Arm Lesions Research Articles

Metastatic bladder transitional cell carcinoma presenting as a vascularised cutaneous right arm lesion

A 65-year-old man presented to the emergency department with a 3-week history of a fast-growing and painful mass in his right antecubital fossa. He felt otherwise well. Four months earlier, he had undergone a radical cystectomy for transitional-cell carcinoma (TCC) of the bladder (grade 3, stage pT1). Two months after the cystectomy, at another hospital, he was diagnosed with, and treated for, a pseudoaneurysm in his right antecubital fossa. Duplex ultrasonography of the presenting lesion revealed a highly vascularised mass with no pseudoaneurysm. Histological and immunohistochemical analysis preceded a diagnosis of cutaneous metastatic TCC. Whole-body CT revealed widespread metastases. This is the first reported case of a highly vascularised cutaneous lesion being the presenting feature of metastatic bladder TCC.

Treatment of mild-to-moderate acne vulgaris using a combined light and heat energy device: Home-use clinical study

Introduction: Light and heat devices have become widely used for the treatment of mild-to-moderate inflammatory acne as an alternative to retinoids and antibiotics. The purpose of this study was to examine whether a hand-held device that emits both light and heat energy can safely and effectively be applied at home to shorten the time to improvement and time to resolution of acne papules and pustules. Methods: A two-center, randomized, placebo-controlled, double-blind study was conducted on 63 subjects with at least four inflamed, facial, acne lesions. Treatments were self-administered twice a day for 4 days. All lesions were photographed on a daily basis. Treatment results were assessed by two blinded evaluators, based on the macro photographs, using a 4-point visual analogue scale (VAS) and a photographic lesion reference scale (PLRS), as well as by the subjects. Safety was assessed based on evaluators and subjects’ reported side effects and adverse events. Results: Twenty-nine subjects in the treatment arm and 32 subjects in the placebo arm, with skin types II–VI, successfully completed the study. Based on blinded VAS scores, 92.24% of the lesions treated with an active device improved within a median time of 1 day versus 75.78% and a median time of 2 days for the placebo arm. At 24 hours the improvement rate was 76.72% for the active arm versus 15.63% for the placebo arm. Based on blinded PLRS scores, 87.07% of the lesions treated with an active device improved within a median time of 2 days versus 64.8% and 3 days for the placebo. A total of 51.7% of the active arm lesions resolved within a median time of 4 days versus 36% (no median) for the placebo arm lesions. No device-related adverse events occurred throughout the study. Conclusion: This study demonstrates the safety and effectiveness of the hand-held, combined light and heat energy device for at-home treatment of individual mild-to-moderate inflammatory acne lesions. Statistically significant shorter lesion improvement and lesion resolution rates were found.

Colagenosis perforante reactiva adquirida: Caso clínico

Acquired reactive perforating collagenosis is a perforating dermatosis characterized by transepidermal elimination of collagen. It is frequently associated to diabetes mellitus and chronic renal insufficiency, but it is also related to other systemic diseases. The lesions tend to resolve once the underlying condition is treated. We report two patients with the condition. A 65 year-old diabetic female on hemodialysis consulted for multiple itching cutaneous ulcers lasting one year. On physical examination, hyperpigmented papules and nodules were observed. A 65 year-old female with chronic renal failure in hemodialysis consulted for itching lesions in hands, forearms and arms. On physical examination, hyperpigmented lesions with ulcers, erosions and crusts were observed. In both cases, the pathological study of the lesions disclosed a reactive perforating collagenosis.

P17.06: Screening for trisomies and fetal anomalies in the second trimester after first trimester genetic scan. What are the benefits?

To investigate the performance of the first trimester screening for trisomies and also for fetal morphologic anomalies, and the performance of subsequent scanning in the second trimester. We performed a prospective study in singleton pregnancies, between 11 weeks 0 days and 13 weeks 5 days. The first trimester the genetic scan (247 cases) included measurement of NT, IT, the NB presence, the FMF angle, the tricuspid and DV Doppler, after FMF recommendations. All additional parameters were included in the combined test. At 16–19 weeks, the genetic sonogram included cardiac morphology. Complete evaluation was obtained at 165 (66.8%) cases. Just one major morphologic anomaly was discovered in the second scan. There were 2 cases of ventricular septal defects, a case of hipoplastic left heart syndrome and 1 case of unilateral arm lesion. In the first trimester, 16 (6.47%) pregnancies were included in the high risk group or in the intermediate risk (from 1 in 51 to 1 in 1000). Of all these cases, only 8 maintained soft markers for chromosomal anomalies in the second trimester. These patients were offered amniocentesis with QFPCR. In 6 cases trisomy 21 was confirmed. There was also a case of partial trisomy 13. It is likely that both trimester assessment could improve the detection rate for chromosomal anomalies, but it is cost effective low and time consuming. It must be established the importance of each additional markers in modifying the risk calculation, both in the first, and in the second trimester. Supporting information can be found in the online version of this abstract. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Weekly paclitaxel improved pathologic response of primary chemotherapy compared with standard 3 weeks schedule in primary breast cancer

The purpose of this study is to compare the efficacy of weekly paclitaxel to every-3-week schedule in terms of pathologic response and toxicity which caused treatment delay in primary chemotherapy of breast cancer. After pretreatment of two cycles of cyclophosphamide/ pirarubicin/ fluorouracil (cyclophosphamide 500 mg/m(2) days 1, 8; pirarubicin 35 mg/m(2) days 1, 8; 5-Fu 200 mg/m(2) day ci day 1-28, every 4 weeks), 219 women with histologically confirmed T(1-3) N(0-2) M(0) invasive breast cancer, whose vertical diameters production of breast tumor reduced not more than 75%, were randomized to receive four cycles of Pq3wC (arm A: paclitaxel 175 mg/m(2) day 1, carboplatin AUC 6 d1, every 3 weeks) or Pq1wC (arm B: paclitaxel 60 mg/m(2) days 1, 8, 15, carboplatin AUC 6 day 1 for every 3 weeks) before surgery, stratified by partial or no response (stable disease and progression of disease) evaluated by ultrasonography. Pathologic response of the primary tumor was assessed by using Miller and Payne grading system. We defined grade 4/5 as excellent response, grade 3/4/5 as response and treatment delay as paclitaxel administration being delayed at least 1 week because of toxicity in this study. 213 patients (2 cases with concurrent bilateral breast cancer) were eligible for analysis, 109 patients with 110 lesions in arm A and 104 patients with 105 lesions in arm B. Patients in arm B had a higher excellent pathologic response rate and a higher pathologic response rate compared with patients in arm A (59.0 vs. 45.5%, P = 0.046 and 86.7 vs. 71.8%, P = 0.007). Pathologic complete response (pCR) rate in breast alone was similar between two arms (P = 0.733), but there was a higher pCR rate in patients with partial response to two cycles of cyclophosphamide/pirarubicin/fluorouracil than those with no response (32.4 vs. 13.9%, P = 0.001). There was no treatment-related death, however more patients in arm B than in arm A experienced treatment delay caused by toxicity (60.6 vs. 11.9%, P < 0.001). Under the condition of same cumulative doses, weekly paclitaxel was more effective than 3 weeks schedule in terms of pathologic response to primary chemotherapy in breast cancer, and caused more treatment delay related to toxicity though well tolerant.

Angiographic Versus Functional Severity of Coronary Artery Stenoses in the FAME Study: Fractional Flow Reserve Versus Angiography in Multivessel Evaluation

The purpose of this study was to investigate the relationship between angiographic and functional severity of coronary artery stenoses in the FAME (Fractional Flow Reserve Versus Angiography in Multivessel Evaluation) study. It can be difficult to determine on the coronary angiogram which lesions cause ischemia. Revascularization of coronary stenoses that induce ischemia improves a patient's functional status and outcome. For stenoses that do not induce ischemia, however, the benefit of revascularization is less clear. In the FAME study, routine measurement of the fractional flow reserve (FFR) was compared with angiography for guiding percutaneous coronary intervention in patients with multivessel coronary artery disease. The use of the FFR in addition to angiography significantly reduced the rate of all major adverse cardiac events at 1 year. Of the 1,414 lesions (509 patients) in the FFR-guided arm of the FAME study, 1,329 were successfully assessed by the FFR and are included in this analysis. Before FFR measurement, these lesions were categorized into 50% to 70% (47% of all lesions), 71% to 90% (39% of all lesions), and 91% to 99% (15% of all lesions) diameter stenosis by visual assessment. In the category 50% to 70% stenosis, 35% were functionally significant (FFR <or=0.80) and 65% were not (FFR >0.80). In the category 71% to 90% stenosis, 80% were functionally significant and 20% were not. In the category of subtotal stenoses, 96% were functionally significant. Of all 509 patients with angiographically defined multivessel disease, only 235 (46%) had functional multivessel disease (>or=2 coronary arteries with an FFR <or=0.80). Angiography is inaccurate in assessing the functional significance of a coronary stenosis when compared with the FFR, not only in the 50% to 70% category but also in the 70% to 90% angiographic severity category.

Necrotic arm lesions in an intravenous drug user

A 62-year-old woman with a history of long-term intravenous drug use and chronic Hepatitis C virus infection was admitted to another hospital unresponsive with profound hypotension. Her symptoms were attributed to a drug overdose leading to a depressed mental status, and possibly septic shock with aspiration pneumonia. She was placed on mechanical ventilation, and treated with vasopressors, high-dose corticosteroids and several broad-spectrum antibiotics. Blood and urine cultures were negative. When she failed to improve after 1 week she was transferred to the intensive care unit at our institution. On transfer, she was unresponsive, intubated, on mechanical ventilation, and hypotensive on vasopressors. We also noted that she had multiple ulcerated skin lesions on both upper extremities (Fig. 1). The lesions involved the dorsum of both hands and wrists, medial aspects of both arms, and the left antecubital fossa. The edges of the lesions were necrotic and the base was macerated. The WBC count was 22,500 mm with 85% neutrophils and 7% band forms. The creatinine was 3 mg/dL. An acute renal failure was attributed to acute tubular necrosis. HIV testing was negative. The CT scans of the chest, abdomen, pelvis, and MRI of the head were unrevealing, and a lumbar puncture was unremarkable. A skin biopsy of the leading edge of the ulcer was performed.

Esporotricosis linfangítica bilateral y simultánea

Sporotrichosis is the most frequent subcutaneous mycoses in Jalisco, Mexico. The forms of transmission described in the literature are from bites of different animals and injuries due to utensils. To present an unusual case with bilateral and lymphangitic cutaneous lesions in the upper limbs caused by a pocket gopher bite (Geomys bursarius). Mycology studies were performed on the arm lesions, including Gram and Ziehl Neelsen stains, direct exam, Sabouraud and mycobiotic cultures at temperatures of 25-28 degrees C. Gram and Ziehl Neelsen stains were negative. Sporothrix schenckii grew in the culture plates. Treatment with saturated potassium iodide solution was prescribed and four months later complete remissions of the lesions were achieved, and the control cultures were negative. The most common clinical presentations of sporotrichosis are the fixed and lymphangitic forms. Bilateral lymphangitic sporotrichosis is rare.

Valacyclovir and topical clobetasol gel for the episodic treatment of herpes labialis: a patient‐initiated, double‐blind, placebo‐controlled pilot trial

Treatment of herpes simplex labialis (HSL) has been associated with modest benefits. This difficulty results from the rapid resolution of the disease accomplished by the immune system, which narrows the window of therapeutic opportunity. The immune response is also responsible for important clinical manifestations, including oedema and pain. The dual role of immune responses (protection, pathology) is well recognized in other infectious diseases. The addition of corticosteroids to antimicrobial agents has been associated with improvement in some of these diseases. We evaluated the combination of oral valacyclovir plus topical clobetasol compared to placebo for recurrent HSL. Eighty-one subjects were screened, randomized, and dispensed medication (valacyclovir 2 g orally twice daily phiomicronrho 1 day and clobetasol gel 0.05% twice daily for 3 days). Forty-two patients developed a recurrence and initiated treatment. There were more aborted lesions in the valacyclovir-clobetasol arm compared to placebo-placebo (50% vs.15.8%, P = 0.04). Combination therapy reduced the mean maximum lesion size (9.7 vs. 54 mm(2), P = 0.002) and the mean healing time of classical lesions (5.8 vs. 9.3 days, P = 0.002). We created a composite statistic, area-under-the-curve (AUC) of classical lesion size versus time. There was a reduction in the AUC in the combination arm compared with placebo (23 vs. 193 mm(2), P < 0.001). Adverse events were minimal. Secondary and post-treatment recurrences were not increased by combination therapy. This pilot study supports the addition of topical corticosteroids to an oral antiviral agent for the treatment of HSL. Larger studies need to confirm the safety and efficacy of this approach.

Results of Radiation Therapy for Treatment of Classic Kaposi Sarcoma

Classic Kaposi sarcoma (CKS) is a vascular neoplasm that primarily affects men of Mediterranean and Ashkenazi Jewish descent. A variety of therapeutic options exist, and choice of treatment depends on clinical form and stage, as well as lesion location and size; options include surgical excision, intralesional interferon alpha-2b, local or extended field radiotherapy, and chemotherapy. The aim of this study was to review the outcome of radiation therapy in the treatment of CKS at a single institution. This retrospective study reviewed patients who receive radiation therapy for histologically confirmed CKS between 1994 and 2006. Sixteen patients were reviewed; the mean age at diagnosis was 74 years, and 13 patients were male. Fifteen patients (94%) presented with leg lesions, and two patients (12.5%) presented with arm lesions. The most commonly prescribed radiation dose was 30 Gy in 15 daily fractions of 2 Gy. All lesions responded to treatment, with a complete response rate of 88% and a partial response rate of 12%. Toxicity was limited to grade I dermatitis (four patients) and grade II dermatitis (two patients). Radiation therapy is an effective treatment modality for CKS and is associated with minimal toxicity.

Unusual Presentation of Multiple Epithelioid Cell Histiocytomas

Epithelioid cell histiocytoma (ECH) is a variant of dermatofibroma that presents typically as a solitary nodule. We report a case of a 20-year-old male who presented with a bleeding nodular lesion on the left arm followed a month later by a nodule on the right nostril. Both lesions had epithelioid cells in the dermis, with focal Factor 13a and CD68 immunoreactivity. The left arm lesion, in addition, showed staghorn vasculature as well. Both lesions were interpreted as ECH. The patient had an unremarkable medical history. To the best of our knowledge, multiple ECHs have not been reported in the literature. An appropriate diagnosis of ECH is important as the differential diagnosis usually includes melanocytic lesions.

Effect of intravenous methylprednisolone on the number, size and confluence of plaques in relapsing–remitting multiple sclerosis

The aim of the present study was to evaluate whether intravenous methylprednisolone (IVMP) pulses affect the confluence and enlargement of T2 lesions in the long term in patients with relapsing-remitting (RR) multiple sclerosis (MS). Of 88 RR MS patients, randomly assigned to regular pulses of IVMP (1 g/day for 5 days with an oral prednisone taper) or IVMP on the same dose schedule only for relapses, and followed up without other disease-modifying drug therapy for 5 years, 81 patients completed the trial as planned. Pulsed IVMP was given every 4 months for 3 years, and then every 6 months for the subsequent 2 years. Calculations were performed for number, size and lesion volume (LV) of T2- and confluent T2-lesions. At study entry, the number, size and LV of T2- and confluent T2-lesions were well matched in the two study arms. At the end of the study, patients who received IVMP pulses every 4-6 months for 5 years had significantly fewer confluent T2 lesions (105 vs. 270, p<0.0001), lower confluent T2-LV (5.4 ml vs. 17.4 ml, p<0.00001), fewer large T2 lesions (>10 mm) (165 vs. 541, p<0.00001), and lower T2-LV/N degrees T2 lesion index (0.52 vs. 1.1, p=0.007) when compared to patients who received IVMP only for relapses. There were more small T2 lesions (1082 vs. 288, p<0.000001) in the IVMP pulsed arm. Patients who received higher total doses of IVMP showed the smallest changes in confluent T2-LV during the study. This study suggests that treatment with pulses of IVMP may prevent the confluence of T2 lesions, which may in turn contribute to slower progression of disability in the long term. However, pulsed IVMP treatment did not significantly slow down accumulation of overall T2-LV and there were more smaller T2 lesions in the IVMP pulsed arm at the end of the study.

CT, MRI and clinical manifestations of Kasabach-Merritt syndrome in children

Objective To improve the awareness of the CT and/or MRI appearances and clinical presentations of Kasabach-Merritt syndrome(KMS),6 cases were reported.Methods The CT and/or MRI and clinical characters of 6 cases of KMS were reviewed and analyzed.Results Thrombocytopenia,and consumption coagulopathy were presented in all 6 cases.The paravertebral mass of posterior mediastinum, right pericardial lesion,skin and soft tissue of left arm were shown as iso-,hypointensity on T1-weighted image,iso-,hyper-intensity on T_2-weighted image,and with heterogeneous enhancement after contrast administration in three cases.Splenomegaly was presented in one case,it showed homogenous hypoattenuation on unenhanced CT,and diffused heterogeneous enhancement after contrast administration. On MRI,spleen was shown as hypointensity on T_1-weighted image,hyperintensity on T_2-weighted image, and with heterogeneous enhancement after contrast administration.There were lesions in both bones and spleen in one case.Osteopenia and thinned cortex were shown on the metaphyses of upper and lower extremities.Spleen enlarged and showed multifocal hypoattenuation lesions,the peripheral region enhanced on the early phase,and some of the lesions filled on the delayed phase after the contrast administration.One case showed huge hypoattenuation lesion in the left lobe of liver with gradually filling of the mass after peripheral enhancement.Conclusion Thrombocytopenia and consumption coagulopathy suggest the entity of extensive hemangioma.Splenomegaly with diffuse or focal hypoattenation or hypointensity in MRI infers the diagnosis of hemangioma.

DCIS and aromatase inhibitors

In patients with hormone receptor positive DCIS tamoxifen reduces recurrence rates by almost 50%. Few data are available with aromatase inhibitors from randomised studies. In the ATAC study there were three DCIS lesions in the anastrozole arm and four in the tamoxifen arm in the women with ER positive invasive cancer. In the MA17 study which randomised patients to up to 5 years of letrozole or placebo there was only one DCIS event in the contralateral breast in patients taking letrozole and five on placebo. There were also four patients in this study who had DCIS in the conserved breast on placebo and none in the letrozole treated group. The few clinical data that are available therefore suggest the aromatase inhibitors are likely to be effective in DCIS. A histological review of a study of 206 postmenopausal women with invasive oestrogen receptor positive breast cancer who were randomised as part of a 14 day preoperative study to receive 2.5 mg of letrozole or 1 mg of anastrozole identified 27 patients with 28 pairs of tumours in whom there was sufficient ER positive DCIS in invasive cancer in the initial core biopsy and in the subsequent surgery specimen, to evaluate for PgR activity and proliferation. Within the DCIS both aromatase inhibitors significantly reduced PgR expression and both drugs also produced a significant fall in proliferation. There was a moderate degree of agreement between the fall in PgR in both the invasive cancer and DCIS (Kappa = 0.5; p = 0.0013) and between the fall in proliferation and between the invasive and in situ components (correlation coefficient = 0.68; p < 0.001). This study has shown significant effects of aromatase inhibitors on DCIS indicating that these agents are therapeutically active in this condition.

Early Arm or Leg Lesions Predict Development of Atopic Dermatitis

Early Arm or Leg Lesions Predict Development of Atopic Dermatitis

Minor stroke and major vascular occlusion. A case report

Occlusion of middle cerebral artery (MCA) is generally associated to severe stroke and poor prognosis; however a few patients with mild to moderate presentation and long-term reversibility of neurological deficits have been reported. A 66-year-old male presented with left-side weakness and dysarthria (NIHSS score 7), which progressively resolved within a few days; ischaemic lesion of the anterior arm of the right internal capsule was found at brain CT obtained 72 h after presentation. Transcranial Colour Doppler showed absence of flow of the right MCA. Cerebral angiography showed occlusion of the right MCA that was retrogradely revascularised by leptomeningeal collaterals. Non-invasive intracranial vascular examinations could identify major intracranial artery lesions in patients who present with mild to moderate stroke symptoms. These patients could be identified and followed to clarify their best treatment and prognosis.

Hanseníase tuberculóide em paciente com Aids

Relata-se o caso de uma criança de oito anos, portadora de Aids, que desenvolveu hanseníase tuberculóide antes do início da terapia anti-retroviral. Apresentava lesões ulceradas nos membros, Mitsuda de 8,5mm, hipoestesia em perna esquerda, e o diagnóstico de hanseníase foi definido pela imuno-histoquímica antiproteína S-100, que mostrou fragmentos de ramos nervosos no interior dos granulomas. A incidência da hanseníase não aumentou com o advento da Aids, e não há modificações na apresentação clínica ou na resposta terapêutica nos casos de hanseníase associados à Aids. Também não se observou neste caso o desenvolvimento da reação tipo 1 como resultado da reconstituição imunológica devido ao tratamento anti-retroviral.

Are children with type 1 diabetes immunocompromised?

In their clinical report of a 4-year-old child with leukemia and an enlarging arm lesion that proved to have been caused by an opportunistic fungus, Ahmed Mater and associates[1][1] state that “[these i]nfections generally occur in immunocompromised patients with conditions such as neutropenia,

Risk Factors for Buruli Ulcer Disease (Mycobacterium ulcerans Infection): Results from a Case-Control Study in Ghana

Morbidity due to Buruli ulcer disease (BUD), a cutaneous infection caused by Mycobacterium ulcerans, has been increasingly recognized in rural West Africa. The source and mode of transmission remain unknown. To identify BUD risk factors, we conducted a case-control study in 3 BUD-endemic districts in Ghana. We enrolled case patients with clinically diagnosed BUD and obtained skin biopsy specimens. M. ulcerans infection was confirmed by at least 1 of the following diagnostic methods: histopathologic analysis, culture, polymerase chain reaction, and Ziehl-Neelsen staining of a lesion smear. We compared characteristics of case patients with confirmed BUD with those of age- and community-matched control subjects using conditional logistic regression analysis. Among 121 case patients with confirmed BUD, leg lesions (49%) or arm lesions (36%) were common. Male case patients were significantly more likely than female case patients to have lesions on the trunk (25% vs. 6%; P = .009). Multivariable modeling among 116 matched case-control pairs identified wading in a river as a risk factor for BUD (odds ratio [OR], 2.69; 95% confidence interval [CI], 1.27-5.68; P = .0096). Wearing a shirt while farming (OR, 0.27; 95% CI, 0.11-0.70; P = .0071), sharing indoor living space with livestock (OR, 0.36; 95% CI, 0.15-0.86; P = .022), and bathing with toilet soap (OR, 0.41; 95% CI, 0.19-0.90; P = .026) appeared to be protective. BUD was not significantly associated with penetrating injuries (P = .14), insect bites near water bodies (P = .84), bacille Calmette-Guerin vaccination (P = .33), or human immunodeficiency virus infection (P = .99). BUD is an environmentally acquired infection strongly associated with exposure to river areas. Exposed skin may facilitate transmission. Until transmission is better defined, control strategies in BUD-endemic areas could include covering exposed skin.

A 4-year-old child with leukemia and an enlarging arm lesion

A 4-year-old boy was admitted to hospital with a diagnosis of pre–B-cell acute lymphoblastic leukemia. Ten days later, he experienced fever, neutropenia and a lesion on the lateral aspect of his left arm just above the elbow. The purplish lesion was 1 cm in diameter and was not painful. The child