A52-year-old white man presented with a pruritic eruption on the neck of 3 months’ duration. The rash had not responded to a potent topical corticosteroid prescribed by another practitioner for the presumed diagnosis of eczema. The patient reported no current health problems. His history included a pubic louse infestation and several episodes of uncomplicated urethral gonorrhea. He readily admitted to having unprotected sexual intercourse with prostitutes. Ted Rosen, MD, of Houston writes that a heavily crusted, fissured plaque encircled the patient’s neck and extended to the upper chest and ears. The differential diagnosis included chronic contact dermatitis; Hailey- Hailey disease; severe atopic eczema; and crusted, or Norwegian, scabies. Innumerable scabies mites were revealed by microscopic examination of a skin scraping placed in mineral oil; Norwegian scabies was diagnosed. Norwegian scabies is a severe, although rare, form of scabies caused by the mite Sarcoptes scabiei. Crusting dermatitis of the hands and feet and erythematous scaling plaques on the neck, head, and back are characteristic. Lymphadenopathy and eosinophilia may also be present, as was the case in this patient. The infestation was successfully treated with 3 oral doses of ivermectin, 200 µg/kg, administered 2 weeks apart and topical applications of permethrin cream. The patient’s history of recurrent sexually transmitted disease and the Norwegian scabies infestation suggested immunosuppression and possible HIV disease. Serologic examination determined the patient was seropositive for HIV. He was lost to follow-up. Mucous Membrane Necrosis Secondary to OTC Bronchodilator Overuse
A 35-year-old man was hospitalized with severe dehydration secondary to necrosis of the throat. He found oral intake impossible because of severe discomfort when swallowing. The patient took no prescription medications; he had not been hospitalized or seen by a medical practitioner recently. During the history, Sam Poser, MD, of Columbus, Wis, learned that the patient had self-diagnosed asthma and had been using an over-the-counter bronchodilator, inappropriately, dozens of times a day at up to 5-minute intervals. All cultures were negative for pathogenic organisms. Normal pulmonary function test results led to the diagnosis of superficial vasoconstriction and subsequent necrosis and sloughing of the mucous membranes caused by the excessive use of an inhaled vasoconstrictor/bronchodilator. After several days of hydration and analgesia, the patient was able to eat and drink without difficulty. The necrotic patches healed without further problems. Infantile Perianal Pyramidal Protrusion
A 3-mm long, double-tipped, polypoid lesion appeared just anterior to the anus on an 8-month-old girl 2 days earlier. The lesion was excised in the office: a local anesthetic was administered, and the base was lightly electrodesiccated. Antibiotic ointment was applied until the area healed. Pathologic findings identified an infantile perianal pyramidal protrusion. Robert P. Blereau, MD, of Morgan City, La, writes that this lesion is similar to an acrochordon, or skin tag. Its location in the midline anterior to the anus may be related to the anatomic characteristics of the perineum and median raphe.1 These lesions are seen more often in girls. The differential diagnosis includes perianal eruptions associated with child abuse, genital warts, granulomatous lesions of inflammatory bowel disease, acrochordons, and rectal prolapse. Wiping of the affected area may increase the size or swelling of the protrusion. There is no specific treatment; usually, conservative follow-up is recommended. A large lesion may be excised to make the patient more comfortable, as in this case. Seborrheic Keratoses
A 70-year-old man was concerned about these dark lesions that covered his back and legs. Sunita Puri, MD, of Decatur, Ala, diagnosed seborrheic keratoses. Also called seborrheic wart and verruca seborrheica, these benign growths can present as a single tumor or as crops of lesions. They often appear on the face, trunk, and legs—where sebaceous glands are most common—and generally do not appear on palms, soles, and mucous membranes. Initially, seborrheic keratoses are flat, sharply demarcated, brown maculae. Over time, the lesions become polypoid with an uneven surface and may be warty, dark brown or black, and greasy (A). They are identified by their “stuck-on” appearance. On the trunk, they may develop in the pattern of a “Christmas tree” (B), as in this case. Because clothes and jewelry can catch on the lesions, they are considered cosmetically undesirable and annoying. The age of onset is typically after the fifth decade. Men and women with a familial tendency are equally affected. Rarely, a sudden appearance of multiple lesions may be associated with underlying malignancy.1 When there is diagnostic doubt, or when a skin cancer is suspected, a biopsy is indicated. These lesions can be removed with cryosurgery, curettage, or laser therapy. This patient was reassured about the benign nature of the lesions. Cavitary Lung Cancer With Metastases
A 60-year-old woman with a 3-month history of cough, chest pain, and shortness of breath was brought to the emergency department. The patient denied any history of fever, chills, or rigors; she complained of mild hemoptysis for 1 week and a 9-kg (20-lb) weight loss during the last few months. The patient had smoked cigarettes for 40 years. A chest film and a CT scan (A, arrow) showed a right upper lobe cavitary lesion. A bronchoscopy with biopsy of the lesion and a transbronchial needle aspiration confirmed a squamous cell carcinoma of the right upper lobe of the lung. Further workup demonstrated metastatic disease in the adrenal glands and the bones. The patient initially responded to combined radiotherapy and chemotherapy. She died of metastatic disease 9 months later. M. Duggal, MD, N. Shah, MD, and Arunabh, MD, of Forest Hills, NY, write that approximately 16% of all peripheral primary carcinomas show evidence of cavitations, which most frequently occur in squamous cell carcinomas.1 Cavitations are also common in bronchoalveolar carcinoma, which is a very well-differentiated adenocarcinoma. Metastatic lesions in the lung also may have cavitations; however, in contrast to primary lung cancers, which are usually solitary, multiple lesions are present in most patients with metastatic disease. Cavitating metastases most frequently occur from head, neck, and esophageal tumors and uterine carcinomas. Cavitations often signal underlying central necrosis. Many conditions can present with cavitations and need to be considered in the differential diagnosis of cavitary lung lesions. Generally, infection is the most common cause; Staphylococcus, Klebsiella, Pseudomonas, and anaerobic organisms frequently cause pneumonia with cavitations (B, arrow). In addition, chronic granulomatous infections, including tuberculosis (C, arrow), histoplasmosis, blastomycosis, and coccidioidomycosis, may result in multiple or solitary cavitary lesions. Lung abscesses develop from pyogenic infections, particularly those caused by aspiration of oral anaerobes that ultimately produce putrid sputum, tissue necrosis, and pulmonary cavities (D, arrows). The course of a lung abscess is usually subacute; most patients present with a history of fever, chills, cough, rigors, and weight loss. Collagen vascular lesions associated with Wegener granulomatosis and rheumatoid arthritis can lead to lung nodules that may cavitate. Idiopathic Esophageal Ulcer
A 36-year-old homosexual man presented with a 2-week history of odynophagia to liquids and solids; he had no dysphagia or heartburn. The patient, who had been seropositive for HIV for 3 years, had refused all antiretroviral drugs and prophylactic agents against opportunistic infections. Lucia C. Fry, MD, and Klaus E. Mnkemller, MD, of Chandler, Ariz, noted white plaques consistent with thrush that covered the tongue and oropharynx. The patient’s CD4+ cell count was 50/µL. Esophagogastroduodenoscopy demonstrated a well-circumscribed ulcer with raised borders in the mid esophagus (arrow). Histopathologic examination of esophageal biopsy specimens showed an ulcer bed of granulation tissue; no cytoplasmic inclusions, granulomas, vasculitic changes, or microorganisms were seen. Immunohistochemistry stains were negative for intracytoplasmic and intranuclear inclusions; special stains yielded no fungi or mycobacteria. Idiopathic esophageal ulcer (IEU) was diagnosed. Candida species are the most common causes of esophagitis in HIV-infected patients; however, these fungi rarely cause esophageal ulcers. Cytomegalovirus (CMV) causes about 50% of esophageal ulcers in HIV-infected patients; herpes simplex virus (HSV) is a less common cause of ulcerative esophagitis in these patients. About 25% of cases of esophageal ulcers have no specifically identified microbial cause. The pathogenesis of IEU is unknown. Esophageal ulcers may be present at the time of HIV seroconversion; however, they usually occur in patients with severe immunodeficiency who have CD4+ cell counts lower than 50/µL. Odynophagia and dysphagia are the main symptoms of IEU and of ulcerative esophagitis from other causes. The diagnosis of IEU is one of exclusion; multiple biopsies of the ulcer margins and base are needed to exclude an infectious process. Oral prednisone, 40 mg/d tapered to 10 mg/wk for 1 month, is the most common therapy. This agent has a healing rate of more than 90% and provides significant pain relief within days.1 Concurrent therapy with a systemic azole preparation can be used to prevent Candida esophagitis and treat it in patients who are coinfected with Candida and CMV or HSV. This patient’s symptoms resolved during the first 3 days of treatment with prednisone. He was also given fluconazole for the thrush. At follow-up 2 months later, the patient was asymptomatic.