Faculty Bibliography

Synovial sarcomas account for approximately 8% of all soft tissue tumors. The hallmark tumor marker is the t(X;18) translocation, which results in fusion of the SYT gene of chromosome 18 to the SSX gene of the X chromosome, creating most frequently either an SYT-SSX1 or SYT-SSX2 transfusion transcript. Clinically, synovial sarcomas most often present on the extremities and average roughly 7 cm in diameter. Metastatic spread to regional lymph nodes and/or the lungs is common. Because the incidence of this tumor is low, most studies have been retrospective; therefore, management and prognostic interpretation has remained controversial. We report a case of a patient who presented with a slowly growing, unusually large mass on the left forearm of 10 years' duration. A diagnosis of monophasic synovial sarcoma was confirmed by biopsy. We also review the literature regarding management strategies for synovial sarcomas.

Cutis laxa (CL) is a rare connective tissue disorder characterized by loosely hanging skin folds. Histopathology reveals degenerative changes in the dermal elastic fibers, although loss of elastin can also occur in alveolar walls, blood vessels, and other organs. The coexistence of autoimmune diseases and monoclonal gammopathies is rare but well documented in the literature. Here we report an unusual case of cutis laxa (CL) preceding the development of serologic evidence of systemic lupus erythematosus (SLE) and a diagnosis of multiple myeloma (MM) by seven and eleven years respectively.

BACKGROUND:There is a long history of using topical coal tar for the treatment of psoriasis and atopic dermatitis (AD). OBJECTIVE:To review the literature on coal tar and its derivatives, without the use of ultraviolet light, for the treatment of psoriasis or AD. METHODS:MEDLINE/PubMed and Cochrane Database of Systematic Reviews literature searches were performed to identify randomized controlled trials and clinical trials of topical coal tar for the treatment of psoriasis or AD. Studies were graded according to a modified version of Sackett's criteria for clinical evidence and evaluated to determine if they support or do not support the use of coal tar therapy. RESULTS:Twenty-five studies meeting the authors' search criteria were identified, only two of which were placebo-controlled. The majority (21, or 84%) supported the use of coal tar products in the treatment of psoriasis or AD, while four (16%) did not support the use of coal tar products. CONCLUSION/CONCLUSIONS:Most studies support the use of coal tar products, although their level of evidence is not strong. Topical coal tar was found to be efficacious in the treatment of psoriasis in two placebo-controlled trials. Coal tar products appear to be therapeutic in psoriasis and AD, are well tolerated with few side effects, and are cost-effective. Staining and odor are deterrents to coal tar therapy. Large, randomized, double-blind, placebo-controlled studies with precise point estimates of treatment effect are needed to establish the efficacy of coal tar preparations.

OBJECTIVE:To critically review the body of clinical trials refuting or supporting the efficacy of topical antihistamines in the relief of pruritus. DESIGN/METHODS:Review of PubMed from January 1950 through September 2009 and the Cochrane Database of Systematic Reviews to identify therapeutic trials of topical antihistamines in the relief of pruritus. MAIN OUTCOME MEASURES/METHODS:All randomized controlled trials or clinical trials of topical antihistaminic compounds used in the treatment of pruritus. The authors found 19 trials throughout the literature. The quality of each trial was ranked by applying a modified version of Sackett's criteria for clinical evidence. Grade A trials are large, randomized, double-blind, placebo-controlled studies with low false-positive (alpha) and low false-negative (beta) errors. Grade B studies are also randomized, double-blind, placebo-controlled studies, but include a small number of patients. Grade C trials lack one or more of the following criteria: randomization, placebo control or blinding. RESULTS:Only four large, randomized, double-blind, placebo-controlled clinical trials with definitive conclusions (grade A) support the use of topical antihistaminic agents, specifically topical doxepin, for relief of pruritus. Of seven grade B trials, four supported the efficacy of topical antihistamines while three refute their use in relieving pruritus. One grade B trial was inconclusive. All remaining trials (grade C) lacked placebo controls or randomization, or contained fewer than 20 patients in each treatment group. CONCLUSION/CONCLUSIONS:While topical antihistamines are widely prescribed for the treatment of pruritus, the evidence to support their use is mixed. Topical doxepin has been demonstrated to reduce pruritus. Evidence is lacking, however, for other topical antihistamines, including diphenhydramine (Benadryl), that are widely used and available without a prescription.

Lipomas are common benign neoplasms of adipose tissue. Lipomatosis, the progressive appearance of multiple lipomas, is most often associated with specific congenital, familial, or idiopathic syndromes. In one reported case, the development of multiple lipomas occurred as a result of treatment with rosiglitazone, a peroxisome proliferator-activated receptor (PPAR) gamma agonist. We report a second case of lipomatosis occurring as a result of treatment with a PPAR gamma agonist. This case occurred in a 77-year-old woman who developed multiple lipomas two years after beginning treatment with pioglitazone, a PPAR gamma agonist. Histopathologic examination confirmed these lesions to be lipomas. Within four weeks of discontinuation of pioglitazone, regression of the lipomas began. We describe a case of PPAR agonist-induced lipoma formation, review relevant literature, and provide a molecular mechanism for this side effect.

Pityriasis lichenoides is a rare cutaneous eruption of unknown cause that spans a spectrum of clinical severity. Infectious agents have long been suspected as etiologic factors. The present case is the first to demonstrate a known EBV-mediated process evolving and resolving in concert with pityriasis lichenoides. Epstein-Barr virus, Toxoplasma gondii, and HIV are the most frequently reported infectious triggers of pityriasis lichenoides. Pityriasis lichenoides may arise secondary to EBV-mediated acute infectious mononucleosis.

Cutaneous sinus tracts of dental origin are often initially misdiagnosed and inappropriately treated because of their uncommon occurrence and the absence of symptoms in approximately half the individuals affected. Patients are often referred with a recurrent or chronic cyst, a furuncle, or an ulcer on the face or neck. Correct diagnosis is based on a high index of suspicion and on radiologic evidence of a periapical root infection. Appropriate treatment results in predictable and rapid healing of these lesions. We present a case report of this common misdiagnosis and a review of the literature with regard to diagnosis and treatment.