJS, Behçet's disease, and viral infection. The clinical condition of the patient worsened, despite the tetracycline suspension, with maculopapular lesions in the thorax, dorsum, and upper limbs, and an increase of the previous injuries. Serological tests were negative for hepatitis, HIV, toxoplasmosis, CMV, herpes, and syphilis. An incisional biopsy of the arm lesion and histopathological examination showed vacuolar interface dermatitis with subtotal epidermal necrosis. Treatment included systemic hydrocortisone and prednisone, local hygiene care, and low-level laser therapy of the oral lesions; all the lesions exhibited remission.

Preliminary observation of superficial brachytherapy for the upper arm skin invasion of breast cancer

Objective To investigate the application of superficial brachytherapy in the treatment of the upper arm skin invasion of breast cancer. Methods This study was conducted on a female patient with ipsilateral chest wall, axillary, and clavicle recurrence, and circumferential skin and subcutaneous soft tissue invasion in the ipsilateral upper arm after modified radical mastectomy for breast cancer. The upper arm lesions were treated with 192Ir high-dose-rate superficial brachytherapy at a dose of 50 Gy in 25 fractions. Dosimetric parameters were compared between superficial brachytherapy and electron irradiation plan. Treatment outcomes and adverse reactions were observed during and after treatment. Results The heterogeneity index (HI) for target volume was 1.62 and 1.94 in superficial brachytherapy and electron irradiation plan, respectively. The D90, D100, and V150% for clinical target volume were higher in superficial brachytherapy than in electron irradiation plan (205 vs. 189 cGy; 163 vs. 110 cGy; 6.3% vs. 3.23%). The D0.1, D1, and D2 for the humerus were also higher in superficial brachytherapy than in electron irradiation plan (155 vs. 80 cGy; 147 vs. 55 cGy; 145 vs. 36 cGy) and much lower than the bone tolerance dose in both treatments. The lesions partially subsided after superficial brachytherapy. The main adverse reaction was grade 2 radiation dermatitis. Conclusions Compared with electron irradiation plan, superficial brachytherapy is a simple and effective approach for irradiation of shallow target volume with a large curvature, such as circumferential upper arm skin invasion of breast cancer. Superficial brachytherapy achieves satisfactory homogeneity and dose distribution. Key words: Breast cancer recurrence; Upper arm invasion; Superficial brachytherapy

Lesions in arm after a tour through the countryside

Lesions in arm after a tour through the countryside

Abstract 100: A Simple Bedside Grading Scale Can Effectively Predict Severe Post-stroke Upper-extremity Spasticity

Introduction: Upper-limb spasticity is a very disabling complication after stroke. There has been no simple clinical standard scale to predict spasticity immediately after stroke. This study aims to develop a simple bedside grading scale with the information collected during the acute phase to predict spasticity at 3 month post-stroke Methods: This is a prospective cohort study (Prediction and Imaging Biomarker of Post-stroke Motor Recovery) of patients with first-ever acute ischemic stroke with various degrees of motor impairment. NIH stroke scale (NIHSS) was assessed 2-7 days after onset of stroke symptoms. Modified Ashworth Spasticity Scale was used as an assessment tool in biceps, wrist flexors and finger flexors at 90 days (± 15 days) and score ≥2 at any muscle was considered as severe spasticity. Infarction volume was measured based on the lesion on MRI/DWI. Independent predictors of upper-limb spasticity at 90 days were identified by multivariate logistic regression. A risk stratification scale was developed with weighting independent predictors based on beta coefficient. Results: One hundred twenty three patients were recruited for this study. Covariates associated with upper-limb spasticity are NIHSS arm score (p&lt;0.0001), sub-cortical location (p=0.004) and lesion volume &gt;65 cc (p=0.025). The proposed grading scale is summation of individual points as followed: NIHSS Arm Score: =4 (2 point), &lt;4 (0 point); infarct location: sub-cortical (1 point), non sub-cortical (0 point); infarct volume: ≥65 cc (1 point), &lt;65cc (0 point). The rates of severe upper limb spasticity for the bedside spasticity scale, in order 0-4, are 8.9%, 29.2%, 65%, 88.7%, 96.2%. In other words, the likelihood of developing severe spasticity increases steadily using the score. Conclusion: A simple bedside grading scale can effectively predict severe post-stroke upper-limb spasticity at 90 days. Validation with an independent external dataset is a planned next step.

Is quantitative coronary angiography reliable in assessing the lumen gain after treatment with the everolimus-eluting bioresorbable polylactide scaffold?

The current study aimed to assess the difference in lumen dimension measurements between optical coherence tomography (OCT) and quantitative coronary angiography (QCA) in the polymeric bioresorbable scaffold and metallic stent. In the randomised ABSORB Japan trial, 87 lesions in the Absorb arm and 44 lesions in the XIENCE arm were analysed. Post-procedural OCT-QCA lumen dimensions were assessed in matched proximal/distal non-stented/non-scaffolded reference (n=199), scaffolded (n=145) and stented (n=75) cross-sections at the two device edges using the Bland-Altman method. In the non-stented/non-scaffolded reference segments, QCA systematically underestimated lumen diameter (LD) compared with OCT (accuracy, -0.26 mm; precision, 0.47 mm; 95% limits of agreement as a mean bias±1.96 standard deviation, -1.18-0.66 mm). When compared to OCT, QCA of the Absorb led to a more severe underestimation of the LD (-0.30 mm; 0.39 mm; -1.06-0.46 mm) than with the XIENCE (-0.14 mm; 0.31 mm; -0.75-0.46 mm). QCA underestimated LD by 9.1%, 4.9%, and 9.8% in the reference, stented, and scaffolded segments, respectively. The protrusion distance of struts was larger in the Absorb arm than in the XIENCE arm (135±27 µm vs. 18±26 µm, p<0.001), and may have contributed to the observed differences. In-device QCA measurement was differently affected by the presence of a metallic or polymeric scaffold, a fact that had a significant impact on the QCA assessment of acute gain and post-procedural minimum LD.

Leishmaniose cutanée à Leishmania infantum associée à une infection par le VIH

In Senegal, reported cases of cutaneous leishmaniasis are often due to Leishmania major. Immunosuppression related to HIV infection contributes to the emergence of leishmaniasis in humans and to cutaneous localization of viscerotropic species. We report the first observed case in Senegal of opportunistic cutaneous leishmaniasis due to Leishmania infantum associated with HIV. A 5-year-old boy presented crusted ulcerative lesions of the scalp and left forearm, together with axillary and cervical lymphadenopathy present for two months. Direct parasitological examination of the scalp and arm lesions, coupled with liquid aspiration of lymph nodes and bone marrow, enabled identification of amastigote forms of Leishmania. Polymerase chain reaction performed on skin, lymph node and bone marrow biopsy samples allowed identification of L.infantum. The child was positive for HIV1. Treatment of HIV infection and leishmaniasis resulted in clinical improvement. Co-infection with cutaneous leishmaniasis due to L.infantum and HIV is a complex combination in terms of the related therapeutic issues. The clinical and laboratory outcomes depend on restoration of immunity and on the efficacy, safety and availability of anti-leishmaniasis drugs.

MP21-17 STANDARD PROSTATE BIOPSY VS NEW DIAGNOSTIC PATH WITH MRI AND FUSION BIOPSY: PRELIMINARY RESULTS OF A PROSPECTIVE RANDOMIZED STUDY.

You have accessJournal of UrologyProstate Cancer: Detection & Screening III1 Apr 2016MP21-17 STANDARD PROSTATE BIOPSY VS NEW DIAGNOSTIC PATH WITH MRI AND FUSION BIOPSY: PRELIMINARY RESULTS OF A PROSPECTIVE RANDOMIZED STUDY. Francesco Porpiglia, Fabrizio Mele, Matteo Manfredi, Riccardo Bertolo, Daniele Amparore, Enrico Checcucci, Roberta Aimar, Marco Cossu, Enrico Bollito, Filippo Russo, Dario Gned, Agostino De Pascale, Stefano Cirillo, and Cristian Fiori Francesco PorpigliaFrancesco Porpiglia More articles by this author , Fabrizio MeleFabrizio Mele More articles by this author , Matteo ManfrediMatteo Manfredi More articles by this author , Riccardo BertoloRiccardo Bertolo More articles by this author , Daniele AmparoreDaniele Amparore More articles by this author , Enrico CheccucciEnrico Checcucci More articles by this author , Roberta AimarRoberta Aimar More articles by this author , Marco CossuMarco Cossu More articles by this author , Enrico BollitoEnrico Bollito More articles by this author , Filippo RussoFilippo Russo More articles by this author , Dario GnedDario Gned More articles by this author , Agostino De PascaleAgostino De Pascale More articles by this author , Stefano CirilloStefano Cirillo More articles by this author , and Cristian FioriCristian Fiori More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.651AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Nowadays, in the suspicion of prostate cancer (PCa), the patient undergoes a prostate biopsy with multiple samples using a standardized template (standard biopsy - SB). Many of these samples are unnecessary and reveal “indolent” tumors. With the introduction of multiparametric prostate MRI can be performed targeted biopsies with a software capable of co-record MRI and TRUS (fusion biopsy - FB), with the aim of reducing the number of biopsy samples and increasing performance. The primary objective of this randomized, prospective, two-arm, study was to evaluate the efficacy of a new diagnostic path based on MRI and on FB, comparing to diagnostic standard. METHODS After approval of the local Ethics Committee, all naïve patients suspected for prostate cancer (PSA <15 ng/ml and negative DRE) were randomized into 2 groups using a computer-generated random allocation in a 1:1 ratio: Arm A (undergoing MRI) and arm B (not undergo MRI). The MRI study consisted of T2-weighted, diffusion-weighted and dynamic contrast-enhanced imaging, all lesions were classified according to PIRADS system. The patients were then biopsied as follows: - Arm A with positive mp-MRI (PIRADS score> 3): MRI/TRUS fusion software-based targeted biopsy using the Biojet® system (D&K Technologies), carrying out at least 3 samples for suspected lesion; - Arm A with negative mp-MRI or lesion of low suspicion (PIRADS score <3) and arm B: transrectal TRUS-guided SB with 12 samples. PCa were considered clinically significant (CS) according to START consortium definition (for FB) and Epstein criteria (for SB). RESULTS During the period 11/2014 – 09/2015 were enrolled 122 patients. Median age was 64 (49-75) years, mean PSA was 6.9 (+ 3.6) ng/ml. The demographic characteristics of patients in both arms and in the subgroups in arm A were comparable. Table 1 shows the preliminary results. CONCLUSIONS In our study, the detection rate of FB was significantly higher than SB with a significantly lower mean number of samples. These results are even more significant considering CS PCa. In patients in arm A submitted to SB, the probability of finding a PCa was minimal and none CS PCa was revealed. Although it is necessary to extend the series, this new diagnostic path based on MRI and FB technique seems to be safer and more effective than the standard. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e251 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Francesco Porpiglia More articles by this author Fabrizio Mele More articles by this author Matteo Manfredi More articles by this author Riccardo Bertolo More articles by this author Daniele Amparore More articles by this author Enrico Checcucci More articles by this author Roberta Aimar More articles by this author Marco Cossu More articles by this author Enrico Bollito More articles by this author Filippo Russo More articles by this author Dario Gned More articles by this author Agostino De Pascale More articles by this author Stefano Cirillo More articles by this author Cristian Fiori More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

SIRFLOX: Differences in site of first progression between mFOLFOX6 ± bevacizumab (bev) versus mFOLFOX6 ± bev + selective internal radiation therapy (SIRT) in first-line patients (pts) with metastatic colorectal cancer (mCRC).

637 Background: SIRFLOX, an international multi-centre open-label RCT in first-line pts with non-resectable, liver-only or liver-dominant mCRC, showed that compared to FOLFOX (± bev) chemotherapy alone [arm A] FOLFOX (± bev) plus SIRT using Y-90 resin microspheres [arm B] did not improve overall PFS (median 10.2 v 10.7 months arm A v B, HR: 0.93; 95% CI 0.77–1.12; p = 0.429). However, liver PFS by competing risk analysis was improved with the addition of SIRT (median 12.6 v 20.5 months in arm A v B, HR: 0.69; 95% CI 0.55–0.90; p = 0.002). The current analysis examines patterns of disease progression and potential impact on the primary study endpoint. Methods: Site and pattern (intra/extra-hepatic) of first progression, and whether progression was due to growth of existing lesions or the appearance of new lesions, was judged by an independent reader blinded to study arm. Results: From Oct 2006 to Apr 2013, 530 pts were randomised (arm A, n = 263; arm B, n = 267); 212 (40%) had extra-hepatic metastases at study entry; 292 (55%) were stratified to receive bev. As of 31 Jan 2015, the total number of patients with disease progression in arm A v B were 178 and 166, respectively. The site of first progression was more frequently in the liver (± other sites) in arm A v B (92.1% v 72.3%; p &lt; 0.001). Conversely, site of first progression was less frequent in the lung (± other sites) in arm A v B (19.1% v 42.8%; p &lt; 0.001). A higher proportion of first progression occurred in the liver alone in arm A v B (77.0% v 52.4%; p &lt; 0.001). Conversely, a lower proportion of first progression occurred only in non-liver sites, primarily lung, in arm A v B (7.9% v 47.7%; p &lt; 0.001). Of patients with first progression in the liver, a higher proportion occurred in existing liver lesions (± extrahepatic sites) in arm A v B (72.5% v48.2%; p &lt; 0.001). Conclusions: The addition of SIRT to FOLFOX chemotherapy alone (± bev) reduced the frequency at which first disease progression occurred in the liver. Where first progression did occur in the liver, the addition of SIRT led to this more frequently being due to the appearance of lesions not evident on baseline imaging. Clinical trial information: NCT00724503.

Noninvasive Computed Tomography-based Risk Stratification of Lung Adenocarcinomas in the National Lung Screening Trial.

Screening for lung cancer using low-dose computed tomography (CT) reduces lung cancer mortality. However, in addition to a high rate of benign nodules, lung cancer screening detects a large number of indolent cancers that generally belong to the adenocarcinoma spectrum. Individualized management of screen-detected adenocarcinomas would be facilitated by noninvasive risk stratification. To validate that Computer-Aided Nodule Assessment and Risk Yield (CANARY), a novel image analysis software, successfully risk stratifies screen-detected lung adenocarcinomas based on clinical disease outcomes. We identified retrospective 294 eligible patients diagnosed with lung adenocarcinoma spectrum lesions in the low-dose CT arm of the National Lung Screening Trial. The last low-dose CT scan before the diagnosis of lung adenocarcinoma was analyzed using CANARY blinded to clinical data. Based on their parametric CANARY signatures, all the lung adenocarcinoma nodules were risk stratified into three groups. CANARY risk groups were compared using survival analysis for progression-free survival. A total of 294 patients were included in the analysis. Kaplan-Meier analysis of all the 294 adenocarcinoma nodules stratified into the Good, Intermediate, and Poor CANARY risk groups yielded distinct progression-free survival curves (P < 0.0001). This observation was confirmed in the unadjusted and adjusted (age, sex, race, and smoking status) progression-free survival analysis of all stage I cases. CANARY allows the noninvasive risk stratification of lung adenocarcinomas into three groups with distinct post-treatment progression-free survival. Our results suggest that CANARY could ultimately facilitate individualized management of incidentally or screen-detected lung adenocarcinomas.

Histopathological and imaging features for soft tissue liposarcoma of extremities

To analyze the histopathological and imaging features for soft tissue liposarcoma of extremities and to provide guide for clinical diagnosis. Nine patients with soft tissue liposarcoma of extremities received treatment in Qinghai University Affiliated Hospital from October 2012 to October 2014. The imaging features of CT and MRI as well as the histopathological features were retrospectively analyzed. The pattern, size and border of tumor were observed, and the correlation between the pathological features and the imaging features was analyzed. Lower limb lesion was found in 8 patients, including the left lower leg, left and right thigh, respectively. One patient had right upper arm lesion, 1 case had bleeding, and 1 case displayed with calcification and liquefaction performance. The CT examination showed low density shadow and linear separated shadow. The ultrasound examination displayed different intensity fat-like echo. There was short signal intensity on T1 weighted imaging and long signal intensity on T2 weighted imaging in MRI. MRI and other imaging examinations show good performance in detecting the features of soft tissue liposarcoma of extremities, which possess diagnostic value.

Endovascular Stent Placement for Hemodialysis Arteriovenous Access Stenosis.

This study aims to report the outcomes of nitinol and polytetrafluoroethylene covered stent placement to treat hemodialysis arteriovenous access stenosis at a single center over a five-year period. Clinical and radiological information was reviewed retrospectively. Poststent primary and secondary patency rates were determined using Kaplan-Meier analysis. Ten clinical variables were subjected to multivariate Cox regression analysis to determine predictors of patency after stent placement. During the study period 60 stents were deployed in 45 patients, with a mean follow-up of 24.5 months. The clinical and anatomical success rate was 98.3% (59/60). Poststent primary patency rates at 6, 12, and 24 months were 64%, 46%, and 35%, respectively. Poststent secondary patency rates at 6, 12, and 24 months were 95%, 89%, and 85%, respectively. Stent placement for upper arm lesions and in access less than 12 months of age was associated with reduced primary patency (adjusted hazards ratio [HR] 5.1, p = 0.0084, and HR 3.5, p = 0.0029, resp.). Resistant or recurrent stenosis can be successfully treated by endovascular stent placement with durable long-term patency, although multiple procedures are often required. Stent placement for upper arm lesions and in arteriovenous access less than 12 months of age was associated with increased risk of patency loss.

Kyrle’s Disease: A Rare Skin Manifestation of Systemic Diseases

A 39-year-old man of diabetic nephropathy presented with pruritic papulo-nodular brown lesions in both arms and legs on extensor surface characterized by central keratin plugs. Lesions were non-tender and numerous, crusted lesions which histologically were perforating disorders, showing features of Kyrle disease. The blood sugar of the patient was kept under control &amp; hemodialysis was started. Dermatological lesions were treated by Isotretinoin, vitamin A, Tretinoin cream and oral antihistamines.DOI: http://dx.doi.org/10.3329/jom.v15i2.20689 J MEDICINE 2014; 15 : 144-145

Pigmented Villonodular Synovitis Masquerading as Metastasis on PET Imaging

Pigmented villonodular synovitis (PVNS) is a metaplastic process that can occur in the synovium, bursae or tendon sheaths and can be localized or diffuse. Its features on radiographs and computed tomography are nonspecific, but magnetic resonance imaging is diagnostic. Its appearance on fluorodeoxyglucose (FDG) positron emission tomography (PET) is not well described. We present a case of recurrent squamous cell carcinoma of the floor of the mouth with an FDG-avid lesion of the left upper arm on a whole-body PET scan that was shown to be PVNS on subsequent biopsy. To our knowledge, this is one of the very few cases reported in the literature describing FDG avidity of PVNS. We explore the features of PVNS on various imaging modalities and its potential for being mistaken for malignancy. J Med Cases. 2014;5(4):253-255 doi: http://dx.doi.org/10.14740/jmc1691w

A Randomized, Controlled Animal Trial Demonstrating the Feasibility and Safety of the Magellan™ Endovascular Robotic System

The success of remotely steerable catheters designed for cardiac ablation procedures in the peripheral vasculature (in the laboratory and in highly select live cases) has led to the development of a vascular robotic system designed specifically for use in the arterial and venous systems. Limited bench-top and animal testing has been successful, but no randomized, controlled study of the system's safety has been performed. In a 3-phase study, we performed a randomized, controlled trial comparing standard manual catheterization and balloon angioplasty of visceral, renal, and contralateral lower extremity vessels in a porcine model. We also demonstrated feasibility of standard device deployment through the system. There was 100% technical success in test (robotic) and control (manual) arm cannulation and balloon angioplasty of all target vessels, without complications. Pathologic analysis at 7 days revealed significantly fewer traumatic lesions in the test animal arm as compared with the control arm (P < 0.001) and, by 30 days, all lesions had healed in both groups. There was 100% success in delivery of standard devices (balloons and stents) without complications. Remotely steerable robotic catheters are at least as safe as manual catheter techniques, and may prove less traumatic to peripheral vessels. Standard devices can be deployed through the system, and the stability of the platform may aid in ease of device delivery in difficult vascular segments.

Kyrle’s Disease: A Case Report

A case of Kyrle's disease in a known patient of Type 2 DM and CKD presented with left ventricular failure is reported. He had papulo-nodular brown lesions in both arms and legs on extensor surface characterized by central keratin plugs. Lesions were non-tender and numerous. Intense pruritus was present. He recovered with anti-failure regime and hemodialysis. Dermatological lesions were treated by Isotretinoin, vitamin A, Tretinoin cream and oral antihistamines. I. Case-report A 39 years old Hindu male was admitted with shortness of breath and cough for 2 days. On examination, B.P was 180/110 mm Hg. and bilateral coarse crackles, raised JVP and S3 were present. He was a known diabetic for the past 10 years , developed nephropathy for last 2 years and was undergoing maintenance hemodialysis for last 5 months. On general examination, he was found to have multiple brown papulo-nodular lesions with central keratin plug and silvery scales distributed over the anterior aspect of both thighs and legs (Fig-1) . There were also numerous papules of varying size on the extensor aspect of both elbows (Fig-2) . The lesions were non-tender and associated with severe pruritus. With treatment, he was relieved of LVF. Subsequently dialysis was done for CKD. Necessary investigations (FBS, PPBS, Blood urea, serum creatinine, serum sodium and potassium, USG abdomen) were done for type-2 D.M. and CKD .The dermatological lesions were diagnosed to be Kyrle's disease.

Pigmented Villonodular Synovitis Masquerading as Metastasis on PET Imaging

Pigmented villonodular synovitis (PVNS) is a metaplastic process that can occur in the synovium, bursae or tendon sheaths and can be localized or diffuse. Its features on radiographs and computed tomography are nonspecific, but magnetic resonance imaging is diagnostic. Its appearance on fluorodeoxyglucose (FDG) positron emission tomography (PET) is not well described. We present a case of recurrent squamous cell carcinoma of the floor of the mouth with an FDG-avid lesion of the left upper arm on a whole-body PET scan that was shown to be PVNS on subsequent biopsy. To our knowledge, this is one of the very few cases reported in the literature describing FDG avidity of PVNS. We explore the features of PVNS on various imaging modalities and its potential for being mistaken for malignancy. J Med Cases. 2014;5(4):253-255 doi: http://dx.doi.org/10.14740/jmc1691w

Schimmelpenning syndrome

Schimmelpenning syndrome (SS) includes an organoid nevus that follows the lines of Blaschko and defects of brain, eyes, bones, or other systems. We report a case of a 3-month old female infant, who presented with several thin plaques, with irregular borders, yellowish color, which had a verrucous appearance, following the lines of Blaschko, mainly occupying the left side of posterior trunk, the left face, the right side of the anterior trunk, and the right upper limb. These plaques had been present since birth. In addition, she had a flat salmon to yellow nevus on the left parietal and temporal region of the scalp, with a bald patch. She was diagnosed after birth with an interauricular communication. The skin biopsy from the lesion of the right arm revealed an epidermal nevus that occupied the epidermis completely. Routine and other complementary laboratory blood tests, including platelet count, thyroid function tests, 25-hydroxy-vitamin D, parathyroid hormone, and plasma and urinary levels of calcium and phosphorus were negative. Cerebral magnetic resonance and renal ultrasound were normal. The diagnosis of SS was established. She is being followed in the clinics of Dermatology, Cardiology, Pediatrics, and Pediatric Neurology. We report this case to point out the importance of investigating patients with epidermal nevus to identify associated conditions.

Photo Quiz: Skin Rash and Extremity Swelling in an Adolescent

A previously well 15-year-old male presented to our institution with a 3-week history of sacral edema that began in his feet then spread to his hands, face, shins, and forearms. The edema was described as taut and shiny, and it was followed by rash of the extremities and trunk. Swelling of the hands made it difficult for the patient to make a fist. He complained of decreased appetite, a 10-lb weight loss, and some mild fatigue, but he denied having fevers, chills, and night sweats. He denied having any ill contacts, and all of his family members were well. The patient had immigrated to the United States from Haiti 3 years earlier. He had received one Mycobacterium bovis BCG vaccine. Physical examination revealed a well-grown, afebrile patient with normal vital signs who was essentially unremarkable except for diffuse, nonpitting edema of the face, hands, feet, and forearms that was not tender to palpation, with erythematous, raised plaques covering his chest, abdomen, back, and extremities. He had a normal joint and neurological exam. A complete blood count (CBC) and metabolic panel were unremarkable. He had a normal albumin level and normal urinalysis and thyroid function test results. His total serum protein was slightly elevated, and his erythrocyte sedimentation rate (ESR) was elevated, at 51 mm/h. A chest X ray was normal. A skin biopsy of a right arm lesion was performed and established the correct diagnosis (Fig. 1). Fig 1 Histopathological appearance of the skin lesion biopsy specimen stained with hematoxylin-phloxine B-saffron.(a) Low-power panoramic view. (b) Higher magnification. (c) Small nerves (arrow). (d) Modified Ziehl-Neelsen (Wade-Fite) stain. (For answer and discussion, see page 213 in this issue [doi:10.1128/JCM.05729-11])

Cutaneous Leishmaniasis With Pseudoepitheliomatous Hyperplasia Simulating Squamous Cell Carcinoma

To the Editors: In Rio de Janeiro state, Brazil, American tegumentary leishmaniasis is caused by Leishmania (Viannia) braziliensis. The main clinical presentation is a single skin ulcer located in areas exposed to vector bites. Diagnosis is established by isolation of Leishmania in culture or by amastigote detection in smears or histological sections, but parasitological demonstration is not always attained.1 Histopathological findings include granulomatous dermatitis and occasionally pseudoepitheliomatous squamous hyperplasia (PESH).2 PESH is considered a response to chronic epithelial irritation of various etiologies and can simulate squamous cell carcinoma (SCC).3,4 Cutaneous neoplasms are also frequently located on exposed areas of the body and are important in leishmaniasis differential diagnosis.5 A 59-year-old man from an endemic leishmaniasis rural area in Rio de Janeiro presented with swelling and redness of the left ear and a nodule on the right forearm, both evolving into ulceration in 3 months. Physical examination disclosed ulcers with raised firm edges on the right forearm (Fig. 1A) and lower pendular portion of the left ear lobe (Fig. 1B), a palpable lymph node beneath the angle of the jaw, and no lesions on mucosae of the upper aerodigestive tract.FIGURE 1: Ulcers with firm raised edges on the right forearm (A) and earlobe (B). Squamous epithelial cell proliferation with infiltrating aspect (C) with cords, small nests (D), horny pearls (E), and rare amastigote forms (inset).Leishmanin skin test was positive, with 21 mm of induration. Indirect immunofluorescence and enzyme-linked immunosorbent assay for leishmaniasis were negative on admission. Biopsy tissue sample submitted to histological examination measured 9 × 4 mm and was 3 mm thick. On microscopy, there was a squamous epithelial downgrowing proliferation with irregular contours and infiltrating aspect (Fig. 1C), arranged in cords and small nests (Fig. 1D) or occasionally, in concentric disposition, forming horny pearls (Fig. 1E). Some cords and nests were situated deep in the dermis. Cytological atypia or atypical mitoses were absent. There was mild mixed inflammatory infiltrate (Fig. 1C) and no granulomas. Two pathologists examined the slides and reported “atypical squamous proliferation consistent with well-differentiated SCC,” with observations that the lesion was partially resected, the sample was superficial, and a hyperplastic process could not be ruled out. Parasitological culture in Novy-Nicolle-McNeal medium and subsequent isoenzyme analysis identified L. (V.) braziliensis. Histological slide review revealed rare structures consistent with Leishmania sp. amastigotes (Fig 1E, insert). Treatment was started with meglumine antimoniate for 30 days. Three months after the end of therapy, lesions were reepithelialized. Histopathology of a new biopsy sample of the arm lesion showed fibrosis and very focal small granulomas. No epithelial proliferation or amastigotes were seen, and the lesion was considered consistent with a healing process. Patient was lost to follow-up. PESH is a microscopic pattern of tissue reaction characterized by uneven growth of squamous cells toward underlying connective tissue. It can be distinguished from SCC by the coexistence of an exuberant inflammatory infiltrate and the lack of histological and cytological signs of malignancy.6 Grunwald et al3 stated that horny pearls are more frequent in SCC but can be seen in PESH. Close clinicopathological correlation beside good communication between attending physicians and pathologists can avoid mistaken diagnoses and unnecessary therapeutic procedures.7,8 Our case also emphasizes the importance of generous sampling and multidisciplinary approach in the differential diagnosis of cutaneous ulcers. A diagnosis of SCC may also be missed if histopathological examination is not included in this investigation.9 Concomitance of American tegumentary leishmaniasis and cutaneous neoplasms is theoretically possible and was recently reported,10 but the patient's evolution and findings on second biopsy make this possibility extremely unlikely. Leonardo Pereira Quintella, MD Tullia Cuzzi, PhD Maria de Fátima Madeira, PhD Cláudia Maria Valete-Rosalino, PhD Mariza de Matos Salgueiro, MD Érica de Camargo Ferreira e Vasconcellos, MD Eliame Mouta-Confort, PhD Sonia Regina Lambert Passos, PhD Armando de Oliveira Schubach, PhD Instituto de Pesquisa Clínica Evandro Chagas (IPEC), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brasil