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Systemic Examination (systemic + examination)
Selected AbstractsEvolution of histoid leprosy (de novo) in lepromatous (multibacillary) leprosyINTERNATIONAL JOURNAL OF DERMATOLOGY, Issue 7 2005Virendra N. Sehgal MD A 26-year-old man presented with persistent redness of the face over the past 2 years and thickening of the ears for a year. The current state was preceded by three to four episodes of epistaxis, 2,3 months previously. The patient had not received any treatment. Cutaneous examination revealed indurated (infiltrated) plaques on the face and ears over an apparently normal-looking skin, and numerous, small, ill-defined, slightly hypopigmented, shiny macules all over the body. They were bilateral and symmetric (Fig. 1a,b). There was no variation in the cutaneous sensations of temperature, touch, and pain. The patient showed loss of the lateral eyebrows and conjunctival congestion. Examination of the nerves revealed enlargement of the ulnar, radial, posterior tibial, and right common peroneal nerves; however, there was no tenderness of the nerves. Systemic examination was within normal limits. Examination of a slit-skin smear (under oil immersion), prepared from a representative lesion (plaque), demonstrated an abundance of solid and uniform-staining acid-fast bacilli, occurring either singly or in parallel clumps/globii, in an average field (6+). Furthermore, a scraping mount (10% KOH) prepared from the lesion on the back was negative. Figure 1. (a, b) Histoid leprosy Hematoxylin and eosin-stained sections prepared from a biopsy taken from a plaque revealed a conspicuous granuloma composed of peculiar spindle-shaped histiocytes. Several of the granulomas were present in the mid and lower dermis. They were characterized by whorled, criss-cross, or parallel patterns. Solid and uniform-staining, slender, rod-like (length three times that of the breadth) acid-fast bacilli were found scattered throughout the section. A few histiocytes closely packed with acid-fast bacilli, together with lymphocytic infiltrates, were also seen. There was a prominent eosinophilic stained clear zone just below the epidermis. It was free from acid-fast bacilli as well as the inflammatory infiltrate (Fig. 2a,b). A definitive diagnosis of untreated lepromatous leprosy (LL) changing to histoid leprosy (de novo) was made. Figure 2. (a, b) Histoid leprosy depicting granuloma formed by histiocytes displaying whorl-wind, criss-cross or interlacing pattern, and a clear zone beneath the epidermis (H&E ×40) Solid and uniform staining acid fast bacilli, , slender, rod-like, length 3 times that of breadth found scattered throughout the granuloma (H&E ×100) [source] Multiple pilomatricoma with perforationINTERNATIONAL JOURNAL OF DERMATOLOGY, Issue 12 2002Emel Fetil MD A 22-year-old woman presented to our clinic with a complaint of masses on various parts of her body. A mass on her right forearm had appeared 5 years ago and had enlarged during the past 6 months. Two lesions on the back of her neck had a 3-year history, one lesion on her eyebrow had a 2-year history, and one lesion on her left forearm had a 1-year history. The lesion on her left forearm was discharging purulent material. Dermatologic examination revealed a 15 × 16 mm tumor on the right forearm, 11 × 6 mm and 10 × 5 mm tumors on the back of the neck, and a 20 × 20 mm tumor on the eyebrow; they were flesh-colored, well-defined, firm tumors. On her left forearm, there was a 12 × 10 mm, well-defined, firm, blue,red tumor discharging chalky white granules; purulent material was detected (Fig. 1). Figure 1. Firm, blue,red tumor discharging chalky white granules There was no regional lymphadenopathy. Systemic examination was normal. Laboratory examination of hematologic, biochemical, and urinalysis tests was normal. There was no family history of similar lesions. Total excision of all the tumors was performed. Histopathologic examination of the material revealed clusters of eosinophilic shadow cells surrounded by a fibrous capsule. There were also foreign body giant cells. Areas of calcification, cholesterol clefts, and ossification were detected. An intraepidermal perforating area was detected from the biopsy material of the left forearm (Fig. 2). There were no recurrences after 1 year of follow-up. Figure 2. Intraepidermal perforating area and clusters of shadow cells (hematoxylin and eosin, × 200) [source] An unusual association of pemphigus vulgaris with hyperprolactinemiaINTERNATIONAL JOURNAL OF DERMATOLOGY, Issue 10 2002MNAMS, Sujay Khandpur MD A 21-year-old unmarried woman presented with oral ulcerations and generalized, itchy, fluid-filled, skin lesions of 10 days' duration. The lesions ruptured spontaneously, resulting in extensive denuded areas covered by crusts. One month prior to this, she experienced pain and enlargement of both breasts with galactorrhea. Her menstrual cycles were normal initially, but later she developed menstrual irregularities. No past history suggestive of any other systemic or skin disease, including atopy or drug allergies, could be obtained. Her family history was not contributory. Dermatologic examination revealed multiple, flaccid bullae and extensive denuded areas of skin covered with crusts over the scalp, face, trunk, and upper and lower limbs (Fig. 1). Bulla spread sign and Nikolsky's sign were positive. The oral mucosa, including the lips, buccal surface, tongue, and palate, showed multiple erosions covered with necrotic slough. The rest of the mucocutaneous and systemic examination was within normal limits. Figure 1. Extensive erosions and flaccid bullae over the trunk with breast enlargement The patient's diagnostic work-up revealed: hemoglobin, 11.2 g%; total leukocyte count, 7400/mm3; differential leukocyte count, P62L34E2M2; erythrocyte sedimentation rate, 34 mm/h. A peripheral blood smear examination, urinalysis, blood sugar, and renal and liver function tests were normal. Venereal Disease Research Laboratory (VDRL) test and enzyme-linked immunoabsorbent assay (ELISA) for human immunodeficiency virus (HIV) were nonreactive. Antinuclear antibody, lupus erythematosus (LE) cell, rheumatoid factor, and anti-dsDNA levels were normal. Serum protein electrophoresis demonstrated increased levels of immunoglobulin G (IgG) antibody. The serum prolactin level was significantly raised to 139.49 ng/mL (normal, 3.6,18.9 ng/mL). The sex hormone levels, however, including follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, and progesterone, were within normal limits. The thyroid hormone profile was also unaltered. Chest X-ray was normal. Ultrasound of the abdomen and pelvis revealed no visceral abnormality and computerized tomography (CT) scan of the pituitary sella showed no adenoma. Mammography was negative for breast malignancy. A Tzanck smear prepared from the base of the erosion showed multiple acantholytic cells and lymphocytes. Histologic examination from an intact vesicle was suggestive of pemphigus vulgaris (PV), showing a suprabasal cleft with acantholytic cells and the basal layer demonstrating a "row of tombstones" appearance (Fig. 2). Direct immunofluorescence (DIF) revealed the intercellular deposition of IgG and C3 throughout the epidermis in a "fishnet pattern." Indirect immunofluorescence (IIF) test performed on rat esophagus for circulating IgG antibody was positive in a titer of 1 : 120. Figure 2. Photomicrograph showing suprabasal cleft with "row of tombstones" appearance, suggestive of pemphigus vulgaris (hematoxylin and eosin, × 40) Based on the clinical and immunohistological features, a diagnosis of PV with idiopathic hyperprolactinemia was made. The patient was treated with bromocriptine mesylate (Tablet Proctinal, Glaxo Wellcome Ltd, India) at a dose of 2.5 mg twice a day. After 2 months of therapy, significant improvement in the skin lesions was observed. The existing lesions re-epithelialized with a drastic reduction in the number and distribution of new vesicles. However, no change in the mucosal erosions was noticed. IIF test demonstrated a lower antibody titer (1 : 40). The breast complaints also improved with a reduction in serum prolactin level to 6.5 ng/mL. The patient refused further treatment as she experienced nausea and dizziness with bromocriptine. After 2 weeks, the disease relapsed with the appearance of new vesicles over the forearms, abdomen, back, and thighs. She again complained of breast tenderness and galactorrhea, and the serum prolactin level was 95 ng/mL. The IgG titer increased to 1 : 120. Hence, treatment with oral prednisolone (2 mg/kg/day) and bromocriptine (2.5 mg twice a day) with an antiemetic was initiated. After 6 weeks, the skin lesions had cleared completely, the breast symptoms had improved, menses had become regular, and the prolactin level had decreased to 4 ng/mL. IIF test was negative for circulating antibody. Steroids were tapered off and maintenance therapy with bromocriptine at a dose of 2.5 mg/day was continued. [source] Choroidal neovascularization associated with cancer-associated retinopathyACTA OPHTHALMOLOGICA, Issue 5 2010Giuseppe Querques Abstract. Purpose:, To report an unusual association between cancer-associated retinopathy (CAR) associated with invasive thymoma and choriodal neovascularization (CNV), treated by photodynamic theraphy (PDT). Methods:, A 39-year-old man affected with thymoma and paraneoplastic syndrome (myasthenia gravis and diarrhoea) was observed between October 1997 and September 2007. The patient developed progressive visual dysfunction including bilateral visual acuity loss and concentric constriction of visual fields. Ophthalmological, immunological and systemic examinations were performed. Immunological evaluations included an assessment of antibody activity by indirect immunohistochemistry on sectioned rhesus monkey eye, and Western blot reactions upon an extract of pig retina. Results:, Fundus ophthalmoscopy and fluorescein angiography revealed retinal vessel attenuation and retinal pigment epithelium degeneration. Electroretinogram suggested both rod and cone dysfunction. Indirect immunohistochemistry identified antibody activity within the photoreceptor outer segments. Western blots on the retina revealed that most of the patient's antibody activity was focused upon a retinal protein antigen approximating 145 kD. These findings share the commonalities of size and retinal distribution of the interphotoreceptor retinoid-binding protein (IRBP), a recognized autoantigen. The surgically resected mediastinal tumour was diagnosed as invasive thymoma. No other malignancy has since been found throughout nearly 10 years of follow-up. In March 2006, the patient developed a subfoveal CNV in his left eye, which was treated by PDT. Conclusion:, We describe the third case of paraneoplastic retinopathy associated with invasive thymoma. This is the first example of CAR involving autoantibodies reactive with a retinal protein having the characteristics of the IRBP, and is also the first complicated by CNV treated by PDT. [source] | ||||||||||