Reddish-purple Nodules Research Articles

METASTASIS OF COLON ADENOCARCINOMA TO ORAL CAVITY: A CASE REPORT

Oral metastatic tumors are rare and usually indicate late stage of the disease. A 50-year-old female patient with previous medical history of treatment for colon adenocarcinoma 2 years earlier was referred for evaluation of an asymptomatic lesion with 1 month of evolution. Additionally, the patient was under investigation of bone metastasis. Extraoral examination did not detect lymph nodes. Intraoral examination revealed a pedunculated reddish-purple nodule measuring around 3.0 × 2.0 cm in the gingiva of the posterior left maxilla with bleeding to palpation. Cone beam computed tomography showed bone loss surrounding the molar region. An excisional biopsy was performed, and according to the microscopic and immunohistochemistry findings, the final diagnosis of colon adenocarcinoma metastasis was established. Metastasis in L2 vertebra also was confirmed. A palliative radiotherapy/chemotherapy was established; however, the patient died 1 month after the diagnosis. Metastatic tumors should be considered as differential diagnosis of oral lesions in patients with history of malignant neoplasms.

Mucoepidermoid Carcinoma of Hard Palate in a Pediatric Case

Salivary gland neoplasms are rare in childhood. Only 1 to5.5% of minor salivary gland tumours occur in children and adolescents. The most common malignant minor salivary gland tumours are mucoepidermoid carcinomas (MECs). Herein, we present a rare case of mucoepidermoid carcinoma occuring in the hard palate. Presentation of Case: A 12-year-old boy visited our hospital with a swelling and ulceration of the right hard palate. Clinical examination revealed a localized mucosal nodule of the right posterior hard palate, measuring 1*1 cm. Biopsy was performed. The tumour was diagnosed as a low grade MEC. Wide excision was performed. The patient didn’t need another therapy. During 15-month follow-up, the patient showed no evidence of local tumour recurrence or metastasis. Discussion: Mucoepidermoid carcinoma occurring in the oral cavity is extremly rare. These tumours are usually presenting as a painless, reddish-purple nodule. Biopsy is necessery for definitive diagnosis. Histologically, MECs are divided into low, intermediate and high grade subtypes. Differantial diagnosis of palatal tumours in children include pleomorphic adenoma, benign or malignant mesenchymal tumours, and less commonly giant cell granuloma. A wide local excision with safe free margins is the operative procedure for low-grade MECs.

Erythema elevatum diutinum coexisting with ankylosing spondylitis.

A 43-year-old woman presented to our hospital with the complaint of a reddish-purple rash on the extensor sides of her forearms. She had been diagnosed with ankylosing spondylitis 7 years ago. On physical examination, reddish-purple nodules were detected on the pretibial areas of both legs and extensor sides of both hands and forearms. Neutrophil, eosinophil, lymphocyte, and mixed-type leukocyte infiltration and erythrocyte extravasation were observed in skin biopsy. Erythema elevatum diutinum (EED) was diagnosed. For treatment, sulphasalazine, colchicine, and diclofenac were started. After 3 months of treatment, the lesions were healed. To the best of our knowledge, this is the first report of EED coexisting with ankylosing spondylitis.

A giant benign clear cell hidradenoma on the anterior trunk

Clear cell hidroadenoma (CCA) is a uncommon variant of bening cutaneous adnexial tumors. These tumors are clinically asymptomatic, solitary dermal nodules. they occur most frequently on the scalp, face, abdomen and the extremities. Growth is slow and malignant change is rare. 45- year-old woman presented us with a nodule with a central ulceration and a minimal hemoragic discharge on her anterior abdomen wall which had begun 4 years ago as a small nodular asymptomatic lesion. On dermatological examination there was a 6.5x4x5 cm non-tender, soft reddish purple nodule with lobular appearence and ulceration. In the laboratory investigations, all the hematologic and biochemical tests were normal. A CT scan demonstrated a cyctic tumor with lobulated countour with contrast enhancement. The lesion excised totally. In histopathological examination the tumor was composed of biphasic smaller dark polygonal cells and larger clera cells and coarse nuclear chromatine. There were duct like structures. Immunohistochemical investigation was done for the suspicion of malignancy. Cytoplasm of clear cells and duct like structures showed PAS positive and d-Pas resistant staining. There was a positive reactivity to epithelial membrane antigen and carcinoembrionic antigen. The mitotic index in Ki 67 examination was low. All these findings confirmed the diagnosis of bening CCA.

Angioinvasive Fusarium and concomitant Enterococcus infection arising in association with leukemia cutis

Leukemia cutis represents the cutaneous infiltration of neoplastic leukocytes or their precursors that results in clinically identifiable skin lesions. For patients with myelodysplastic syndrome, developing such a lesion may indicate impending leukemic transition. These patients are also often immunocompromised, putting them at risk for infection by opportunistic fungal pathogens such as Fusarium. We describe an 85-year-old man with myelodysplastic syndrome who presented with a reddish-purple nodule with a surrounding erythematous plaque on his shin. Histopathologic examination revealed a dense diffuse infiltrate of large atypical cells in the reticular dermis, with ulceration and necrosis. Immunohistochemical studies showed positive staining with CD15, CD68 and myeloperoxidase of constituent large cells. Concurrently, there were branching and septate hyphae with occasional macroconidia-like structures throughout the infiltrate. Cultures from this lesion grew Fusarium and Enterococcus, supporting the diagnosis: leukemia cutis with superinfection involving both Fusarium and Enterococcus. To our knowledge, this is a novel report of two separate infections occurring in a lesion of leukemia cutis. This case shows that in patients with a hematologic malignancy and skin lesions, a high index of suspicion for infection is necessary when reviewing both the clinical and histopathological data to avoid overlooking an important occult infectious agent.

Umbilicated erythematous papules in an immunocompromised patient

A 53-year-old woman, with no notable medical history, presented with a non-pruritic rash after several months of weakness and low-grade fevers, 27 kg weight loss, and non-bloody productive cough. The rash was asymptomatic and had been present for 1 month on her legs and had spread to her chest and neck before presentation. Physical examination identifi ed multiple erythematous 2–3 mm well demarcated, non-tender, umbilicated papules on her upper chest, anterior neck, and anterior lower legs bilaterally (fi gure A). An HIV antibody test was positive and a CD4 cell count of 18 cells per μL was recorded. Skin biopsy results showed lobular capillary proliferation and primarily neutrophilic infl ammatory infi ltrate with Gram-negative rods within the cytoplasm of rare endothelial cells, consistent with bacillary angiomatosis (fi gure B). The patient’s lesions improved with 4 months of treatment with azithromycin 600 mg daily, combined with ethambutol 400 mg twice daily for coexisting Mycobacterium avium-intracellulare infection. For treatment of HIV, she began daily therapy with ritonavir 100 mg, atazanavir 300 mg, tenofovir 300 mg, and emtricitabine 200 mg. However, her CD4 cell count remained at fewer than 20 cells per μL and she died of respiratory failure, secondary to sepsis, 4 months after initial presentation. Bacillary angiomatosis is due to infection with Bartonella henselae or Bartonella quintana and is most often seen in immunocompromised individuals. It is typically seen in patients with AIDS with a CD4 cell count fewer than 100 cells per μL, but has also been reported in patients who have had transplant and those undergoing chemotherapy. It can occur as a single lesion or as multiple lesions. Bacillary angiomatosis usually presents as reddish-purple nodules or plaques and can often resemble Kaposi’s sarcoma. Bleeding and ulceration can occur. Diagnosis is typically made by histopathology; therefore, it is important to diff erentiate this disorder from other umbilicated lesions associated with immunosuppression, such as cryptococcosis or molluscum contagiosum. Patients can be treated with either macrolide or tetracycline antibiotics; however, a treatment duration of less than 3 months is associated with relapse.

Necrosis grasa del recién nacido: A propósito de un caso

Newborn fat necrosis is an unfrequent disease that compromises the adipose tissue and develops during the first weeks of life. It is characterized by reddish-purple nodules and/or plaques with a hard elastic consistency, isolated or multiple, localized at the back, shoulders, buttocks, arms, thighs and chin. They evolve spontaneously to regression and unfrequently develop complications, being hypercalcemia the most observed. The pathogenesis of newborn fat necrosis is unknown, although certain risk factors for its development have been identified. Case-report: A 36 weeks preterm male newborn with a clinical picture compatible with fat necrosis. The diagnosis was made according to the clinical findings and his perinatal history, confirming it with pathology. The patient evolution was complete improvement and regression of the lesions, without complications.

Synovial Hemangioma in the Stifle Joint of a Dog

Synovial hemangioma was diagnosed in an 8-year-old castrated male Belgian Sheepdog with lameness of 3 months' duration. Pain, soft-tissue swelling, and hemarthrosis were localized to the left stifle joint. Projections of synovial membrane with reddish-purple nodules, excised via arthrotomy, were composed histologically of variably sized vascular channels that were lined by well-differentiated endothelial cells and separated by fibrous septa. Distension of some channels resulted in endothelial disruption, thrombosis, hemorrhage, necrosis, and focal spindle-cell proliferation. The limb was amputated to remove remaining neoplastic tissue. The hemangioma extended focally into the joint capsule and popliteal soft tissue but did not invade skeletal muscle or bone. The dog was free of detectable neoplasia 6 months after amputation. Synovial hemangioma is a rare benign vascular proliferation in people, most commonly in the knee, and should be included in the differential diagnosis for canine synovial tumors.

Merkel cell carcinoma in an HIV-1-infected man

Merkel cell carcinoma (MCC) is a rare cutaneous malignancy thought to be derived from neuroendocrine cells. It is usually found in elderly men on the head, neck and extremities, and appears as a reddish-purple, non-tender nodule. Most often it presents as localized disease, but not infrequently it manifests regional node involvement and metastasizes distantly. Immunosuppression as a result of disease (chronic lymphocytic leukemia) or iatrogenic (organ transplantation) results in an increased frequency of MCC. We recently encountered a middle-aged male who was HIV-1 infected and manifested MCC on the dorsum of the hand. The patient is a 57-year-old podiatrist who has been HIV-1 positive for 14 years. He has never experienced an opportunistic infection and his CD4 cell counts have ranged from 357 to 573 cells/μl during the past 3 years. His viral load is consistently undetectable. In April 2002, he was found to have a 7 mm reddish-purple nodule on the dorsum of his right middle finger. A biopsy revealed MCC, and a wide excision was undertaken without further therapy. By June 2003, the tumor had recurred and now measured 1.5 × 1.5 cm on the dorsum of the right hand. Slightly firm and non-tender right-sided epitrochlear and axillary nodes measuring 0.5 × 0.5 cm were palpated. A positron emission tomography scan displayed slightly increased activity at these nodal sights. A computerized tomography scan of the chest, abdomen and pelvis as well as a bone scan were unremarkable. A complete blood count, chemistries, urinalysis and thyroid studies were normal but the neurone-specific enolase (NSE) was elevated to 19 (normal < 10). Moh's micrographic resection of the tumor with ultimately clear margins ensued. A previous lymphoscintigraphy and sentinal node biopsy failed to demonstrate metastatic nodal disease. He received radiotherapy to 6000 rads at the tumor sight. In June 2004, he developed ascites and paracentesis revealed a transudate with negative cytology and cultures including fungi and acid fast bacilli. Computerized tomography scans of the chest, abdomen and pelvis were unremarkable other than for the ascites. Laboratory studies revealed a slight elevation of the transaminses and alkaline phosphatase and a mild normocytic, normochromic anemia. Hepatitis A, B and C antibodies were undetected but the NSE remained elevated. A liver biopsy revealed moderate fibrosis without infiltrates, granulomata or neoplasm. It was decided to initiate combination chemotherapy despite the lack of cytological confirmation of neoplasia with carboplatin and etoposide, which he received for six cycles every 3 weeks. The patient is now more than a year post-chemotherapy and 40 months since the initial diagnosis of MCC with no evidence of disease and a normal NSE. MCC has only been reported in seven patients infected by HIV-1 [1–6] before this case report. However, a recent review by Engels et al. [7], using linked AIDS and cancer registries encompasing 309 365 patients, identified six cases of MCC corresponding to a relative risk of 13.4 (95% confidence interval 4.9–29.1) compared with the general population. However, the study could not examine whether MCC increased over time relative to AIDS onset or with CD4 lymphocyte depletion and HIV-1 viral load. Of the eight HIV-1 patients we reviewed with MCC their mean age was 48 years (36–60 years), all but one was male, and the woman was from Africa. In the United States, more than 85% of MCC patients uninfected by HIV-1 are men over the age of 60 years, whereas in patients with concomitant HIV-1 infection only one out of eight was at least 60 years of age. The mean time of established HIV-1 infection to a diagnosis of MCC was reported in six patients, and ranged from 3 to 15 years in five, and was simultaneous in one. Four out of six were receiving HAART therapy. The HIV-1 viral load ranged from 0 to 750 000 copies/ml3 in six patients in whom it was recorded. In one patient it was 750,000 copies/ml3, in two it was undetectable, and in the remainder ranged from 11 000 to 32 000 copies/ml3. The mean CD4 cell count was 309 cells/μl. In four out of eight patients the MCC was found on the buttock or in the groin, in three on the face or neck, and in our patient on the hand. In four individuals the initial lesion was associated with regional node involvement. None of the eight patients had evidence of systemic metastases at the time that MCC was discovered. Surgical excision of the MCC was accomplished in all patients and six received local or regional radiation therapy. None received adjuvant chemotherapy, but three were given chemotherapy for confirmed or presumed metastatic disease and one patient was not. Three of the four latter patients died. With the persistence of HIV disease one would anticipate increasing numbers of MCC, necessitating a study of the role of adjuvant chemotherapy in preventing metastases.

Adalimumab for Treatment of Cutaneous Sarcoidosis

The patient, a 46-year-old black woman, was referred to the dermatology clinic at Washington University, St Louis, Mo, for evaluation of reddish-purple nodules on her face and shins. The patient’s medical history was significant for hypothyroidism and an arrhythmia. Findings from a punch biopsy from her right nasal ala showed confluent granulomas with central caseous necrosis in the dermis. Findings from a wedge biopsy specimen from her right shin showed granulomas in the dermis and subcutis with necrotizing foci. Acid-fast bacteria and Giemsa stains of both specimens were negative for mycobacteria and fungal organisms. Because of continued concern that she had an infection, an excisional biopsy specimen from the right leg was taken. Tissue culture for bacteria, mycobacteria, and fungi failed to grow any organisms. Histologic examination of this specimen revealed a septal panniculitis consistent with a diagnosis of erythema nodosum. Despite the caseating granulomas found on histologic examination of the specimens from the initial 2 biopsies, a diagnosis of sarcoidosis was made based on exclusion of an infectious etiology and the clinical appearance of the lesions. Further evaluations included a complete blood cell count with differential cell count and complete metabolic panel, both of which revealed no significant abnormal findings. The patient had no reaction to purified protein derivative but did react to Candida antigen. A computed tomographic scan of her chest revealed a 4-mm nodule in the left upper lobe of the lung and a 1.3-cm left axillary lymph node. A 2.2-cm rim-enhancing lesion in the right hepatic lobe consistent with a hemangioma was noted. Pulmonary function tests revealed a forced expiratory volume in 1 second (FEV1) of 1.72 (72% predicted of normal for the patient’s age group) and a forced vital capacity (FVC) of 2.02 (70% predicted), with an FEV1/FVC ratio of 85%. Her diffusion capacity of carbon monoxide was 65% predicted of normal for her age group. These abnormalities in the findings were not felt to be clinically significant by the patient’s pulmonologist. The patient was treated with minocycline hydrochloride, 100 mg twice daily, and 0.05% clobetasol propionate cream. The minocycline therapy was discontinued after she developed headaches and tinnitus. The patient subsequently developed ulcerations of the nodules on her legs. Findings from a repeated biopsy from an ulcerating nodule on her left leg revealed a granulomatous panniculitis. Acid-fast bacteria and Giemsa stains were again negative for mycobacteria or fungal organisms, as were tissue cultures for bacteria, mycobacteria, and fungi. Antineutrophil cytoplasmic antibodies were not detected in her blood. The patient was treated with Unna wraps and 0.05% clobetasol ointment to her legs and continued treatment with 0.05% clobetasol cream to her face. A 3-week trial of 40 mg of prednisone daily led to modest improvement. She subsequently failed treatment with hydroxychloroquine sulfate (Plaquenil; Sterling Winthrop Inc, New York, NY), 200 mg, twice daily; pentoxifylline, 400 mg, 4 times daily; and multiple intralesional injections of triamcinolone acetonide (Kenalog; Bristol-Myers Squibb Co, New York, NY), 5 mg/cm, to the nose. Physical examination at this time revealed reddish-purple nodules on her nose (Figure 1), eyebrows, chin, and upper lip, as well as numerous hyperpigmented patches and nodules with atrophic centers and erosions on her legs (Figure 2). An alternative treatment was needed.

Two Cases of Diaper Area Granuloma of the Adult

Two cases of diaper area granuloma are reported. Patient 1, a 34-year-old man, had multiple reddish-purple nodules over the diaper area of the right part of the genitocrural region. Candida albicans was not detected from the lesion. Histological examination of the nodule showed acanthosis and dense infiltrates. The granulomas became smaller and flatter after the control of urination. Patient 2, a 28-year-old man, had two large decubitus lesions and multiple nodules over the diaper area of the gluteal region. The decubitus became smaller and the granulomas disappeared after the lesion was kept clean. Because these granulomas resemble granuloma gluteale infantum, but occurred in adults rather than in the aged or infants, we propose to call this condition "granuloma gluteale adultorum." We suggest that these granulomas may represent an inflammatory reaction to the irritation of urine or feces. It is, therefore, of great importance to treat and prevent this condition by controlling the flow of urine and keeping the region clean.

Lymphangiosarcoma Arising from Postmastectomy Lymphedema

SINCE 1948, when Stewart and Treves reported six cases of lymphangiosarcoma developing in a lymphedematous arm following radical mastectomy,173 cases of this syndrome have been reported in world medical literature. However, many others must have been seen and treated without being reported and probably many more have not been diagnosed. We are now reporting three additional cases in this presentation. The clinical picture of all 76 cases is rather similar (Tables 1 and 2). The patients usually give histories of radical or simple mastectomy complicated by lymphedema of the arm, or long-standing lymphedema due to reasons other than mastectomy. The first sign of new lesions is the appearance of a bluish or reddish-purple nodule in the skin of the arm. As the lesion enlarges, other lesions arise around the original one. To the patients, the first lesion simulates a bruise. Subsequent course of the disease is fast, and