Faculty Bibliography

We report the case of a 30-year-old woman with a three-year history of papules, nodules, and multiple ulcers of the left lower extremity. A skin biopsy specimen showed dermal fibrosis and patchy granulomatous inflammation in the upper-to-mid dermis that was associated with a perivascular, lymphohistiocytic infiltrate along with granulomas and necrosis in the subcutaneous fat. Tissue culture showed Mycobacterium avium complex infection. Clinical manifestations of cutaneous nontuberculous mycobacterial infections are discussed as well as their potential association with pedicures.

We report a 34 year-old woman with psoriasis, systemic lupus erythematosus (SLE), and recent anti-TNFa therapy, who presented with multiple, eruptive dermatofibromas (MEDF). Although the pathogenesis of MEDF remains unknown, there is substantial evidence that this phenomenon represents an aberrant immune response. Like the more common presentation of solitary dermatofibromas, these lesions are benign, and no treatment is required. However, MEDF is increasingly recognized as a sign of immune dysregulation and an appropriate work-up should be initiated to identify an underlying cause in patients without a known trigger.

BACKGROUND: Neutrophils in the setting of systemic lupus erythematosus (SLE) are commonly associated with bullous disease. Rare cases of nonbullous neutrophilic lesions have been reported in patients with SLE. OBJECTIVE: This study used clinical and histologic findings of 4 patients to further define the newly emerging entity of nonbullous neutrophilic lupus erythematosus (LE). METHODS: We reviewed the clinical and pathological findings of 4 patients with known SLE who developed urticarial papules, plaques, subcutaneous nodules, or a combination of these. RESULTS: All patients were women with established SLE. Histopathological findings in all patients included an interstitial and perivascular neutrophilic infiltrate with leukocytoclasia, and variable vacuolar alteration along the dermoepidermal junction. Direct immunofluorescence study results in two patients were positive for C3, IgG, and IgM along the basement membrane zone. One patient also presented with neutrophil-rich lupus panniculitis. All clinical lesions resolved with immunomodulating/immunosuppressive agents. LIMITATIONS: This study was limited by the small number of cases. CONCLUSIONS: Nonbullous neutrophilic LE is an important entity to consider in the differential diagnosis of neutrophil-mediated eruptions. In addition, the histologic finding of neutrophils in the setting of lupus should alert one to the possibility of systemic disease.

INTRODUCTION: Nephrogenic systemic fibrosis is a condition that has recently been recognized in patients with chronic renal disease and is associated with use of gadolinium-based contrast agents of ubiquitous use in magnetic resonance imaging scans. The condition is believed to arise through inadequate renal clearance of the gadolinium-based contrast agents, resulting in bodily deposition of the gadolinium; this is most widely recognized in the skin, but also occurs in other tissues. CASE PRESENTATION: We report the case of a 52-year-old Caucasian man with hypothyroidism and chronic renal disease who developed nephrogenic systemic fibrosis upon repeated exposure to gadolinium, and who presented with a subsequent malabsorption of levothyroxine. This malabsorption resolved only partially upon amelioration of other conditions that might contribute to malabsorption, including edema and infectious diarrhea. The presence of gadolinium was quantified in specimens from his gastrointestinal tract. Our patient otherwise demonstrated adequate gastrointestinal nutritive absorption, objectively shown by normal albumin levels, resolution of diarrhea, and maintenance of his bodily weight. CONCLUSIONS: Our observations suggest that nephrogenic systemic fibrosis can also affect tissue of the gastrointestinal tract, potentially contributing to partial malabsorption of levothyroxine in patients with hypothyroidism.

Introduction. Cutaneous foot melanoma is rare, challenging to manage, and not adequately examined in the literature. This study evaluated the prognostic variables and surgical management of foot melanoma. Materials and Methods. Foot melanoma cases managed at an academic center from 1985 to 2010 were retrospectively reviewed. Results. 46 patients were identified with a broad range of demographic characteristics. Overall recurrence was 32.6%: 19% acral lentiginous, 57% nodular, 66% superficial spreading, 30% melanoma unspecified, 50% severely atypical; 53% ulcerated, 23% nonulcerated; 29% on the dorsum of the foot, 17% heel, 60% ankle, 22% toe, 50% plantar; 0% <1 mm thick, 47% 1-4 mm, 33% >4 mm. 13 had positive nodes, 4 (31%) of whom recurred. Prognostic factors and recurrence did not correlate, and survival was 96% with a median followup of 91 months. Conclusions. Aggressive management of foot melanoma may result in excellent long-term survival even following disease recurrence.

Rhabdomyomatous mesenchymal hamartoma is a rare dermal lesion comprised of skeletal muscle, adipocytes and collagen. The vast majority has been described in very young patients on the head and neck. To our knowledge, there are only two reports of rhabdomyomatous mesenchymal hamartoma outside the head and neck region. Both of those lesions were located in the perianal area. We describe a rhabdomyomatous mesenchymal hamartoma in a 36-year-old man located on the great toe. Although rhabdomyomatous mesenchymal hamartoma is uncommon, it is important to be aware of this entity, its possible association with congenital syndromes and its potential for localization outside of the head and neck region.

The accurate diagnosis of inflammatory conditions in dermatopathology requires integrating the histopathologic findings with the clinical features. This second part of a 2-part review of inflammatory cutaneous conditions presents a pattern-based approach to the diagnosis of dermatologic disorders and reviews the salient clinical and histologic features.

The accurate diagnosis of inflammatory conditions in dermatopathology requires integrating the histopathologic findings with the clinical features. This can be difficult when skin biopsies are seen infrequently and the terminology is unfamiliar, as in a general surgical pathology practice. This 2-part review of inflammatory cutaneous conditions presents a pattern-based approach to the diagnosis of dermatologic disorders and reviews the salient clinical and histologic features. Part I will focus on the spongiotic, psoriasiform, interface, and bullous patterns, whereas Part II will review the perivascular, vasculitis, panniculitis, and nodular and diffuse patterns.