Biomedical subjects
Dirk M Elston
Publications and source records attributed to Dirk M Elston.
Atypical junctional melanocytic proliferations in benign lichenoid keratosis.
Melanocytic lesions with lichenoid regression may mimic a benign lichenoid keratosis (BLK) histologically. A total of 336 BLKs were reviewed and deeper sections obtained to determine the frequency of this phenomenon. Two cases (0.6%) showed at least 1 melanocytic nest or junctional multinucleated melanocyte (starburst melanocyte) on deeper sections confirmed by MART-1 immunostaining. Both of these cases demonstrated solar elastosis, and 1 case had an effaced rete ridge pattern. Not included in the histological study are 5 additional cases in which the initial slide showed only lichenoid dermatitis, but deeper sections obtained before to the initial sign-out revealed a melanocytic proliferation. These 5 cases would have been signed out as "consistent with BLK" if deeper sections had not been obtained. Fluorescent in situ hybridization (FISH) was performed on 3 cases; in each case, the melanocytes demonstrated a loss of chromosome 9p21 DNA copy number. The finding of nests of genetically altered melanocytes on severely sun-damaged skin strongly suggests that these cases represent lichenoid regression of melanoma in situ. Pathologists should approach a diagnosis of BLK cautiously in the setting of severely sun-damaged skin.
Giant right plantar keloid treated with excision and tissue-engineered allograft.
Plantar keloids are a management problem as a result of the pain and mechanic restriction with ambulation. We present the treatment of a patient with a particularly large plantar keloid that was refractory to multiple excisions, adjunctive intralesional steroids, and radiation therapy, who was successfully treated with excision, intralesional steroids, and tissue-engineered allograft placement.
What is your diagnosis? Dermatomyositis.
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What's eating you? Strongyloides stercoralis.
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What is your diagnosis? Pseudocyst of the auricle.
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Invasive synergistic fungal infection after motor vehicle collision.
Primary invasive fungal infections occur after direct contact or direct inoculation of the skin with fungal spores. Rhizopus species and Aspergillus terreus are opportunistic fungal species that rarely cause disease in immunocompetent hosts. In susceptible patients, infection may progress rapidly. Aggressive surgical debridement and use of systemic antimycotic agents may successfully control disease and prevent systemic dissemination. We describe the case of a patient with a scalp infection, caused by Rhizopus species and A. terreus, that occurred after contact with pavement during a motor vehicle collision. Control was achieved with repeated debridement and use of systemic antifungal therapy.
What's eating you? Enterobius vermicularis (pinworms, threadworms).
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Primary systemic amyloidosis.
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What is your diagnosis? Exostoses.
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What's eating you? Megalopyge opercularis.
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War and rebuilding: what can we expect in the aftermath of the war in Iraq?
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Bullous eruption: a manifestation of lupus erythematosus.
Bullous lupus erythematosus (BSLE) is a rare subset of systemic lupus erythematosus (SLE), often associated with autoimmunity to type VII collagen. Generally, patients with BSLE meet the criteria for SLE as defined by the American College of Rheumatology. We present a case of a 17-year-old adolescent girl who presented with a vesiculobullous eruption without detectable type VII collagen antibodies and without full criteria for SLE. Differential staining was characteristic for lupus erythematosus (LE), suggesting her eruption is related to LE. We review the spectrum of bullous disease in patients with LE and discuss the pathogenesis and histology of these eruptions, as well as current therapeutic options.
Diseases encountered during war and rebuilding: lessons from past conflicts.
As we face the task of helping to rebuild Iraq, it is worthwhile to review our experience with past humanitarian aid missions and past conflicts. These efforts serve as models for the types of problems we may encounter today. It also is critical to review available data concerning the unique aspects of cutaneous diseases in that part of the world.
What is your diagnosis? Pachyonychia congenita.
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What's eating you? Canine scabies.
Infestation with Sarcoptes scabiei var canis, the causative strain of canine scabies, can produce a pruritic rash in humans. The rash generally manifests within 24 to 96 hours of contact with the affected pet. Scrapings are generally negative, and the correct diagnosis requires a high index of suspicion.
Metastatic aggressive digital papillary adenocarcinoma.
A 52-year-old white man presented with 2 complex cystic masses in his left inguinal region. On histopathologic examination, an asymptomatic nodule between the third and fourth metatarsal heads was diagnosed as an aggressive digital papillary adenocarcinoma (ADPAca), and the complex cysts from the groin represented metastatic disease from the primary acral tumor. The primary tumor was focally positive for immunoreactivity to ferritin antibody, an immunohistologic marker for sweat gland malignancies. Ferritin antibody may prove useful in the diagnosis of aggressive digital papillary adenoma (ADPA) and ADPAca.
Mohs micrographic surgery for melanoma: a case series, a comparative study of immunostains, an informative case report, and a unique mapping technique.
BACKGROUND: Mohs micrographic surgery (MMS) has been established as an alternative to standard surgical excision for local cutaneous malignant melanoma (MM) and melanoma in situ (MIS). The use of melanocyte-specific immunohistochemical stains may improve the diagnostic accuracy of MMS frozen sections. OBJECTIVE: We used MMS with immunostains to determine the maximum and minimum margins required to clear 52 melanomas, mostly MIS of the head and neck. We sought to identify the most sensitive melanocyte immunostain for use in MMS frozen sections and to improve the clinicopathologic correlation of perilesional pigmented lesions. METHODS: We studied 52 consecutive cases of invasive melanoma (n = 10) and MIS (n = 42), tabulating the maximum and minimum margins required for complete tumor resection in any one direction during MMS. In 10 of these cases we studied the relative sensitivity of the immunostains MART-1, S-100, and HMB-45 in Mohs frozen sections. We describe a case highlighting the importance of the increased sensitivity of MART-1. In 12 patients we used a unique mapping technique to help determine the clinical relevance of a total of 35 perilesional pigmented foci. RESULTS: The maximum margin averaged 10.1 mm (range 3-26 mm) for MM and 9.4 mm (range 3-18 mm) for MIS. The minimum margin averaged 7.0 mm (range 3-13 mm) for MM and 5.5 mm (range 3-11 mm) for MIS. For individual tumors, the difference between the minimum and maximum margin averaged 3.7 mm (range 0-13 mm). This difference was >or=5 mm in 38% (20/52) and >or=10 mm in 10% (5/52), highlighting that subclinical tumor extension is often broad and asymmetric. While five of six MM less than 1.0 mm in depth would have been cleared with a routine 1 cm excision, a standard 5 mm margin would have cleared less than one-quarter of the cases of MIS (10/42). In Mohs frozen sections, MART-1 proved superior in sensitivity to both HMB-45 and S-100. Our mapping technique provided clinically relevant histologic correlation for perilesional pigmented lesions, improving the Mohs surgeon's ability to evaluate equivocal foci in frozen sections. CONCLUSION: MM, especially MIS on the head and neck, often exhibits an asymmetric growth pattern, making it quite suitable for treatment with MMS. The use of MART-1 immunostain may improve the diagnostic accuracy of Mohs surgeons. We believe that HMB-45 should not be used to rule out the diagnosis of MIS in equivocal sections because of its inferior sensitivity. We introduce a new mapping technique as an adjunctive measure to aid in the clinicopathologic evaluation of perilesional skin.