Nonspecific Skin Lesions Research Articles

Cutaneous Manifestations of Dermatomyositis: a Comprehensive Review.

Dermatomyositis (DM) is an idiopathic inflammatory myopathy characterized by the presence of skin lesions and inflammation of skeletal muscles; however, this feature may be absent in amyopathic DM. DM is a rare disease, occurring at any age, and has two peaks of incidence: one in childhood between 5 and 15years of age and one in adulthood between 40 and 60years, with a female preponderance. DM has been associated with malignancy; therefore, every newly diagnosed patient should undergo screening investigations, but evidence-based guidelines on their extension are lacking. The etiopathogenesis is still unclear, but a range of factors such as genetic predisposition, environment triggers, and immune- and non-immune-mediated mechanisms play a role in the development of the disorder. Some dermatological findings and new discoveries on immunological mechanisms in DM, including the association of certain autoantibodies with cancer, can be helpful in clinical practice. Therapy should consider both skin and muscle or internal organ involvement. Photoprotection, including the use of antimalarial drugs, plays an important role in the therapeutic approach of skin involvement. Treatment of muscle and internal organ involvement is based on systemic corticosteroids, alone or in association with disease-modifying antirheumatic drugs. Intravenous immunoglobulins have been demonstrated to be effective as second-line therapy. Rituximab is an emerging treatment for difficult-to-treat DM, both in adults and children. In this review article, we discuss DM subforms, focusing on their dermatological manifestations that can be classified as pathognomonic, characteristic, compatible, less common, rare, recently-described, and non-specific skin lesions.

A rare association: celiac disease and multiple myeloma in an asymptomatic young patient / Asemptomatik genç bir hastada çölyak hastalığı ve multipl myelom’un nadir birlikteliği

Abstract Celiac Disease (CD) is a gluten-sensitive enteropathy, and an autoimmune disorder involving an innate and adaptive immune response that occurs in genetically predisposed patients who are exposed to gluten-containing foods and other environmental factors. Early diagnosis and treatment are essential in preventing complications of the disease. Symptoms may appear both in childhood or adulthood by the ingestion of gluten and are usually characterized by gastrointestinal symptoms; however, the diagnosis may be delayed because of various extraintestinal manifestations, such as iron deficiency anemia, osteoporosis, or non-specific skin lesions in adult patients. Although CD has been shown to have an increased risk of all malignancies, plasma dyscrasias, especially multiple myeloma (MM) associations, are rare and reported to be seen in elderly patients. The current report presents a 42-year-old female patient with a recent dysphagia after a hot food ingestion with no other complaints. Laboratory investigations revealed a mild anemia and high serum protein levels. CD was diagnosed after a small bowel biopsy and MM was diagnosed after a serum protein electrophoresis with immunotyping studies (IgA lambda as the monoclonal protein) and bone marrow biopsy. In the laboratory, Immunotyping studies of monoclonal protein included two alternative methods; Immunofixation electrophoresis and immunosubtraction method with capillary electrophoresis. Our patient, is young to have MM, since the median age at diagnosis of MM is 66 years and only 2% of patients are younger than 50 years. We believe that celiac disease played a significant role in the development of MM in this particular patient with IgA monoclonality and conclude that CD patients, even if they are young, must be monitored for plasma dyscrasias in addition to other malignancies.

Work up for the clopidogrel hypersensitivity that led to recognising the undiagnosed myelodysplastic syndrome.

Work up for the clopidogrel hypersensitivity that led to recognising the undiagnosed myelodysplastic syndrome.

A Rare Cause of Neuropathic Pain in the Back: Notalgia Paresthetica.

Notalgia paresthetica (NP) is a neuropathy with unknown cause of thoracic spinal nerves T2-T6, particularly their dorsal branches. It is a chronic disease that can be seen among the elderly and females. Despite its unknown etiology, NP is thought to result from posterior spinal nerve impingement or chronic nerve trauma. In addition, increased dermal innervation and viscera-cutaneous reflex mechanisms are other mechanisms responsible for their chemical neurotoxicity. It is a clinical condition associated with a character of neuropathic pain, itching, and nonspecific skin lesions with brown pigment in both the dorsal vertebrae and scapular areas (1).

Skin manifestations of hematologic malignancies

Hematologic malignancies can present with various cutaneous manifestations. These include specific cutaneous diseases & non-specific cutaneous lesions. Non-specific skin lesions are more common in patients with hodgkins diseases. Generalized severe pruritus may precede other findings of Hodgkins disease by many months . So an evaluation for underlying lymphoma should be considered in patient with severe itching. Leukemia cutis (specific skin lesions of Leukemia) most commonly occurs concomitant with or following the diagnosis of leukemia. The skin may also be the site of relapse of leukemia after chemotherapy. Uncommonly leukemia cutis may be identified while the bone marrow & peripheral blood are normal. Those patients are classified as aleukemic leukemia cutis. This cross sectional observational study was carried out in the Hematology department of Bangabandhu Sheikh Mujib Medical University from January 2012 to January 2013 with the intention to know the prevalence of skin manifestations of hematologic malignancies & to help diagnose and manage hematologic malignancies in some extent. Total 127 consecutive patients who were already diagnosed as haematological malignancies & hospitalized were evaluated at the period of one year. Different types of cutaneous lesions were found in our study population, Infections were the highest number, 32(25.19%) patients suffering from various infections. Other findings includemalignant infiltration, 10(7.87%); hemorrhagic 121 lesions (petechia and ecchymosis), 17(13.38%); drug reaction, 5(3.93%); gingival hyperplasia, 3(2.36%); pruritus, 23(18.11%); pigmentation, 20(15.74%); prurigo, 8(6.29%) and ichthyosiform lesion, 19(14.96%).Bangladesh Med J. 2014 Sep; 43 (3): 121-124

Cutaneous lupus erythematosus: pathogenesis, clinical pattern, diagnostics, therapy

This article contains the latest information about the mechanisms of development of lupus erythematosus based on the literature review. The modern classification of specific and non-specific skin lesions in lupus erythematosus is shown.The authors described the clinical pattern of cutaneous forms of lupus erythematosus very detailed. the data about pathological and immunological criteria for the disease diagnostics, modern methods of pharmacotherapy lupus erythematosus was classified.

Self‐Healing Extranodal Cutaneous Rosai‐Dorfman in a Child

Sinus histiocytosis with massive lymphadenopathy, or Rosai-Dorfman disease (RDD), is commonly characterized by painless cervical lymphadenopathy. Exclusively cutaneous Rosai-Dorfman disease is rare. In the absence of massive lymphadenopathy, the nonspecific skin lesions may complicate the diagnosis. To our knowledge, the case reported herein is the youngest case of extranodal cutaneous RDD.

Study on Cutaneous Manifestations of Leukemia and Lymphoma

Leukemia and Lymphoma can present with various cutaneous manifestations. These include specific cutaneous diseases and non-specific cutaneous lesions. Non-specific skin lesions are more common in patients with Hodgkins diseases. Leukemia cutis (specific skin lesions of Leukemia) most commonly occurs concommitent with or following the diagnosis of leukemia. The skin may also be the site of relapse of Leukemia after chemotherapy. Uncommonly leukemia cutis may be identified while the bone marrow and peripheral blood are normal. Those patients are classified as aleukemic leukemia cutis. The objective of this study is to know the prevalence of skin manifestations of hematologic malignancies and to help the diagnosis and management of hematologic malignancies in some extent. It is a cross sectional observational study in which the skin lesions of the patients in hematologic malignancies who were already diagnosed & hospitalized in the hematology department of Bangabandhu Sheikh Mujib Medical University were evaluated in the period of one year. We found malignant infiltrative lesions & hemorrhagic findings both were predominate in leukemia. Infections were predominant in both Leukemia & Lymphoma.
 CBMJ 2015 July: Vol. 04 No. 02 P: 31-34

Dermatitis by Tropical Rat Mite, Ornithonyssus bacoti (Mesostigmata, Macronyssidae) in Italian city‐dwellers: a diagnostic challenge

Editor Mesostigmata (Gamasida) is a suborder of mites within the order Parasitiformes.1 Some species can bite humans, typically causing pruritic, non-specific skin lesions. The mesostigmatic mites most commonly associated with cases of dermatitis are from the Macronyssidae and Dermanyssidae families.1 All are haematophagous non-burrowing mites of very similar size and shape, and can be seen with the naked eyed as they range from 0.5 to 1.5 mm in size.1 Adults are able to survive several weeks without a blood meal.1 The tropical rat mite, Ornithonyssus bacoti, Hirst (Macronyssidae) is one of these species. It can occur worldwide mostly as an ectoparasite of wild rats and mice,2, 3 but also pet and laboratory rodents may occasionally be the source of the mite.2, 4-6 As a nest parasite, it only visits its host to feed, mainly during the night; and then returns to its nearby hiding place during the day. In the absence of its natural host, human beings may become subject to mite infestation. Outbreaks of tropical rat mite (TRM) dermatitis have been reported in humans in urban areas in Europe, because of wild/pet rodent infestation of flats2-4 but also due to occupational exposure,5 including a single record from Italy.6 These scattered cases show that parasitization by the TRM is not obvious and skin lesions are usually misdiagnosed, unless the mite is discovered and correctly identified. To confirm this, we report an urban outbreak of TRM dermatitis diagnosed by identifying the parasite. In November 2013, veterinary entomologists from the Zooprofilactic Institute (IZSPB), Foggia were contacted to inspect a house for mites. Owner referred that her 2-year-old daughter suffered from multiple erythematous papules over a 9-month period. Cutaneous lesions were generalized but predominantly located in groups on the neck and body areas covered by clothes (trunk, upper extremities and abdomen) (Fig. 1). Her 71-year-old grandmother had also experienced the same symptoms after spending a single night in the child's home. Bites by arthropods/non-burrowing mites/wood-mite and Streptococcus spp. infection respectively, were diagnosed after two paediatric and two dermatological consultations. Symptomatic relief was also unsuccessful. Mites were detected in dust samples and in child's bedding, after careful investigation of the patient's living quarters by IZSPB staff. All of the parasites were identified as Ornithonyss bacoti based on morphological keys1 (Fig. 2). The source of the mites was a previously eliminated rats' nest in the living-room. Medical texts and parasitology manuals rarely mention mesostigmatic mites in association with human parasitization; detection and correct identification of these ectoparasites is also difficult. This makes it a challenge for physicians, including dermatologists, to recognize epizoonotic mite-associated dermatitis, including skin disorders caused by O. bacoti. This inevitably leads to failures in treatment. In addition to O. bacoti, mestostigmatic avian mites such as Ornithonyssus sylviarum and Ornithonyssus bursa (Macronyssidae), and more frequently Dermanyssus gallinae (Dermanyssidae) can be associated with urban dermatitis in Europe,2, 7, 8 including Italy.9 When unexplained pseudoscabious eruptions occur on patients in urban areas, investigation for mesostigmatic mites should always be undertaken. If small rodents are held as pets, animals and their bedding should be carefully examined by a veterinarian. Diagnosis and treatment of these infestations require accurate anamnesis, detection and identification of the parasite, removal of the source and disinfestation. As studies suggest that the rat mite may be a reservoir of various zoonotic pathogens and a vector of Bartonella henselae,10 its early diagnosis remains crucial. Dermatitis by mesostigmatic mites, including the TRM dermatitis, are without doubt more frequent than one might expect. Increased physicians awareness of the possible role of these ectoparasites in urban infestations of humans, and applying the One Health approach will be essential for diagnosis, treatment and prevention.

Clinical characteristics of haematological malignancy patients diagnosed with leukaemia cutis: Experience of a single centre.

We evaluated the clinical characteristics of patients with haematological malignancies at our centre who were diagnosed with leukaemia cutis (LC). In addition, we describe the spectrum of other skin lesions, including, secondary skin malignancies and nonspecific benign skin lesions in haematological malignancy patients. We defined 58 skin lesions that developed in 54 inpatients hospitalised in the Department of Haematology, Trakya University Medical Faculty, Turkey. All skin lesions that developed in inpatients between 2006 and 2012 had been evaluated by a dermatologist. The patients' clinical features, skin biopsy results and therapies were obtained from hospital files. The diagnosis of LC was based on clinical features and histopathological examinations of the skin biopsy. There were 11 patients with LC. Six (54.5%) had acute myeloblastic leukaemia. In nine patients (82%), LC was present at the initial presentation. Secondary skin malignancy was detected in 11 patients (five basal cell carcinoma, four Kaposi's sarcoma, one squamous cell carcinoma, one malignant melanoma); and malignancy was present in two patients (18%) at the initial presentation. Nonspecific benign skin lesions, the most frequent of which were drug eruptions, were determined in 32 of our patients. LC had a significantly higher likelihood of being present at initial presentation than other skin lesions (P < 0.01). The median survival in LC patients was quite short (4.5 months). LC was usually diagnosed at the initial presentation of the patient or during the early course of the disease. Having LC was a poor prognostic factor.

Penile Crohn's disease resolved by infliximab

Crohn's disease is a chronic relapsing, granulomatous, and inflammatory bowel disorder. Variable extra-intestinal manifestations may occur, which include erythema nodosum, erythema multiforme, pyoderma gangrenosum, and other non-specific skin lesions. Here, we present a case of metastatic penile Crohn's disease without scrotal involvement, which was initially approached as a balanoposthitis with penile cellulitis, and completely treated with infliximab infusion in a short time.

Leukemic vasculitis: a rare pattern of leukemia cutis

Although non-specific skin lesions are quite common in patients with leukemia, the specific infiltration of the skin by blast cells, known as leukemia cutis, is rare. Its incidence ranges from 1 to 50% and depends on the specific type of leukemia. Leukemic vasculitis represents a rare form of leukemia cutis consisting of the involvement and destruction of vessel walls by leukemic cells, which in themselves cause the vascular injury. To date, only few cases of leukemic vasculitis have been described. Here, we report two cases of this rare skin condition, one of which mimicked cutaneous polyarteritis nodosa.

Involvement of scalp and nails in lupus erythematosus

Lupus erythematosus (LE) is a systemic autoimmune disorder associated with polyclonal B-cell activation resulting in diverse patterns of autoantibody production and a heterogeneous clinical expression constituting a spectrum extending from limited cutaneous disease to life-threatening systemic manifestations. For daily clinical practice, the characteristics of cutaneous lupus erythematosus (CLE) have been well defined in terms of morphology, and clinical and laboratory criteria are available for the classification as systemic lupus erythematosus (SLE). The many different types of skin lesions encountered in patients with LE have been classified into those that are histologically specific for LE and those that are not. While LE non-specific skin lesions on their own do not enable a diagnosis of LE, they can be important reflections of underlying SLE disease activity. This also applies to the involvement of the scalp and nails. Finally, it must be kept in mind that LE patients may also develop drug-related, or other unrelated common disorders of the hair and nails that do not reflect LE disease activity.

Lupus erythematodes

The typical clinical forms of cutaneous lupus erythematosus (LE) are the butterfly rash, acute, subacute and chronic cutaneous lupus, intermediate lupus (lupus tumidus), chilblain- and bullous lupus, lupus profundus, and ulcerating lesions on the mucous membrane. Besides the typical lupus forms, nonspecific skin lesions are also observed such as dermal mucinosis, acneiform skin lesions, different variants of livedo, necrotizing vasculitis with ulcers, purpura, urticaria vasculitis, neutrophilic dermatosis, hyperpigmentation, hair and nail changes as well as overlap syndromes with erythema multiforme, scleroderma, Sjögren syndrome, Raynaud phenomenon, lichen planus, bullous pemphigoid und psoriasis. There are lupus imitators which create differential diagnostic challenges, such as infections with atypical mycobacteria or subcutaneous T-cell lymphoma both of which are similar to lupus profundus. All these skin lesions can present as maximal pathological findings seen in lupus or be caused by a variety of pathological laboratory findings such as the anti-phospholipid antibodies or a deficiency of complement factors. In the latter situation severe lupus often with complications can be expected.

A clinical and epidemiological study of lupus erythematosus at a tertiary referral dermatology clinic in Korea

Dermatological examination is critical for the evaluation of lupus erythematosus. However, little is known about the epidemiology and clinical characteristics of the lupus erythematosus patients that visit dermatology clinics with the chief complaint of skin lesions, especially among Asian populations. We performed this study to determine the epidemiology of cutaneous lupus erythematosus for three subtypes: acute cutaneous lupus erythematosus, subacute cutaneous lupus erythematosus, and chronic cutaneous lupus erythematosus, and for lupus erythematosus non-specific skin disease. Also, we sought to determine the relationship between each type of lupus erythematosus, by the skin manifestations and systemic lupus erythematosus. The medical records of lupus erythematosus patients that were diagnosed by their clinical manifestations, skin biopsy results, and laboratory findings from January 1998 through December 2007 were reviewed. A total of 117 patients were diagnosed with lupus erythematosus; 62 cases had chronic cutaneous lupus erythematosus, 11 had subacute cutaneous lupus erythematosus, and 41 had acute cutaneous lupus erythematosus. The remaining three had systemic lupus erythematosus features with lupus erythematosus non-specific skin lesions such as Raynaud phenomenon, livedo reticularis/vasculitis, non-scarring alopecia, and periungual telangiectasia. The acute cutaneous lupus erythematosus subgroup showed extreme female predominance (9.2:1) whereas subacute and chronic cutaneous lupus erythematosus subgroups did not. Patients with chronic cutaneous lupus erythematosus tended to be older than other groups (peak incidence in the fifth decade). Incidence of laboratory abnormalities, including positive connective tissue markers such as antinuclear, double-strand DNA, and Ro/SS-A antibodies, were present in the order acute, subacute, and chronic cutaneous lupus erythematosus. Acute cutaneous lupus erythematosus almost always indicated systemic involvement of lupus erythematosus, whereas chronic cutaneous lupus erythematosus did not predict the development or existence of systemic lupus erythematosus and had a benign clinical course. Careful consideration of lupus erythematosus non-specific skin lesions may help detect systemic lupus erythematosus regardless of the diagnosis of cutaneous lupus erythematosus.

Une maladie d’importation rare : la lèpre

Although rare in occidental countries, leprosy is an endemic disease throughout the world. Physicians may encounter imported cases and thus need to be aware of this diagnosis. We here report a 41-year-old male patient from French West Indies who presented with nonspecific extensive skin lesions and a peripheral neuropathy. Skin biopsy examination led to the diagnosis of borderline lepromatous leprosy.

Extramammary Paget's Disease of the Scrotum Associated with Hepatocellular Carcinoma

Extramammary Paget's disease (EMPD) is a rare cutaneous carcinoma of epidermal origin. The diagnosis is frequently delayed, and the disease tends to be associated with an underlying adnexal or internal malignancy. There have been several reports of EMPD associated with carcinoma of the bladder, prostate, kidney, and colon. The association of hepatocellular carcinoma (HCC) with EMPD appears to be exceedingly rare; to our knowledge, it has been reported only once in the English literature. Herein, we report an unusual case of EMPD of the scrotum associated with HCC. EMPD was diagnosed 1 year after the appearance of an erythematous plaque, and HCC was noted 19 months after the diagnosis of EMPD. From our experience and literature review, in patients with nonspecific skin lesions that are unresponsive to conventional treatment, EMPD should be considered and skin biopsy performed. Long-term follow-up is needed to watch for the appearance of adnexal carcinoma or internal malignancy.

Cutaneous manifestations of systemic lupus erythematosus in a tertiary referral center.

Background:Systemic lupus erythematosus (SLE) is an autoimmune disease with multiorgan involvement. The skin is the second most commonly affected organ. SLE with skin lesions can produce considerable morbidity resulting from painful skin lesions, alopecia, disfigurement, etc. Skin lesions in patients with lupus may be specific (LE specific) or may be non specific (LE non specific). Acute cutaneous LE (Lupus specific) has a strong association with systemic disease and non-specific skin lesions always indicate disease activity for which patients present to rheumatologists and internists. Therefore, a thorough understanding of the cutaneous manifestations of SLE is essential for most efficient management.Aims:The aims of this study were to evaluate the patterns and prevalence of skin lesions in patients with SLE and to assess the relationship between skin lesions and other systemic involvement.Materials and Methods:At the Department of Rheumatology and Clinical Immunology, IPGME&R in Kolkata, 150 patients with SLE fulfilling the clinical and laboratory criteria of the American Rheumatology Association (updated 1982) were examined and followed-up for cutaneous manifestations between January 2002 and January 2007.Results:Skin lesions were important clinical features. About 45 patients (30%) presented with skin lesions although all patients had skin lesions during the follow-up period. Skin changes noted were as follows: Lupus specific lesions: malar rash in 120 patients (80%), photosensitive dermatitis in 75 patients (50%), generalized maculopapular rash in 40 patients (26.67%), discoid rash in 30 patients (20%), subacute cutaneous lupus erythematosus (SCLE) in 5 patients (3.34%), lupus profundus in 5 patients (3.34%). The lupus non-specific lesions were non-scarring alopecia in 130 patients (86.67%), oral ulcers in 85 patients (56.67%), vasculitic lesions in 50 patients (33.34%), bullous lesions in 15 patients (10%), Raynaud's phenomenon in 10 patients (6.67%), pyoderma gangrenosum in 2 patients (1.34%), erythema multiforme in 10 patients (6.67%), and nail fold infarcts in 2 patients (1.34%); however, mucosal discoid lupus, lichenoid discoid lupus, livedo reticularis, sclerodactyly, etc. were not detected. Patients having lupus-specific skin lesions e.g., malar rash were associated with systemic involvement, whereas those having lupus non-specific skin lesions were associated with disease flare.Conclusions:Skin lesions in patients with SLE are important disease manifestations and proper understanding is essential for diagnosis and efficient management.

Ulcerative Sarcoidosis: Case Report and Review of the Japanese Literature

,Sarcoidosis is a chronic multi-system disease of unknown origin involving the eyes, skin, lungs, heart, bones and nerves. Skin lesions are relatively common, and are clas-sified as either specific or non-specific (1). Specific le-sions are those that show the typical sarcoid granulomas, including lupus pernio, infiltrated plaques, maculopapular eruptions, subcutaneous nodules and infiltration of old scars (1). The most typical non-specific skin lesion is erythema nodosum. The patient described here had skin lesions that first suggested a diagnosis of erythema indu-ratum of Bazin, but we ultimately diagnosed sarcoidosis based on other findings, including uveitis, bilateral hilar lymphadenopathy, an increased level of serum angio-tensin-converting enzymes (ACE) and a negative response to purified protein derivative of tuberculin (PPD).CASE REPORT

Chronic cutaneous lesions of sarcoidosis

Sarcoidosis involvement of the skin is common. The skin lesions of sarcoidosis may be nonspecific, showing a nondiagnostic inflammatory reaction pattern on histologic evaluation. Nonspecific skin lesions are often associated with an acute presentation of sarcoidosis and, in general, portend a good prognosis. Specific sarcoidosis skin lesions reveal typical sarcoid granulomas on histologic examination. These lesions tend to be chronic and require therapy for resolution. This article will review the epidemiology, diagnostic evaluation, and description of the various chronic skin lesions of sarcoidosis. Various images of these skin lesions will be demonstrated.