Biomedical subjects
Publications and source records attributed to L Garcia e Silva.
The case reported concerns a 57-year-old man with a 35-year history of hidradenitis suppurativa lesions confined to his buttocks and recently complicated by a large, ulcerated, well-differentiated squamous cell carcinoma. Wide surgical excision and grafting, requiring temporary colostomy, were performed with no recurrence or metastasis during the following 12 months. The relevant literature is reviewed and discussed.
A 52 year old housewife was vaccinated against smallpox at the age of 18, on her right deltoid area. At the age of 50 she noticed erythema and scaling on the vaccination scar and 2 years later a nodule appear that enlarged during the following 3 months. There was no history nor skin changes suggestive of significant sun exposure. The histological examination of an initial biopsy and of the subsequently excised lesion revealed a basal cell carcinoma of the solid type. The relevant literature was reviewed and discussed with emphasis on sex and age incidence, age and site of vaccination, free interval between inoculation and tumor appearance, coexistence or not of other sun induced neoplasias and precancerous lesions and other possibly relevant clinical and etiopathogenetic aspects.
A 12-year-old diabetic girl is reported who developed faintly violaceous nodules on the back of the right thigh. These spread to the posterior aspect of the left thigh and to both legs. She complained of some muscular weakness. A diagnosis of cutaneous polyarteritis nodosa was considered. No blood eosinophilia was detected. Skin biopsy disclosed scattered dermal foci of eosinophilic and granular degeneration of collagen with a palisade of histiocytes and eosinophils in a flame configuration. The lesions did not correspond to the sites of insulin injections. Eight childhood cases of eosinophilic cellulitis were found in the literature, all of them in males. The specificity and meaning of the flame configuration are discussed.
The case of a 48 year old woman is reported with confluent nodules on the base of her nose and adjacent infraorbital areas, isolated ones on her face, and endotracheal masses with severe lumen reduction. Histologically the dermis and chorion of the nasal and tracheal mucosa were infiltrated by normal looking plasma cells. There was an increased ESR and a polyclonal gammapathy but no radiological evidence of skeletal involvement, bone marrow infiltration by atypical plasma cells or Bence Jones proteinuria. Cobalt-therapy was rapidly effective in reducing the endotracheal masses. The skin lesions were unaffected by roentgen-therapy and by several chemotherapeutic schedules. Laboratory values almost reverted to normal and her general condition has been satisfactory for the last two years. The differential diagnosis with multiple myeloma and extramedullary plasmocytoma was discussed and the condition classified as chronic, probably benign, mucocutaneous plasma cell infiltration.
Out of 3,000 consecutive basal cell carcinoma 81 (2.7%) were located on the scalp of 77 patients (41 males, 36 females). The age at diagnosis was 50.8 +/- 14 years. Seventy five patients had a single lesion, one had 2 and another 4. Significant etiological factors were organoid nevi (11), syringocystadenoma papilliferum (1), androgenic alopecia (5), wound scar (1) and radiodermatitis (1). Out of 29 patients who answered a specific enquiry 10 admitted to having been treated by X-ray epilation for tinea capitis in childhood and 4 to have taken arsenic containing medicines. The evolution of the tumors varied from several months to more than 10 years. They were mostly nodular, pigmented and, less commonly, ulcerated with a pearly border, pendunculated or sclerosing in type. Histologically they were mainly solid or adenoid, with 2 sclerosing and 1 keratotic in type. In two cases there was underlying bone involvement. Treatment was by conventional surgery (54), Mohs' surgery (24) and cryotherapy (3). Four lesions recurred but the follow-up was below 5 years in most cases. We cannot confirm the impression of a more aggressive behaviour often suggested in the literature.
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Fifteen patients with clinical and histological features of Crosti's reticulosis are reviewed. Twelve patients had lesions on the upper back and these were the only ones in eight of them. The other ones had extradorsal lesions. The histological picture was always compatible with Crosti's reticulosis. All the patients were treated by superficial roentgen therapy (1,200-1,500 rads) with total regression of the lesions. Four patients were lost for follow up. One progressed to lymphocytic lymphoma and another to Hodgkin's disease. It is possible that Crosti's reticulosis is not an autonomous entity, but a localized stage of more than one lympho-histiocytic neoplasia.
Out of 210 cases of ulcerative colitis 41 had skin and mucosal lesions: skin lesions in 23 (11%), oral ones in 11 (5.2%) and perianal in 16 (7.6%). Cutaneous lesions were: maculopapular rashes (5.2%), erythema nodosum (2.9%), pyoderma gangrenosum (1.4%), papulopustular lesions, vasculitis and erythema multiforme (1% each). Aphthae were the commonest oral complication (4.3%) and fissures and fistula the more prevalent perianal ones (4.3% and 3.4%). More than one mucocutaneous complication occurred in 17.1% of the patients and in 18 patients there were associated articular (36.6%), ocular (9.8%) and hepatic (2.4%) changes. The colitic type of arthritis and keratoconjunctivitis sicca were the commoner joint and eye manifestations.
Erythema nodosum (EN) has been reported in patients with ulcerative colitis (UC) since 1909. The reported incidence varies from 0.9 p. 100 to 18.9 p. 100. A wide range of incidence of EN has also been found in Crohn's disease (CD), with figures varying from 0.7 p. 100 to 8 p. 100 (fig. 1). Different criteria for the diagnosis of EN, UC and CD probably account for the scattering of values. A review of 324 cases of inflammatory bowel diseases revealed 21 cases with one or more episodes of EN: 6 out of 195 cases of UC (3.1 p. 100) and 15 out of 129 cases of CD (11.6 p. 100). The incidence was higher in females (5.7 p. 100 in UC, 17.5 p. 100 in CD) than in males (0 in UC, 6.9 p. 100 in CD). At the time of the eruption, patients with CD were younger (mean 24.3 years) then those with UC (mean 37.5 years). The interval between the onset of the intestinal symptoms and the nodular eruption was shorter in patients with CD (2.6 years) than in those with UC (8.2 years). The inflammatory bowel disease (whether UC or CD) started earlier in patients with EN than in EN-free patients. EN antedated the onset of intestinal manifestations in one patient with UC. In the remaining 20 patients the intestinal symptoms came first. EN was often recurrent, and the 21 patients suffered 32 episodes at varying intervals. One patient had 4 and another 3 episodes; six patients had 2 and 13 had one single episode. Three patients with UC had 2 episodes and 5 patients with CD had 2 or more episodes. The morphology and distribution of the lesions was fairly classical, except in 2 patients who had only 1 and 2 nodules respectively on one leg. The eruption subsided in all cases within 2 to 5 weeks, and no atrophy, suppuration or ulceration was observed. Most episodes of EN occurred during active phases of the intestinal disease. This was not so, however, in 2 cases in which the eruption followed an acute streptococcal throat infection. EN was more often found in total UC than in the less extensive distal and rectal types (Table I). It was also more frequent in the ileocolic form than in the exclusively ileal and colonic forms (Table II).(ABSTRACT TRUNCATED AT 400 WORDS)
The case of a 60 year old woman with an umbilical nodule of sudden onset, followed one year later by cholestatic jaundice and weight loss, is reported. The histology of the nodule suggested a metastatic adenocarcinoma of undetermined origin. Laboratory and radiological investigations, abdominal echography and laparotomy disclosed carcinoma of the gallbladder with invasion of the main biliary duct and peritoneal dissemination. A biliodigestive derivation was found technically impossible at the surgical operation and the neoplastic disease far too advanced tu justify chemotherapy. Only eleven cases of biliary tract carcinoma with umbilical metastases could be found in the literature. The relative incidence of the primary tumors giving umbilical metastases, the different ways in which they can reach the umbilicus and the ominous meaning of these metastases are discussed and the relevant literature is reviewed.
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A 17 years old male patient with acne vulgaris since the age of 13 is reported in whom a sudden exacerbation occurred with large, inflammatory, exquisitely tender, nodular lesions on the back and shoulders. Some were ulcerated and covered by hemorrhagic crusts. The lesions healed with large, unsightly, atrophic scars. With the cutaneous flare there was fever, arthralgia, loss of weight, leucocytosis and increased ESR. Systemic antibiotics (tetracycline, dicloxacillin, erythromycin) were unable to prevent or control the general and cutaneous symptoms that rapidly subsided on oral steroids. The initial relatively low dose could not be significantly reduced without further relapses. Attempts to replace prednisone by dapsone or clofazimine were unsuccessful. The relevant literature is reviewed and commented upon.
A 54 year old woman with an asymptomatic small cutaneous horn on her chin for several years is reported. Histologically the lesion had the combined features of an inverted follicular keratosis on its upper part and a nodular intradermal trichilemmoma with central cystic degenerative changes underlying the inverted follicular keratosis exophytic one. The relationships between the two lesions is discussed as well as the main controversial histogenetic hypothesis.
A 20 year old male patient is reported who has, since the childhood, two adjacent, slightly depressed, orifices on the midline of the dorsum of the nose through which a few hairs came out. The histology of the excised lesion revealed a central cystic cavity, open to the surface, in which converge multiple mature hair follicles, either of vellus and terminal types. There are conspicuous, well developed sebaceous glands. No secondary or tertiary hair follicles could be found and hair shafts are often thick, long and pigmented. The differential diagnosis is discussed, particularly with the trichofolliculoma and the fistula of the dorsum of the nose. The lesion shares most of the features of this last lesion and probably is a superficial variety of fistula of the dorsum of the nose. The lesion is quite different from the classical type of trichofolliculoma and the name sebaceous trichofolliculoma is considered to be an inadequate one.