Lesions In Patients Research Articles

Instructions for Patients

This is a nonbook in the sense that it was not written be read from beginning end, or used as a reference, or supply enjoyment or education its owner. It consists of handouts for patients on 249 subjects, including 21 diets, and an additional 17 anatomic line drawings that can be marked illustrate the patient's lesions. It is paperbound. Each page is perforated for tearing out, and three holes are present for saving them in a loose-leaf binder. On the back of the title page is a brief statement inviting physicians to reproduce these instruction sheets on their office copying machines for distribution patients. The sheets are more than Instructions for Patients. Each begins with a section headed General Information, and most of these provide excellent explanations of the problems under consideration. The subjects encompass a wide range, suitable for primary physicians whose practices

Haemophilus ducreyi infections--time for reappraisal.

As the literature on Haemophilus ducreyi and clinical chancroid is reviewed, it becomes obvious that many significant findings have been forgotten over the years. As a result, from the time of Ducrey's original description of the organism in 1890 until about 1977, both clinical and laboratory experts in the United Kingdom believed that H. ducreyi infections were rare, generally acquired abroad, and almost impossible to confirm in the routine laboratory! In consequence it was a common view that it was not worth looking for H. ducreyi until all other possible causes of genital ulceration had been excluded. Moreover, the search for such an infection stopped as soon as any other cause for the patient's lesions had been found. A decision to ignore this 'rule' in Sheffield led to our looking for H. ducreyi in specimens from an unselected series of patients with genital ulceration including a number with herpes genitalis infections. The surprise finding of H. ducreyi in circumstances suggesting that it was a secondary invader made us re-examine the whole question of H. ducreyi infections and chancroid and wonder if the same organism can act as a primary pathogen and as a secondary invader. An account of the media and methods we used and of the characteristics of the organism is presented. In an attempt to find out more about the characteristic coherent colonies of H. ducreyi we studied them with the scanning electron microscope. It is clear that the whole subject of H. ducreyi infections has been neglected in the United Kingdom, but we believe that interest has now been aroused and progress will surely follow. Some areas for further investigation are suggested.

The Effects of Deep-Reaching Lesions in the Cortical Face Area on Phonation a Combined Case Report and Experimental Monkey Study

The present study compares the phonatory ability of a patient with a deepreaching left-sided lesion in the region of the cortical face area with that of two squirrel monkeys in which the patient's lesion has been reduplicated bilaterally. The lesion involved Broca's area, the inferior pre- and postcentral cortex, rolandic operculum, inferior parietal cortex insula, claustrum, parts of the putamen and white matter underlying the inferior frontoparietal and insular cortex.While the squirrel monkey did not show any phonatory deficits, the patient became aphonic for more than 10 weeks following the insult. After that period, phonation recovered steadily to a slightly breathy but monotonous voice with a somewhat reduced singing capacity. During the aphonic period, there was a bilateral complete paresis of the vocal folds. Both, patient and monkey, showed a paresis of the lower facial and tongue muscles which was accompanied by dysarthria and buccolingual apraxia in the patient and feeding difficulties in the monkey. The discrepancy between human aphonia and intact monkey phonation, on the one hand, and intact phonation and defective orofacial behaviour in the monkey, on the other, is explained by the anatomical fact that there is a direct cortical projection to the nucleus ambiguus in man but not in monkey, whereas the facial and hypoglossal nuclei receive direct cortical projections in man and monkey. The lack of direct cortical control of the laryngeal motoneurones in the monkey is paralleled by a lack of volitional control of fine vocal fold movements.

Minocycline Therapy for Acne

To the Editor.— Following the publication of my and Dr Paul W. Kohnen's recent article Localized Hemosiderosis as a Sequela of Acne ( Arch Dermatol 114:1695-1697, 1978), I have received reports from clinicians commenting on similar conditions in their patients. One consistent finding is that all of the patients had been receiving long-term minocycline therapy for acne. Our patient had been taking 100 mg of minocycline twice daily for nearly three years when the blue-black macules first appeared on her face. Hemosiderin was demonstrated, by electron microscopy, to be the pigment retained in our patient's lesions and was observed within dermal macrophages as well as in extracellular deposits. No membrane-bound intracellular hemosiderin aggregates could be identified, suggesting that the pigment persisted because of an inability of the macrophages to surround the toxic iron compound with protective lysosomal membranes. It is plausible that this defect may, in some way, have been the

Congenital nephrotic syndrome: Report of a patient with cystic tubular changes who recovered

associated cutaneous hemangiomata, and the absence of a bruit or thrill on multiple prior examinations argue against a congenital origin for our patient's lesion. The only reports in the recent literature concerning fistulas in patients with hemophilia describe the surgical creation of arteriovenous fistulas in adults to permit easier transfusion therapy. A cephalic vein to radial artery anastomosis was utilized in one patient~; autologous saphenous vein grafts were used to create fistulas in two others. Since our literature search was negative, we consider our patient to be the first reported in whom an arteriovenous fistula has developed in a hemophiliac child secondary to repeated venipuncture. The development of fistulas in nonhemophiliac children secondary to repeated venipuncture is known to occur.' We speculate that a hematoma developed around the median cubital vein, gradually organized, and caused the vein to become adherent to the underlying brachial artery. The repeated impact of arterial pulsation led to thinning of this ,common wall, and perhaps eventually to its spontaneous breakdown. Alternatively, deep passes of needles during venipuncture attempts may have punctured the posterior wall of the vein, perforated the adherent artery, and allowed its rupture into the vein. There have been no apparent ill effects of this fistula, such as high output cardiac failure, consumption of coagulation factors or platelets, bacterial endocarditis, or distal vascular compromise/~ The first mentioned of these potential complications is of particular concern in this child for he has a progressively diminishing lung volume due to worsening kyphoscoliosis. His lesion has been followed conservatively. All subsequent venipunctures have been performed on other veins in the left arm. Based on this experience we are now advising our patients on home treatment, as well as physicians caring for patients with hemophilia, to avoid repeated puncture of any vein associated with a persistent hematoma. This case illustrates the need for periodic examination of the peripheral veins of hemophiliac patients, and for emphasizing proper venipuncture techniques.

Facial Granuloma Annulare

Of six cases of granuloma annulare of the face, three cases were not associated with lesions on the extremities or trunk. Histologic examination exhibited typical features of granuloma annulare. One patient's lesion was a recurrent solitary subcutaneous nodule.

Lichenoid tattoo hypersensitivity.

Four patients are described who developed granulomatous reactions in the red portions of their tattoos. Histopathological and immunofluorescence studies showed features of lichen planus. Mercury was identified in only one patient's lesion, and hypersensitivity to mercury was shown by patch testing in one other patient. Tattooing may provide a localised antigenic challenge resulting in spontaneously occurring lichen planus.

Use of Metronidazole in Cutaneous Leishmaniasis

To the Editor.— We were interested in the report of Pedersen and Sawicki on the apparently successful use of metronidazole in cutaneous leishmaniasis ( Arch Dermatol 111:1343, 1975). As the lesion in their patient had already been present for seven months before treatment was started, spontaneous resolution may have occurred. In a previous report on the use of metronidazole in cutaneous leishmaniasis, 1 the patient's lesion had been present for four months before therapy commenced, and had shrunk to half its size by the tenth day of treatment. In the only reported series of patients with leishmaniasis treated with metronidazole, 21 of 30 patients with South American leishmaniasis were cured. 2 Following these reports, we undertook to assess the value of metronidazole in an area of high endemicity for cutaneous leishmaniasis in southern Iran. The study formed part of a double-blind trial involving other anti-leishmanial regimens. All cases were confirmed cytologically

Herpes simplex: cicatricial type

An example of a cicatricial form of recurrent herpes simplex is presented. Although the initial appearance of the lesions was identical with non-scarring forms of herpes simplex, this patient's lesions progressed insidiously to eschar formation. Healing was delayed for four to seven weeks, with subsequent atrophic scar formation. Scarring and local recurrence could be prevented by curettage, and acridine orange and ultraviolet light therapy within 48 hours of an attack. Other modalities employed over a fourteen year period were largely ineffectual. It was concluded that the ulceration and scar formation were an intrinsic part of the herpetic process in this patient.

Treatment of Variola Major with Cytosine Arabinoside

A controlled study of the efficacy of cytosine arabinoside in the treatment of patients with variola major was performed. Cytosine aravinoside was given intravenously at a dose approximating 3 mg/kg of body weight every 24 hr for up to seven days. All nine patients receiving cytosine arabinoside and four of the 11 patients receiving placebo died. In three of the patients receiving cytosine aravinoside, death occurred late in the illness at a time when the patient's lesions began to dry up, the patient's temperature became normal, and the patient's general condition appeared to improve. The virus could be isolated from the blood at day 7 from three of four patients treated with cytosine arabinoside as compared with zero of six control patients. Hematologic data showed a depression in the number of circulating granulocytes. It is possible that the drug lowered the resistance to infection either through direct suppression of granulocytes or through interference with other immune mechanisms. Cytosine arabinside administered in the doses used in this study is not effective in the treatment of variola major.

Lymphangiosarcoma and Congenital Lymphedema of the Extremity

Lymphangiosarcoma is known to be associated with chronic lymphedema of an extremity, especially when it is secondary to radical mastectomy. Only rarely has this malignant neoplasm been secondary to chronic lymphedema without the previous occurrence of a malignant neoplasm. Our patient had lymphangiosarcoma secondary to congenital lymphedema, which is a very rare occurrence. Clinical, microscopic, histochemical, and ultrastructural studies were performed. Multiple early biopsy specimens of this patient's lesion showed no definite neoplasm. If an area of ulceration occurs within a chronically lymphedematous extremity, multiple deep biopsies should be performed; one or two normal biopsy findings do not rule out the presence of malignant disease. The prognosis in this malignant condition is poor, but the best chance of long-term survival is prompt diagnosis and radical surgery.

Letter: Ethaverine therapy for multiple leiomyomas.

To the Editor.— A 41-year-old white man has been followed up during the past year for multiple leiomyomas. The patient's lesions are scattered in a general and symmetrical distribution, sparse on the torso, slightly increased on the upper extremities, but almost confluent on the lower extremities. The patient came to me with a history of prior examination at University of California Los Angeles clinics; the treatment consisted of excision of painful nodules, desiccation and curettage, and amitriptyline hydrochloride (Elavil HCl) therapy, which brought intermittent relief of the pain. The major complaint was pain. The patient also indicated that pain could be brought on by a cool breeze and changes in temperature. Since, ethaverine HCl (Ethaquin) therapy produces smooth muscle relaxation affecting the larger blood vessels, I hoped that this therapy might lessen the pain, which I attributed to contraction of abnormal smooth muscle cells. The patient is being maintained on

Isolation of Mycobacterium rhodochrous From a Cutaneous Lesion

Mycobacterium rhodochrous was isolated from the skin of a knee lesion that was acquired following horseback riding. The location of the patient's lesion and the finding of similar lesions in the horse suggest the possible transmission of the disease from the horse to the patient. Clinical history and bacteriological data are discussed. The suggestion is made that M rhodochrous could be a pathogen in this case.

Dichotic signs of the recognition of speech elements in normals, temporal lobectomees, and hemispherectomees

When patients with hemispherectomies or temporal lobectomies listen to dichotic pairs of equal-intensity C-V syllables, they do poorly identifying the stimuli presented to the ear contralateral to the lesion. This effect is similar to that seen for normals, who in the same circumstances, perform poorly on the left-ear stimulus. (The ear contralateral to a lesion for patients and the left ear for normals will be designated the "weak ear", the ear ipsilateral to a patient's lesion and the right ear for normals will be called the "strong ear".) To further explore these phenomena we investigated the ability of stimuli other than C-V's in the strong ear to suppress the perception of C-V's in the weak ear. Suppression was found when the strong-ear stimulus was a vowel. Somewhat more suppression was seen when the strong-ear stimuli were computer-generated signals with acoustic features similar to C-V's ("bleats"). Suppression was seen even if the strong-ear vowels and bleats were 20-40 dB less intense than the syllables in the weak ear. A model was developed that interprets weaker suppression to be, in part, a consequence of the interaction of the auditory features of the dichotic signals prior to phonetic processing.

Hereditary benign intraepithelial dyskeratosis.

A mother and her daughter had hereditary benign intraepithelial dyskeratosis of the bulbar conjunctiva. The daughter's lesions were studied histologically; they were quite similar to those previously described of patients living in Halifax County, North Carolina. The patient, however, had always lived in Philadelphia. Since the patient's lesions were clinically and histologically so like those in other patients previously reported from North Carolina, an environmental factor (or factors) is considered highly unlikely; the entity is genetically transmitted as a simple mendelian dominant. This case illustrates the importance of the awareness of genetically determined diseases that may be introduced into communities where they had not existed previously.

Mucha-Habermann's Disease Simulating Lymphoma Cutis

Two patients are presented whose clinical histories suggested Mucha-Habermann's disease. The first was referred to us because of a previous biopsy diagnosis of lymphoma cutis. Our biopsy of the patient's lesions, although showing features of Mucha-Habermann's disease, also showed several highly atypical cells in the infiltrate. Several pathologists were consulted regarding the slides. The majority made a diagnosis of or suggested lymphoma cutis, although a clear subepidermal zone was absent. The biopsy specimen of the second patient also showed atypical cells in the infiltrate and initially was diagnosed as lymphoma cutis. In both cases the correct diagnosis was confirmed by the subsequent clinical course of Mucha-Habermann's disease. A short review of the literature shows no mention of atypical cells in the infiltrate of Mucha-Habermann's disease, as was observed in the two cases reported.

SUCCESSFUL REPLACEMENT OF THE ENTIRE ASCENDING AORTA AND AORTIC VALVE.

The first successful replacement of the entire ascending aorta from the aortic annulus to the innominate artery, with reimplantation of the coronary ostia and replacement of the aortic valve was performed on a 57-year-old white male. The patient's lesion was a luetic and arteriosclerotic aneurysm of the ascending aorta plus aortic valvular insufficiency. The ascending aorta was replaced with a woven Teflon graft and the aortic valve with a Starr-Edwards prosthesis using extracorporeal support and cold cardiac arrest. The coronary ostia were attached to the Teflon tubular prosthesis. The patient is well without evidence of thrombosis or embolization 13 months later.

Unusual manifestations in a case of relapsing, nodular, febrile panniculitis (Weber-Christian disease)

A case of relapsing, nodular, febrile panniculitis (Weber-Christian syndrome) is presented. Trauma was the inciting etiologic factor of the patient's lesions, many of which underwent liquefaction. This case is unusual in manifesting marked bone involvement. Acute myocardial infarction, which occurred in this patient, is considered as a possible rare complication of the disease.

Generalized vaccinia and probable induced thiamine deficiency in a congenitally hypothyroid child

<h2>Summary</h2> An example of generalized vaccinia in a congenitally hypothyroid child isreported. A virus was isolated from one of the patient's lesions. Animal experimentrevealed the immunizing properties of this virus to be identical to those of vaccinia virus. The administration of thiamine chloride promptly relieved marked irritabilityattributed to thiamine deficiency induced by overdosage with desiccated thyroid. The administration of B complex vitamins had no appreciable effect onrecurrent attacks of mild fever which accompanied thyroid therapy. These supplementary vitamins and a voracious appetite also failed to prevent welght loss during the first four months of thyroid therapy.