Papular Skin Lesions Research Articles

Unusual presentation of cutaneous metastatic malignant melanoma

This report describes an unusual presentation of cutaneous metastases suspected to have occurred through lymphatic spread in a patient with malignant melanoma. Punctate papular skin lesions correlated histologically with small tumor foci in the papillary dermis.

The exanthema of acute (primary) HIV infection. Identification of a characteristic histopathological picture?

A male homosexual presented with a skin rash, pharyngitis, fever and lymphadenopathy. The clinical symptoms were suggestive of an acute primary HIV infection. The diagnosis was confirmed serologically. We describe here the clinical and histopathological picture of the exanthema. Biopsy from a papular skin lesion revealed a possibly characteristic pattern.

American cutaneous leishmaniasis: presentation and problems of patient management.

We report our experience with the diagnosis and treatment of 60 patients with American cutaneous leishmaniasis. They were infected in Panama (55), Brazil (4) or Colombia (I). Among 35 patients with a 3 week exposure in Panama, the mean maximum incubation period was 33 days (range 4-81 days). Diagnosis was delayed an average of 93 days after onset of skin lesions, due to the patient's delay in seeking medical attention (31 days), medical personnel's delay in considering the diagnosis (45 days), and the laboratory's delay in confirming the diagnosis (17 days). Forty-four patients (73%) developed ulcers typical of cutaneous leishmaniasis. Sixteen additional patients (27%) had atypical macular, papular, squamous, verrucous or acneiform skin lesions that were diagnosed only because leishmanial cultures were obtained. Of the 59 patients treated with pentavalent antimonial drugs, only 34 (58%) were cured after the first course of treatment. Lesions which were at least 2 cm in diameter, ulcerated, or caused by Leishmania braziliensis were less likely to be cured after a single course of treatment than were lesions smaller than 2 cm, nonulcerated or caused by Leishmania mexicana or Leishmania donovani.

EPITHELIOID HAEMANGIOMA-LIKE VASCULAR PROLIFERATION IN AIDS: MANIFESTATION OF CAT SCRATCH DISEASE BACILLUS INFECTION?

Papular and nodular skin lesions that clinically resembled Kaposi sarcoma, but histologically showed a distinct epithelioid haemangioma-like appearance, were noted in seven patients with the acquired immunodeficiency syndrome. Clusters of bacteria that had the structure of gram-negative rods were identified within each of the vascular proliferations by electron microscopy. The bacteria did not stain with the Brown-Brenn, acid-fast, or other histochemical stains for infectious organisms, but did stain with Warthin-Starry—ie, the staining profile was that described for the cat scratch disease (CSD) bacillus. Immunoperoxidase staining, using antisera raised in rabbits against cultured CSD bacillus, showed a positive reaction with the bacterium in all five cases tested. The two surviving patients have both given histories of having been scratched by a cat. In several patients, the vascular lesions regressed after therapy with antibiotics appropriate for CSD bacillus infection.

Scleromyxedema

Scleromyxedema is a rare fibromucinous connective tissue disorder characterized by papular skin lesions associated with sclerosis and a serum monoclonal gammopathy. Little is known about either the natural history or the systemic manifestations of this disease. We reviewed the medical records of 19 patients with biopsy-proven scleromyxedema seen from 1950 to 1985 for evidence of systemic disease. There were 10 males and 9 females with a median age at diagnosis of 53 years. Monoclonal gammopathy was present in 13 patients. Eight patients complained of dysphagia; 3 had proximal esophageal dysfunction and 1 had total esophageal aperistalsis on barium swallow. Proximal muscle weakness was noted in 5, with an inflammatory myopathy in 3. Six patients complained of dyspnea on exertion. Of these, 5 had reduced diffusing capacity, 3 had reduced volumes, and 2 developed cor pulmonale. Pathologic changes characteristic of "scleroderma kidney" were demonstrated in 1 patient at postmortem. One patient had Raynaud's phenomenon and 2 had arthralgias/arthritis with noninflammatory synovial fluids. Although 8 of 12 patients treated with melphalan noted regression of their skin changes, no consistent improvement in the extracutaneous manifestations was demonstrated. Furthermore, 2 patients died of sepsis related to melphalan-induced myelosuppression, and 4 developed hematological malignancies following melphalan therapy. In conclusion, systemic manifestations in scleromyxedema are more prevalent than previously recognized, and can resemble those of scleroderma. Significant toxicity occurred with the use of alkylating agents in these patients, with treatment-related complications developing in 45% of patients treated with melphalan. The lack of definitive data regarding the natural history of this disease complicates the question of optimal therapy, but the use of alkylating agents should be reserved for those patients with severe debilitating skin disease.

Peculiar papular skin lesions occurring in hepatitis B carriers

Various cutaneous signs and syndromes have been associated with hepatitis B virus infection. This is a report of the clinical, pathologic, immunofluorescence, and immunoperoxidase studies of peculiar papular lesions that have been observed to occur during the chronic phase of hepatitis B virus infection. A total of thirteen patients positive for hepatitis B surface antigen (HBsAg) were studied. Twelve had asymptomatic, recurrent, erythematous papular lesions localized on the back, chest, and proximal areas of the upper extremities that lasted 6 to 7 days. The histopathology of these skin lesions showed a superficial and deep perivascular dermal mononuclear cell infiltrate. Immunoperoxidase studies for HBsAg and direct immunofluorescence for IgG, IgM, IgA, and C3 showed negative results. An abnormal host response to viral antigens other than HBsAg is suggested as a possible mechanism responsible for appearance of these skin lesions.

Treponema pallidum in macular and papular secondary syphilitic skin eruptions

The ultrastructure of biopsies from dry macular and papular secondary syphilitic skin lesions of 10 patients were studied by electron microscopy. In all biopsies few diffusely distributed treponemes were observed. This may explain the difficulties in demonstrating treponemes by darkfield examination of tissue fluid from dry secondary syphilitic skin lesions. The outlines of treponemes were less distinct as compared to those of primary syphilis. The periplastic membranes were almost invariably absent and the cytoplasmic membranes appeared in close contact with an enclosing layer of irregularly demarcated, electron dense amorphous substance. This substance may be a manifestation of the immune reaction of the host cells to the treponemes. Degenerations were noted in both unmyelinated and myelinated nerve tissue. This accounts for the fact that skin lesions in secondary syphilis are usually without symptoms. Also in the vessel walls treponemes were demonstrated. The vascular endothelial cells were proliferating and the basement membranes were multilaminated and split.

Multinucleate cell angiohistiocytoma—a new entity

A series of five cases is reported of unusual papular skin lesions which had unique and previously undescribed histological appearances. Four of the five patients were female and their ages ranged from 47 to 66 years. The lesions developed slowly over many months, were multiple, reddish-purple in colour, and individual papules measured 2–10 mm. In four of the patients the lesions were situated on acral sites, usually unilateral, and all were asymptomatic. Clinical diagnoses had included lichen planus, Kaposi's sarcoma, histiocytoma and granuloma annulare. The striking histological features of these lesions included the presence of numerous small blood vessels in the mid-dermis associated with scattered inflammatory cells and larger bizarre histiocytoid cells. Many of these latter cells were multinucleate and had an irregular or angulated cell outline. The pattern of vascular proliferation was quite unlike that seen in venous stasis, Kaposi's sarcoma or histiocytoma, and we believe these lesions represent a previously unrecognized disorder. Full clinical and pathological details of these five cases will be summarized and the value of newer histochemical, immunological and monoclonal antibody labelling techniques in deter mining the histogenesis of such lesions will be emphasized.

Live Attenuated Varicella Vaccine: The KMcC Strain in Healthy Children

The KMcC strain of live, attenuated varicella-zoster virus vaccine was studied in healthy children as a preliminary step toward varicella vaccine studies with this strain in children with leukemia. Forty-three children were immunized: 26 with the 40th passage vaccine and 17 with the 50th passage. Studies included surveillance for clinical reactivity, oropharyngeal excretion of vaccine virus, viruria, and viremia. Antibody responses were assayed by fluorescent antibody to membrane antigens and immune adherence hemagglutination. Cell-mediated immune responses were assayed by lymphocyte proliferation to varicella-zoster virus specific antigens. There was 100% seroconversion to the KMcC passage 40 and 50 vaccines (by fluorescent antibody to membrane antigen assay). Every child studied developed in vitro lymphocyte proliferation to varicella-zoster virus antigens. Papular skin lesions, probably vaccine related, occurred in 31% of the 40th passage vaccinees but in only 6% of the 50th passage vaccinees. The 50th passage KMcC strain vaccine is sufficiently immunogenic and safe to initiate clinical studies with leukemia patients.

Trichosporon beigelii fungemia and cutaneous dissemination

• Trichosporon beigelii fungemia and multiple, purpuric, papular skin lesions developed on the chest wall and extremities of a 22-year-old man with acute granulocytic leukemia. Histologically, the skin lesions demonstrated dermal budding yeasts, which were identified as T beigelii in culture. Unexplained biventricular, congestive heart failure and sepsis with Streptococcus intermedius developed, and the patient died 28 days after his admission to the hospital. (<i>Arch Dermatol</i>1982;118:343-345)

Trichosporon beigelii Fungemia and Cutaneous Dissemination

Trichosporon beigelii fungemia and multiple, purpuric, papular skin lesions developed on the chest wall and extremities of a 22-year-old man with acute granulocytic leukemia. Histologically, the skin lesions demonstrated dermal budding yeasts, which were identified as T beigelii in culture. Unexplained biventricular, congestive heart failure and sepsis wit Streptococcus intermedius developed, and the patient died 28 days after his admission to the hospital.

Immunoglobulin and complement deposits in the skin and circulating immune complexes in scabies

Sixteen patients with papulovesicular, 6 with nodular and one with a Norwegian scabies were studied. Direct immunofluorescence (IF) examination revealed C3 deposits in the skin lesions of 13 of the 18 patients. Among them were all 6 cases with nodular scabies. C3 was found mostly in dermal vessel walls and 3 of the patients also showed IgM and 2 IgA deposits at the same site. No circulating immune complexes were found, with a solid-phase C1q radioimmunoassay (RIA), but HSV- and RSV-RIA methods detected IgM antibodies of rheumatoid factor type in 5 of the 15 sera examined. These results suggest that local complement activation and perhaps also immune complex deposition may by important in the pathogenesis of the papular and nodular skin lesions of human scabies.

Pruritic Folliculitis of Pregnancy

• We studied the clinical and pathologic features of a pruritic, erythematous, papular eruption occurring in six pregnant women between the fourth and ninth months of gestation. All patients were in good health and without symptoms associated with the eruption. The lesions were generalized except in one patient. The clinical diagnosis in each case was papular dermatitis of pregnancy. The histopathologic feature of acute folliculitis was observed in five of the six women. The sixth patient demonstrated parakeratosis limited to the acrotrichium. No microorganisms were found in the six patients, and direct immunofluorescence microscopy was negative for deposition of immunoreactants in the four patients that were observed. Deliveries were normal, and all infants were healthy. The lesions cleared spontaneously at delivery or in the postpartum period. We believe that papular skin lesions in pregnant women should undergo biopsy to obtain further data regarding the dermatitis and its natural history. ( Arch Dermatol 117:20-22, 1981)

Necrobiotic Granulomas of the Skin Associated With Hodgkin's Disease

Hodgkin's disease (HD) may exhibit cutaneous manifestations in about 25% of the cases. Nonspecific involvement including pruritus and prurigo, eczematous eruptions, exfoliative dermatitis, pigmentation, alopecia, and ichthyosis is most commonly seen. Specific papular, nodular, and ulcerative skin lesions are also seen, but much less frequently. A patient had an unusual eczematoid dermatitis that showed the histologic features of palisading necrobiotic granuloma associated with HD. To our knowledge, this is the first case of this manifestation reported in the literature. Report of a Case A 68-year-old man was referred to us in June 1979 with increasing malaise, anorexia, arthralgias, and a pruritic dermatitis that had spread from the legs to the upper parts of the trunk and arms during the previous eight months. He had a medical history of psoriasis of the feet, toenails, and fingernails, chronic obstructive pulmonary disease, and hypertension. His medications included prednisone and a thiazide diuretic. Initial

Pruritic Folliculitis of Pregnancy

We studied the clinical and pathologic features of a pruritic, erythematous, papular eruption occurring in six pregnant women between the fourth and ninth months of gestation. All patients were in good health and without symptoms associated with the eruption. The lesions were generalized except in one patient. The clinical diagnosis in each case was papular dermatitis of pregnancy. The histopathologic feature of acute folliculitis was observed in five of the six women. The sixth patient demonstrated parakeratosis limited to the acrotrichium. No microorganisms were found in the six patients, and direct immunofluorescence microscopy was negative for deposition of immunoreactants in the four patients that were observed. Deliveries were normal, and all infants were healthy. The lesions cleared spontaneously at delivery or in the postpartum period. We believe that papular skin lesions in pregnant women should undergo biopsy to obtain further data regarding the dermatitis and its natural history.

Hypopigmentation in Alopecia Mucinosa

Alopecia mucinosa was found in the hypopigmented skin of two black patients. Alopecia mucinosa should be included in the differential diagnosis of hypopigmented papular skin lesions.

Fever, Rash, and Muscle Tenderness

Five patients had fatal, disseminated candidiasis. At the onset of candidemia, a remarkably similar and distinctive triad of high fever, papular erythematous skin lesions, and diffuse severe muscle tenderness developed in each patient. This previously unreported clinical syndrome is sufficiently unique to justify a presumptive diagnosis of disseminated candidiasis and the use of empiric antifungal therapy pending culture and biopsy results.

Macroglobulinemia Cutis

Abnormal lymphoid cell infiltration, amyloid, and macroglobulin depositions have all been described in patients with Waldenström's macroglobulinemia. The liver, lymph nodes, spleen, kidneys, bone marrow, synovia, skeletal muscle, gastrointestinal tract, CNS, lungs, and skin have all been reported to be involved by these processes.^1,2The purpose of this report is to describe a patient who had papular skin lesions of the knees that histologically resembled lichen amyloidosus, but on further study were found to be deposits of IgM. <h3>Report of a Case</h3> A 72-year-old man was initially seen at University of Kansas Medical Center in August 1970 with a chief complaint of "numbness of the legs" of three years' duration and a 20-lb weight loss. Results of laboratory studies showed a serum viscosity of 1.80, ESR of 25 mm/hr, a positive Sia water test, and an elevated gamma fraction without peaks on protein electrophoresis. Immunoglobulin assay showed an aberrant

Hereditary Multiple Fibrofolliculomas With Trichodiscomas and Acrochordons

In a sibship of nine, six members had hereditary medullary carcinoma of the thyroid. Two of those with thyroid neoplasms and two without had numerous small papular skin lesions. These proved to be a type of pilar tumor that we named fibrofolliculoma. Further investigation of the total kindred of 70 showed no other evidence of thyroid neoplasm. Skin tumors only appeared after the age of 25 years. Fifteen of 37 members older than the age of 25 years exhibited the typical skin lesions. Obviously, the original sibship was the repository of two dominantly inherited traits. The fibrofolliculoma is characterized by abnormal hair follicles with epithelial strands extending out from the infundibulum of the hair follicle into a hyperplastic mantle of specialized firbrous tissue. Associated skin lesions in this kindred were trichodiscomas and acrochordons.

Basal-Cell Carcinoma

TOPICAL fluorouracil has been effective for the management of superficial basal-cell carcinoma. This topical chemotherapy can also unmask otherwise undiagnosable lesions.1A patient experienced an inflammatory reaction around a skin lesion while taking intravenous fluorouracil, which prompted us to perform a biopsy of the area. Report of a Case A 56-year-old man, after a partial colectomy for adenocarcinoma of the sigmoid colon in 1971, experienced anorexia and weight loss in September 1974. He was found to have liver metastasis and was given floxuridine (FUDR) by hepatic artery infusion. After this infusion, maintenance therapy with fluorouracil, 1 gm intravenously per week, was started. Following the third dose of fluorouracil, he experienced diarrhea, stomatitis, a facial skin eruption, and intense inflammation and pruritus involving a previously asymptomatic, inconspicuous papular skin lesion on the chest. Physical examination showed a macular erythematous facial eruption. In addition, a prominent nodular ulcerative lesion not noted