Transepithelial Elimination Research Articles

34530 Pyogenic granulomatous formation due to transepithelial elimination of abdominal hernia mesh

Foreign body reactions occur when nonnative material is embedded into the body, with subsequent rejection of that material leading to granulomatous formation. Granulomatous responses to foreign material most often present with a sarcoidal or palisading arrangement. Pyogenic granulomatous formation is reported, albeit a rarer presenting sign. This is a case of an 80-year-old Caucasian woman who presented to an outpatient clinic with a 3-month history of indurated red-brown-purple papules coalescing into plaques with ulceration on her central abdomen. Within the exophytic friable lesions, cream-colored linear fibers were appreciated and were physically extracted with pressure. Prior to her presentation, she received 6 abdominal wall hernia repairs (3 with plastic mesh, 3 with biologic mesh). Concern for a Marjolin’s ulcer prompted a shave biopsy. The biopsy showed pyogenic granuloma with adjacent scar. A diagnosis of transepithelial elimination of her abdominal hernia mesh was made. Surgical debridement from her general surgeon was performed to remove the offending mesh. The patient tolerated the debridement well and has since undergone reepithelization of the area.

Successful treatment of acquired reactive perforating collagenosis with itraconazole

BackgroundAcquired reactive perforating collagenosis (ARPC) is a rare form of transepithelial elimination in which altered collagen is extruded through the epidermis.Case presentationA 23-year-old male presented with cup-like ulcerated lesions on his limbs since 3 months. A series of serological and immunological tests showed no abnormalities. A diagnosis of ARPC was based on skin biopsy findings. The patient was cured using treatment with itraconazole for 8 weeks, in the absence of a fungal infection.ConclusionsThe anti-inflammatory and anti-angiogenic effects of itraconazole can have good therapeutic benefits for ARPC.

Patterns of Mycobacterium avium-intracellulare complex infection in duodenal endoscopic biopsies in HIV/AIDS patients

Mycobacterium avium-intracellulare complex (MAIC) is a nontuberculous opportunistic infection in immunocompromised patients. Involvement of the gastrointestinal tract (GIT) is usually part of a disseminated disease in AIDS patients with a low CD4 count, however with standard antiretroviral therapy (ART), a localized presentation is more likely. It can affect any part of the GIT, mostly the duodenum and typically as patches. Incomplete or refractory ART for HIV-strains, therapy-related side effects, noncompliant or incomplete treatment to previous MAIC infections, superimposed complications and comorbid opportunistic infections may result in atypical clinical, endoscopic and histopathologic manifestations. We performed a retrospective review study retrieving cases of MAIC in duodenal endoscopic biopsy. We found five cases of MAIC in HIV/AIDS patients. They were males with an average age of 40-years. They showed different histopathologic features, variable patterns of MAIC-histiocytic infiltrates, and varying intensity of intracellular acid-fast positive bacilli. Enterocytes vacuolization and transepithelial elimination were also observed. Three cases were associated with cytomegalovirus and cryptococcal infections. A case was complicated by lymphangiectasia-associated protein-losing enteropathy. Initially, three cases were morphologically missed. Ziehl-Neelsen stain helped reach the correct diagnosis. Pathologists have an important role in patients' management by guiding clinicians to the correct diagnosis. Pathologists should be aware of these different histopathologic manifestations, their potential pitfalls, look for certain helpful clues complemented with multiple levels and special stains. In particular, AFB stains are mandatory in all mucosal biopsy specimens from HIV/AIDS patients regardless of their appearances.

Perforating Granuloma Annulare Mimicking Psoriasis

Perforating granuloma annulare (PGA) is a rare inflammatory condition characterized by transepithelial elimination of necrobiotic collagen with granulomas in the dermis. It commonly presents as umbilicated papules or pustules on the extremities and dorsal hands. The distribution of PGA can be described as generalized or localized, with only 9% of patients presenting with a single lesion. Herein, we report an unusual presentation of PGA as a single localized plaque on the forearm that resembled psoriasis.

Familial reactive perforating collagenosis in two siblings

Reactive perforating collagenosis (RPC) is a rare form of transepithelial elimination disorder, in which genetically altered collagen is extruded through the epidermis. Of the acquired and inherited form, the latter is extremely rare. Here, we present two cases of inherited form of RPC in siblings aged 4 and 7 years presented with a history of itchy raised lesions of 9 months and 3 years duration, respectively. Dermatological examination revealed multiple papules with a central keratotic plug distributed mainly over face and extensors of upper and lower extremities. Koebnerization was present. Skin biopsy revealed perforating collagen bundles in the upper dermis and epidermis.

Clinical and dermoscopic correlation of reactive perforating collagenosis

The acquired perforating dermatosis is constituted by a group of diseases whose main characteristic is the transepithelial elimination of altered dermal material. It has the clinical appearance of crateriform papules or nodules, with central keratotic plug, which may suggest some kind of transepithelial purging; nevertheless the final diagnosis is histologic. The dermoscopic examination is a useful tool that helps to exclude similar dermatoses, such as nodular prurigo and hypertrophic lichen planus. The present article discusses the clinical and dermoscopic correlation of this dermatosis.

Elastosis perforans serpiginosa, a transepithelial elimination skin disease diagnosed by histopathology: case report

Elastosis perforans serpiginosa is a disease that belongs to the group of perforating dermatoses, in which dermal elastic tissue extrusion occurs through epidermis. It generally affects young male individuals, and is clinically characterized by keratotic papules of verrucous aspect with centrifugal and serpiginous growth. We report the case of a male patient presenting with papular keratotic lesions since the age of 5. Some of the lesions display a central keratotic plug and converge into circular, arciform and serpiginous lesions.

Familial reactive perforating collagenosis: a report of two cases.

Reactive perforating collagenosis (RPC) is a rare form of transepithelial elimination, in which genetically altered collagen is extruded through the epidermis. Of the acquired and inherited form, inherited form is extremely rare. Here, we present two cases of inherited form of RPC in a family.

Transepithelial elimination in sarcoidosis: a frequent finding

Transepithelial elimination is a process by which dermal materials are expelled through an active epithelial-dermal connective tissue interaction. It has been described as a regular or sporadic occurrence in a variety of dermatologic conditions, including sarcoidosis. Our patient demonstrated a rare presentation of sarcoidosis involving the genital region, with histopathologic evidence of transepithelial elimination of granulomas. This prompted us to conduct the first case series documenting the frequency of transepithelial elimination in sarcoidosis. Slides of skin biopsies from patients (n = 50) with cutaneous sarcoidosis from the University of Alabama at Birmingham were evaluated for transepithelial elimination. Transepithelial elimination was defined as epithelial channel formation with a sarcoidal-type granuloma completely surrounded by squamous epithelium on the section examined. Transepithelial elimination was found in 9 of 50 cases (18%). This is the first report of transepithelial elimination in a lesion of sarcoidosis localized to the vulvar area, and one of only six reports in the English literature documenting cutaneous sarcoidosis with histopathologic evidence of transepithelial elimination. These reports are reviewed herein. Surprisingly, the results from this case series indicate that transepithelial elimination is more common in cutaneous sarcoidosis than one may surmise from the current literature.

Transconjunctival Elimination of Keratin From an Intratarsal Meibomian Cyst

An unusual example of an intratarsal meibomian keratinous cyst is described in a 69-year-old man with spontaneous transepithelial (conjunctival) elimination. The lesion created an externally visible lump in the eyelid, which on eversion was found to be accompanied by yellow-whitish protruding material with a surrounding circular mound of reactive tissue. Excision revealed a large mass and smaller fragments of anuclear keratin (trichilemmal-type) embedded and sequestered in fibrous tissue with a granulomatous response. A re-excision was required because of persistent and irritating keratinous material, contrasting with the more indolent course of an uncomplicated epidermoid cyst of the eyelid dermis. This is the first documented instance of spontaneous rupture and extrusion of a meibomian tarsal cyst's keratin contents.

Collagénose perforante réactionnelle

Reactive perforating collagenosis (RPC) belongs to the group of perforating dermatoses, which comprises elastosis perforans serpiginosa, RPC, perforating folliculitis and Kyrle's disease. RPC was initially described as a distinctive form of transepithelial elimination of altered collagen related to superficial trauma. Two types are distinguished: a hereditary type (MIM 216700), which is rare and begins during early childhood, and a second type, called acquired RPC, which is more frequent, appears in adults and is associated with other diseases, diabetes mellitus, renal insufficiency, solid tumors, lymphomas and AIDS. We report the case of a young man whose illness began during infancy, militating in favor of a diagnosis of a hereditary form of RPC. The description of similar lesions in the patient's brother confirmed our diagnosis. A 26-year-old man, the child of consanguinous parents, presented crusted papular lesions on his hands. The cutaneous lesions, located on the external side of the limbs, had been present since childhood, with flares during winter. Histologic analysis showed a cup-shaped depression in the epidermis containing keratinous material with extruded degenerated collagen towards the cutaneous surface. Treatment with topic retinoids did not result in any real resolution of the disease. The patient reported the presence of similar lesions in his brother, which was consistent with our diagnosis. The pathogenesis of hereditary RPC is still unknown, even if superficial trauma is suspected as the cause of RPC. In contrast, in diabetes, acquired RPC pathogenesis has recently been related to advanced glycation end-products of collagen.

Resolution of leucocyte‐mediated mucosal diseases. A novel in vivo paradigm for drug development

Removal of disease-driving inflammatory leucocytes is central to resolution of inflammation. The current pharmacological dogma teaches leucocyte elimination through apoptosis followed by phagocytosis. However, actual resolving roles of apoptotic-phagocytic processes have been difficult to demonstrate in the major diseases that are characterized by mucosal tissue inflammation. Many current in vivo observations rather demonstrate that leucocyte elimination occurs by transepithelial locomotion. Findings in diseased gut and bladder mucosae support this notion. Respiratory disease data are particularly compelling. Eosinophils and neutrophils abound in sputum and tracheal aspirates during treatment-induced recovery from severe asthma. Prolonged sputum neutrophilia, along with clinical improvement, follows upon smoking cessation in COPD. Eosinophils, neutrophils, lymphocytes, mast cells and dendritic cells also move in large numbers into the bronchial lumen at spontaneous inflammation resolution following allergen challenge in allergic rhinitis and asthma. A corresponding reduction of infiltrated cells in the bronchial mucosal tissue demonstrates efficiency of the transepithelial elimination pathway. Underscoring its operational role, drugs impeding transepithelial elimination of leucocytes aggravate mucosal/parenchymal inflammation. Hence, relying on lumen cell data alone can lead to paradoxical conclusions regarding anti-inflammatory drug efficacy. Conversely, drugs promoting non-injurious transepithelial elimination of leucocytes could resolve mucosal inflammatory diseases.

Keratotic papules and plaques in an adolescent with Down syndrome

Conflict of interest: none declared. A 16‐year‐old adolescent boy presented with multiple asymptomatic skin lesions involving mainly the arms. The lesions started appearing around 1 month previously, and had been persistent since then. Treatment with topical steroids did not improve the condition. The patient’s family history was negative for a similar condition. The patient has Down syndrome (DS), which was diagnosed during early childhood. On physical examination, multiple erythematous keratotic papules and plaques were seen, with some assuming an annular configuration on the arms (Fig. 1a). A punch biopsy specimen from a representative lesion was sent for histopathological examination (Fig. 1b–d). ... On histopathological examination, focal parakeratosis was seen, overlying an area of epidermal acanthosis with epidermal transepithelial elimination of basophilic material composed of neutrophils, nuclear debris and eosinophilic fibres. The latter were seen to enter the epidermis through an epithelial channel from the underlying papillary dermis. A Verhoeff–van Gieson stain confirmed theses to be elastic fibres.

Elastosis Perforans Serpignosa: Treatment with Liquid Nitrogen Cryotherapy and Review of the Literature

Elastosis perforans serpiginosa (EPS) is a rare skin disease in which abnormal elastic tissue fibers, other connective tissue elements, and cellular debris are expelled from the papillary dermis via transepithelial elimination. It is characterized by an eruption of small grouped hyperkeratotic papules in a serpiginous arrangement. This condition presents a therapeutic challenge as many treatments have been reported with inconsistent efficacy. This article reports a case of a 13-year-old male who presented to our outpatient clinic with a 1-year history of facial lesions showing multiple annular keratotic plaques with slight central atrophy. We report a case of EPS treated successfully with liquid nitrogen cryotherapy. Liquid nitrogen cryotherapy is well tolerated, with few side effects, and can be considered in the management of EPS.

Acquired perforating dermatoses in patients with diabetic kidney disease on hemodialysis

Acquired perforating dermatoses (APD) is an uncommon skin disorder seen in patients with diabetes mellitus, chronic kidney disease, or both together. We present the clinicopathological features of APD in patients with diabetic kidney disease and discuss the recent advances in management. We retrospectively analyzed the data of 8 patients with APD presenting to our center. All patients were known cases of Type 2 diabetes and chronic kidney disease requiring maintenance dialysis. Acquired perforating dermatoses was diagnosed based on clinical presentation of itchy, keratotic papulonodular lesions, and characteristic histopathological features of transepithelial elimination on skin biopsy. The patients were subdivided into 4 types of APD based on the biopsy features. All our patients had Type 2 diabetes over 5 years duration and were on maintenance dialysis for more than 6 months before presentation. Acquired perforating dermatoses symptoms appeared 2 to 6 months before presentation. The majority of patients (6/8) had a subtype of reactive perforating collagenosis. All the patients showed significant resolution with topical glucocorticoid therapy. Acquired perforating dermatoses is a skin complication seen in Type 2 diabetes, chronic kidney disease, or when both are present together. Early identification and therapy prevents the associated morbidity.

Dermatose perfurante adquirida associada à insuficiência hepática em paciente transplantado de fígado

A dermatose perfurante adquirida é entidade clinicopatológica caracterizada por eliminação transepitelial de material dérmico degenerado, ocorrendo em muitas condições, entre elas diabetes mellitus, insuficiência renal crônica e colangite esclerosante. Relata-se o caso de paciente de 17 anos, com dermatose perfurante adquirida associada à insuficiência hepática crônica, conseqüente à complicação hepática de transplante de fígado para tratamento de sua doença de base, a glicogenose tipo I.

Perforating folliculitis associated with tumour necrosis factor-? inhibitors administered for rheumatoid arthritis

Perforating dermatoses are characterized by transepithelial elimination of dermal structures. We report a 61-year-old man with rheumatoid arthritis who developed a perforating folliculitis following the administration of two tumour necrosis factor (TNF)-alpha inhibitors, infliximab and etanercept. To our knowledge, no perforating disorders have been reported associated with these drugs. This report suggests, for the first time, a role for TNF-alpha in the pathogenesis of perforating folliculitis.

Transepithelial elimination of elastic fibres in the regenerated human epidermis.

The elimination of elastic fibres through the regenerated epidermis of human skin was studied using histochemical, immunofluorescent and electron microscopic techniques. No abnormality was detected in the elastic fibres which were being eliminated, but they were in direct contact with the cytomembranes of some lymphocytes and were captured by histiocytes. It seemed that these elastic fibres were recognized as a foreign substance and provoked inflammation. Lymphocytes and histiocytes may play an important role in the transepithelial elimination of elastic fibres.

表在性真菌症および深在性皮膚真菌症の病態と防御機構

To determine the pathophysiology of the fungal infection and defense mechanisms against superficial dermatomycosis, two series of experimental infections of Trychophyton mentagrophytes were made on the forearm of a male volunteer. One series was applied topical steroid ointment, the other the vehicle alone. The infected sites were biopsied from each row weekly up to the 4th week, and the set of sites were studied and compared clinically, histopathologically and immunohistochemically. For the study against subcutaneous fungal infection, the same experiments were studied using the subcutaneous inoculation of Sporothrix schenckii. The pathophysiology of the superficial dermatophytosis was thought to be the same as those of the contact (allergic) dermatitis, including the physiodynamics of CD-1 cells. The principal mechanism of the defense lay in the removal of the foreign materials (fungi) together with keratinocytes whose turnover increased because of the eczematous reaction. It was proved that the topical application of steroid ointment suppressed the immune reactions locally, thus forming a paradoxical feature with little inflammatory reaction and abundant fungal elements (so-called atypical tinea). The pathophysiology of the subcutaneous fungal infection was thought to be a suppurative granulomatous reaction and pathologically showed a mixed cell granuloma. The neutrophils and macrophages engulfed and digested the fungi in the forefront, but the circumference was surrounded by epithelioid cells and/or foreign body granuloma. Transepithelial elimination also played some role in the defense. It was proved that when the defense mechanism was weakened by the topically applied steroid ointment, not only the clinical symptoms but also the fungicidal tissue reaction were subdued, and histocytes only engulfed fungi to protect them from dispersion. The trichophytin reaction turned positive on the 14th day, and the sporotrichin reaction on the 7th day.

Perforating Pilomatricoma: Transepithelial Elimination or Not

We present a 56-year-old woman with a perforating pilomatricoma in the left eyebrow region. Histologically, the tumor consisted mainly of basophilic cells and shadow cells, and the tumor components were being eliminated through an ulcer with damage to the epithelial structures. In past reports of perforating pilomatricoma, this elimination pattern has often been described as transepithelial elimination. In many patients with perforating pilomatricoma, elimination is accompanied by ulceration and epithelial damage. Mehregan recently stated that elimination accompanied by epidermal necrosis and superficial ulceration constituted one form of transepithelial elimination. Epidermal necrosis and ulceration generally constitute severe damage. However, when Mehregan first proposed the concept of transepithelial elimination, it was defined as a phenomenon with relatively little or no damage to the epithelial structures, differentiating it from other types of elimination. This original definition makes transepithelial elimination a unique and interesting phenomenon, and its most important feature is that there is relatively little or no damage to the epithelial structures. Therefore, the terms "epidermal necrosis" and "ulceration" should not be used in association with transepithelial elimination. Hence, in patients with perforating pilomatricoma, the elimination of tumor components from ulcers with damage to the epithelial structures, as seen in the present case, should not be described as transepithelial elimination.