Images in clinical medicine. Positive Tzanck smear.
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Aged↗
Biomedical subjects
L M Cohen
Publications and source records attributed to L M Cohen.
Hypermelanotic nevus: clinical, histopathologic, and ultrastructural features in 316 cases.
We report on a series of benign melanocytic nevi that have unique clinical, histopathologic, and ultrastructural features. Between March 1993 and February 1994, 316 examples of hypermelanotic nevi were received by the dermatopathology laboratory at Denver General Hospital. Our study identified the clinical characteristics, histopathologic criteria, and ultrastructure of this lesion. Clinically, the lesions were dark brown to black macules or papules. The most common location was the back. There was a slight female predominance, and the mean age of our patients was 40 years. Histopathologically, the nevus showed the following characteristics: (a) melanin within a compact stratum corneum, (b) small nests of nevus cells at the dermal-epidermal junction and (in 52% of the cases), nests within the papillary dermis, (c) heavy melanin within keratinocytes in the lower epidermis, (d) a sparse to moderate lymphocytic infiltrate and melanophages in the superficial dermis, and (e) an absence of cytologic atypia. Electron microscopy revealed that abundant melanin was packaged in melanosome complexes within keratinocytes. Less pigmented melanocytes and nevus cells contained well-developed dendritic processes and golgi, indicative of efficient melanin transfer. According to our retrospective case control analysis, patients with hypermelanotic nevi were older and more likely to be male than those with ordinary nevi. Hypermelanotic nevi were more likely than controls to be junctional nevi; they were smaller, dark brown or black in color, and clinically suspicious for melanoma. We propose the name "hypermelanotic nevus" to describe this benign lesion, which is often biopsied to exclude melanoma.
Adolescent↗
Lentigo maligna and lentigo maligna melanoma.
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Diagnosis, Differential↗
Ambivalence and dialysis discontinuation.
Although dialysis discontinuation is the second leading "cause" of death among individuals who are maintained with chronic dialysis, little attention is accorded in the literature to patient ambivalence with this crucial decision. Three cases are presented of clinical situations involving termination of dialysis and ambivalence. The ambivalence of the patients is mirrored by the literature's vacillation between viewing cessation of life-support as pathological, and perceiving it as rational. There is considerable variability in the presentation of these cases, and they require exquisite sensitivity and flexibility on the part of medical personnel. As patient-physician communication is encouraged, and staff attempt to honor requests for initiation and/or discontinuation of treatment, we will see increasing numbers of ambivalent patients.
Adult↗
The starburst giant cell is useful for distinguishing lentigo maligna from photodamaged skin.
BACKGROUND: Because lentigo maligna (LM) occurs in areas of the body that are subjected to long-term UV radiation (UVR), it may be difficult to distinguish atypical melanocytes in LM from the pleomorphic, atypical melanocytes in actinically damaged skin. OBJECTIVE: The purpose of this study was to determine whether the presence of multinucleated melanocytes would help to make this distinction. METHODS: A total of 89 cases of LM were reviewed for the presence or absence of multinucleated melanocytes and, if present, the maximum number of nuclei was recorded. As controls, 107 elliptical excisions of basal cell carcinoma or squamous cell carcinoma were randomly selected. The tips of the ellipses were reviewed for the presence or absence of multinucleated melanocytes. RESULTS: Multinucleated melanocytes with a "starburst" appearance, because of their prominent dendritic processes, were present in 85% of LM cases but in only 21% of sun-damaged control specimens (p < 0.00001; odds ratio [OR] = 22.6; 95% confidence interval [CI] = 10.6-47.9). The sensitivity and specificity of starburst giant cells (SGCs) in the diagnosis of LM was 85% and 78%, respectively. The maximum number of nuclei per SGC ranged from 2 to 30 in the LM cases (mean, 6.8 +/- 6.1) and from 2 to 6 in the controls (mean, 2.7 +/- 1.1) (p < 0.001). If only those SGCs with more than two nuclei are considered, 76% of cases but only 8% of controls contained SGCs (p < 0.00001; OR = 35.3; CI = 15.2-81.7). Similarly, 64% of cases and 3% of controls had SGCs with more than three nuclei (p < 0.00001; OR = 61.8; CI = 18.1-210.6). CONCLUSION: The SGC is a useful indicator for the diagnosis of LM. The diagnosis of LM is also more likely as the number of nuclei in SGC increases.
Adult↗
Multiple retiform hemangioendotheliomas. A low-grade angiosarcoma.
We present the case of a 30-year-old woman who over a 10-year period has developed multiple well-differentiated angiosarcomas involving the trunk and extremities. The clinical and histologic features are characteristic of retiform hemangioendothelioma (RH), a distinctive form of low-grade angiosarcoma. This case is unique in that multiple lesions developed in different anatomic sites. We discuss the clinical and histologic characteristics, diagnosis, and prognosis of RH.
Adult↗
Widespread papules and nodules in a Ugandan man with acquired immunodeficiency syndrome. African blastomycosis.
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Acquired Immunodeficiency Syndrome↗
Recurrent lentigo maligna invading a skin graft successfully treated with Mohs' micrographic surgery.
Lentigo maligna (LM) is a pigmented lesion occurring on sun-exposed skin that may become lentigo maligna melanoma (LMM). The tumor can behave in an aggressive fashion, causing significant cosmetic disfigurement, often extending significantly further than the clinical margin. Complete surgical excision is the treatment of choice. We describe a 74-year-old woman with a large LM of the left cheek, upper and lower eyelids, and preauricular skin that had recurred twice. The tumor was removed using Mohs' micrographic surgery (MMS) with rush permanent sections and was found to infiltrate extensively the split-thickness skin graft that had been placed five years earlier. LM can invade and replace a skin graft. Although destructive modalities and conventional surgery are recommended by some authors, MMS offers the greatest likelihood of cure, the ability to examine nearly 100 percent of the surgical margins, and maximal tissue sparing. Complete excision of LM at its earliest recognition may prevent invasive LMM and will limit cosmetic disfigurement.
Adult↗
Panniculitis: diagnosis and management.
Panniculitis, or inflammation of the subcutaneous fat, may present in a variety of ways. It is generally divided into septal and lobular types based on the histopathologic features. The different types of panniculitis are associated with a wide range of etiologies and systemic manifestations. Although some forms of panniculitis are self-limited, treatment depends upon eliminating the underlying cause in addition to using anti-inflammatory and immunosuppressive agents.
Diagnosis, Differential↗
Dialysis discontinuation. A 'good' death?
BACKGROUND: Approximately 10% of the deaths of patients receiving long-term dialysis for end-stage renal disease are preceded by discontinuation of dialysis. We prospectively studied the decision to discontinue dialysis and whether, as is often stated, these patients have a prompt, predictable, and comfortable death. METHODS: All patients receiving hemodialysis in a hospital-based and a freestanding unit whose long-term dialysis was discontinued in 1990 were included in the study. Patients, providers, and families of prospectively enrolled cases were interviewed to determine the reasons for discontinuation; the patients' terminal courses were reviewed daily to collect information describing their quality of death. Retrospectively enrolled cases were studied by chart review and interviews of providers. The reasons for discontinuation of dialysis and a rating of the quality of their deaths (for prospectively studied patients only) were determined by interdisciplinary team consensus. Quality of death was rated on scales of 1 (worst) to 5 (best) according to duration of dying, discomfort, and psychosocial circumstances. RESULTS: Eighteen patients discontinued dialysis after a mean duration of 43.6 months of hemodialysis, and they lived a mean of 9.6 days after termination. The quality of death of the 11 patients who were enrolled prospectively was subjectively assessed as "good" (> 10 of a possible 15 points) for seven patients and "poor" for four patients. A good quality of death was more likely if dialysis was discontinued because of medical deterioration from progressive chronic disease (P = .009); none of the three patients whose dialysis was discontinued for other reasons had a good death (P = .024). CONCLUSIONS: A majority of the prospective cohort of patients who discontinued dialysis experienced a good death by our largely subjective criteria. Improved palliative therapy for some of these dying patients, however, could have ameliorated prolonged suffering, delirium, and inadequately treated pain that led to a poor quality of death.
Aged↗
Lentigo maligna and lentigo maligna melanoma.
Lentigo maligna (LM) is a pigmented lesion that occurs on the sun-exposed skin, particularly the head and neck areas, of an older patient. The lesion increases in size and at some point, often many years after its onset, may become lentigo maligna melanoma (LMM). For this reason, most authors consider LM a form of melanoma in situ. Treatment includes surgical or destructive modalities; the preferred form of therapy is surgical removal. Histopathologic features include a proliferation of atypical melanocytes along the basal layer of the epidermis and adnexal structures. This article discusses the clinical, histopathologic, and epidemiologic features of LM. The prognosis and treatment of LM are reviewed. Although the lifetime risk of the development of LMM is unclear, LMM is discussed briefly.
Combined Modality Therapy↗
Disseminated Fusarium solani infection.
Disseminated fungal infections commonly occur in immunocompromised hosts; Candida spp. are the most common. Fusarium spp., soil saprophytes once considered pathogenic only in plants, have emerged as serious pathogens in neutropenic patients with malignancies. We describe two patients, one with acute myelogenous leukemia and the other with metastatic breast cancer, in whom disseminated Fusarium solani infection developed. Both patients had neutropenia and fever when generalized, tender, erythematous papules developed; most of the papules had black necrotic centers. Despite aggressive therapy with antifungal agents and granulocyte-macrophage colony-stimulating factor, both patients died within 1 month. Disseminated Fusarium infection can be a life-threatening condition in which skin lesions are frequently the initial sign. Early recognition and hematopoietic recovery offer the best chance for survival.
Adult↗
Complications of office based arthroscopy of the knee.
OBJECTIVE: To analyze the complication rates associated with office based arthroscopy in 2 community based rheumatology practices. METHODS: A retrospective analysis of 335 office based arthroscopy performed on 306 patients over a 35 mo period. All patients met specific clinical criteria to qualify for office based arthroscopy. Patients were followed postarthroscopy for a minimum of 12 weeks to assess the rates and types of complications. RESULTS: Of the 335 office based arthroscopies, 131 were diagnostic only, while 204 procedures were diagnostic and therapeutic. A total of 280 interventions were performed. Both major and minor complications were seen. The complication rates for major and minor events were 1.2 and 12.8%, respectively. There was no mortality or longterm morbidity. CONCLUSION: Office based arthroscopy in patients with rheumatic diseases has a safety profile that compares favorably with arthroscopy performed in an ambulatory surgical center or operating room setting.
Adult↗
Successful treatment of lentigo maligna and lentigo maligna melanoma with Mohs' micrographic surgery aided by rush permanent sections.
BACKGROUND: Lentigo maligna (LM) is a pigmented neoplasm on sun-exposed skin of elderly patients. LM slowly increases in size and may become lentigo maligna melanoma (LMM), a potentially fatal malignancy. Complete excision is the treatment of choice. Mohs' micrographic surgery (MMS) with frozen and permanent sections may be used for complete eradication of the lesion, while sparing as much normal tissue as possible. The authors studied the efficacy of MMS for the treatment of LM and LMM. METHODS: Between 1985 and 1992, 45 patients with LM (26) and LMM (19) were treated with MMS. The authors' technique was to use examination of frozen sections and rush permanent sections (prepared and read within 24 hours). Positive frozen sections warranted further excision. For negative or equivocal frozen sections, surgery was interrupted until the examination of permanent sections was performed. RESULTS: All 45 patients were free of local disease and evidence of metastases at an average of 29.2 months (range, 4-81 months) after therapy. CONCLUSIONS: MMS aided by rush permanent sections yielded a prolonged disease free survival for all 45 patients with LM or LMM. Because the MMS technique minimizes the removal of normal tissue, and the local cure rate in this study was superior to that reported for conventional surgery, the authors recommend this technique for the treatment of LM and LMM.
Adult↗
Management of lentigo maligna and lentigo maligna melanoma with tangential paraffin-embedded sections.
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Frozen Sections↗
Options for balancing the OASDI Trust Funds for the long term.
This article explores policy alternatives that can bring Social Security (OASDI) into long-term balance. The alternatives conform to long-standing principles that benefits are: an earned right, related to pay and time in the workforce, not based primarily on need; and related to annual changes in the cost of living. Furthermore, the OASDI is self-financed, employers and employees contribute equally, and participation is compulsory. In order to maintain public support, the policy alternatives also spread the "pain" of change between workers and beneficiaries, maintain income replacement rates for low-income earners, and retain a positive correlation between taxes and benefits. The article discusses varying four policy parameters to balance the funds: the primary insurance amount, the cost-of-living adjustment; the normal retirement age; and the payroll tax rate. Only by changing several policy parameters can all the objectives be satisfied. Discussed in detail are three scenarios, each of which includes a COLA cut and a pay-as-you-go FICA tax rate.
Adult↗
Do clinical and formal assessments of the capacity of patients in the intensive care unit to make decisions agree?
BACKGROUND: The complex environment and technology of intensive care unit (ICU) care may impair the ability of patients to participate in medical decision making or give informed consent. We studied the agreement of the intuitive assessments of residents and nurses of ICU patients' cognition, judgment, and decision-making capacity, and whether those assessments agreed with abbreviated formal mental status testing. METHODS: Using a prospective survey case study, we assessed 200 English-speaking patients within 24 hours of their ICU admission. Formal assessment of cognition, judgment, and insight was performed by a research assistant. We obtained independent intuitive ratings by nurses and residents of patient cognition, judgment, and ability to participate in medical decision making or give informed consent. RESULTS: Residents' and nurses' assessment of cognition and judgment showed a high degree of agreement with weighted ks of greater than 0.76. Assessments of cognition by residents and nurses agreed with Folstein Mini-Mental State Examination in 70% and 73.6% of cases, respectively. Forty percent of the population had an unimpaired Mini-Mental State Examination score of greater than 23, and an additional 12% of the subjects were mildly impaired with scores of 20 to 23. When asked whether they would approach patient or family for consent for an invasive procedure, nurses and physicians said they would request informed consent from 66% and 62% of the patients, respectively. CONCLUSIONS: Residents and nurses caring for patients newly admitted to the ICU agree in their assessment of cognition, judgment, and capacity to participate in medical decision making, and are not unduly influenced by ventilator status. Their assessments correlate highly with abbreviated formal mental status testing.
Cognition↗
Unilateral emboli in a patient with thrombotic thrombocytopenic purpura.
Thrombotic thrombocytopenic purpura is a rare disease most commonly associated with microangiopathic hemolytic anemia, thrombocytopenia, fever, neurologic disorders, and renal dysfunction. We describe a patient with a history of thrombotic thrombocytopenic purpura that had been quiescent for 4 months; he had a 3-week history of painful purpuric lesions on the left hand only. He also had mottling and a livedoid purpura of the distal fingertips, splinter hemorrhages of the left fingernails, and a decreased radial pulse. Findings of a biopsy specimen revealed multiple capillary and small vessel thromboses. Contrast aortography demonstrated a pseudoaneurysm of the proximal descending thoracic aorta with stenosis of the left subclavian artery at its origin and an associated thrombus.
Adult↗