SEARCH · Search PubMed
Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.
Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.
We report a case of Rocky Mountain "spotless" fever with a localized rash at the site of the tick bite that resembled the erythema migrans rash of Lyme borreliosis. Physicians who practice in geographic areas where Rocky Mountain spotted fever occurs should be aware of this unusual presentation.
The course of the illness and the outcome of pregnancy were investigated in a prospective study of 58 consecutively enrolled pregnant women with typical erythema migrans at the University Medical Centre of Ljubljana, Slovenia. Thirteen patients (22.4%) acquired borrelial infection in the first trimester of pregnancy, 27 (46.6%) in the second trimester, and 18 (31%) in the third trimester. All patients were treated for 14 days: 2 (3.4%) with phenoxymethylpenicillin (1 million IU thrice per day), 3 (5.2%) with benzylpenicillin (10 million units twice per day), and 53 (91.4%) with ceftriaxone (2 g daily). For 51 of the 58 women (87.9%), the pregnancies were normal and the infants were born at term, were clinically healthy, and had normal psychomotor development. Of the remaining 7 pregnancies, 1 ended with a missed abortion and 5 with preterm birth; 1 of the preterm babies had heart abnormalities. One child born at term was found to have urologic abnormalities at 7 months of age. A causal relationship between borrelial infection and fetal adverse effects has not been proven, and for at least some such cases a reasonable explanation (not associated with Lyme borreliosis) was found.
Immunologic and clinical manifestations of erythema nodosum leprosum (ENL) and their response to thalidomide therapy were evaluated. Circulating tumor necrosis factor-alpha (TNF alpha) levels were assayed in serum obtained from lepromatous leprosy patients at diagnosis, during multidrug therapy, at the onset of ENL episodes, and during treatment with thalidomide. Patients with systemic ENL demonstrated the highest serum TNF alpha levels, which decreased significantly during thalidomide treatment. Serum TNF alpha in nonreactional patients was associated with mild flu-like symptoms and local inflammatory lesions. Serum interferon-gamma (IFN-gamma) was also elevated in patients with high TNF alpha levels. Thalidomide therapy reduced not only serum TNF alpha levels and the clinical symptoms but also the dermal infiltration of polymorphonuclear leukocytes and T cells. The expression of intercellular adhesion molecule 1 and major histocompatibility complex class II antigens on the epidermal keratinocytes was also down-regulated. These results indicate that the thalidomide-induced alleviation of clinical symptoms of ENL was associated with a reduction of TNF alpha levels.
Dietary antioxidants contribute to endogenous photoprotection and are important for the maintenance of skin health. In the present study, 2 groups of women consumed either a high flavanol (326 mg/d) or low flavanol (27 mg/d) cocoa powder dissolved in 100 mL water for 12 wk. Epicatechin (61 mg/d) and catechin (20 mg/d) were the major flavanol monomers in the high flavanol drink, whereas the low flavanol drink contained 6.6 mg epicatechin and 1.6 mg catechin as the daily dose. Photoprotection and indicators of skin condition were assayed before and during the intervention. Following exposure of selected skin areas to 1.25 x minimal erythemal dose (MED) of radiation from a solar simulator, UV-induced erythema was significantly decreased in the high flavanol group, by 15 and 25%, after 6 and 12 wk of treatment, respectively, whereas no change occurred in the low flavanol group. The ingestion of high flavanol cocoa led to increases in blood flow of cutaneous and subcutaneous tissues, and to increases in skin density and skin hydration. Skin thickness was elevated from 1.11 +/- 0.11 mm at wk 0 to 1.24 +/- 0.13 mm at wk 12; transepidermal water loss was diminished from 8.7 +/- 3.7 to 6.3 +/- 2.2 g/(h x m2) within the same time frame. Neither of these variables was affected in the low flavanol cocoa group. Evaluation of the skin surface showed a significant decrease of skin roughness and scaling in the high flavanol cocoa group compared with those at wk 12. Dietary flavanols from cocoa contribute to endogenous photoprotection, improve dermal blood circulation, and affect cosmetically relevant skin surface and hydration variables.
Understanding the role that nymphal and female ticks, Ixodes scapularis, have in the epidemiology of Lyme disease is essential to the development of successful prevention programs. In this study, the authors sought to evaluate the seasonal and annual relations between tick densities and patients > or = 16 years of age diagnosed with erythema migrans (EM), the rash associated with early Lyme disease. Ticks were collected weekly by drag sampling throughout most of the year from 1991 to 1996 in Westchester County, New York. The number of EM cases was based on patients diagnosed at the Westchester County Medical Center using Centers for Disease Control and Prevention (CDC) criteria. No patients with EM were diagnosed from January through April, when only adult ticks were active. Correlation analysis between monthly tick densities and EM incidence was significant for nymphs (r = 0.87, p < 0.01), but not for adult ticks (r = -0.57, p > 0.05). There was a strong, although not significant, correlation between peak annual number of patients with EM and peak nymphal tick abundance (r = 0.76, p = 0.08). These data indicate that bites from adult I. scapularis only rarely result in Lyme disease, and that annual nymphal tick abundance determines exposure. This suggests that annual fluctuations in Lyme disease case numbers are largely due to natural changes in tick abundance and, therefore, that control of nymphal I. scapularis should be a major component of Lyme disease prevention efforts.
Ticks were collected during 1977 in communities east of the Connecticut River where there was a high incidence of erythema chronicum migrans and Lyme arthritis and were compared with collections from a similar area 20 km west of the river where cases of the disease were rare. Ixodes scapularis was much more abundant on the east side than on the west. Immature I. scapularis were 13 times more abundant on white-footed mice (Peromyscus leucopus), and adult I. scapularis 16 times more abundant on white-tailed deer (Odocoileus virginianus) in the east than in the west communities. In addition, all active stages in the life cycle of this tick--larvae, nymphs, and adults--both males and females, were found on humans (mostly patients) in the east communities. Both nymphs and adults were abundant on dogs and cats in this area. Attempts to recover an etiologic agent from ticks were unsuccessful.
A lesion of erythema chronicum migrans was examined by light and electron microscopy. Spirochetes were identified by light microscopy with Steiner silver stain. Electron microscopy was performed on deparaffinized tissue of the biopsy specimen and a spirochete was identified in the tissue. This treponema-like spirochete has morphological characteristics similar to those described previously for spirochetes obtained from ticks in areas endemic for Lyme disease.
A 70-year-old man with erythema elevatum diutinum developed new lesions on his right hand 4 years after initiation of treatment with dapsone. An unusual protruberant appearance of these lesions grossly and a peculiar fibrosing quality histopathologically of one lesion are features that, to our knowledge, have not been reported previously.
The recent discovery that spirochetes transmitted by the tick Ixodes ricinus are involved in the etiology of erythema chronicum migrans Afzelius (ECMA), Bannwarth's syndrome, and acrodermatitis chronica atrophicans (ACA) has thrown new light upon these disorders. Thirty-two patients showing clinical and serological evidence of ACA were investigated. Histologically, constant findings in active ACA lesions were telangiectases and a lymphocytic infiltrate with a moderate to rich admixture of plasma cells. Clinically, besides ACA lesions, lichen sclerosus et atrophicus (LSA)-like lesions were found in five patients. Four of these patients displayed a histopathological picture compatible with LSA. These findings suggest a relationship between ACA and LSA. In six patients spontaneous healing of ECMA was followed by ACA lesions after a latency period of 1-8 years. Six patients reported histories of cranial nerve involvement. Radiography revealed subluxation of joints in hands or feet in six patients, and periosteal thickening in another three patients. The results indicate that ACA may be a late manifestation of infection with the same spirochete that causes ECMA and Bannwarth's syndrome. If untreated, the infection may continue for many years and result in irreversible degenerative lesions.
We obtained biopsies from early, fully developed, and late lesions of erythema elevatum diutinum (EED) in a 49-year-old man. The histologic and electron-microscopic findings were compared with those reported in the literature and three other cases from our files. Early lesions show leukocytoclastic vasculitis with capillary proliferation. Later lesions show vasculitis, dermal aggregates of neutrophils, fibrosis, and areas of granulation tissue. Newly formed vessels in granulation tissue may be more susceptible to damage by immune complexes, and the early formation of granulation tissue in EED may prevent an early resolution of vasculitis. Damage to dermal connective tissue in EED incites either scarring or, rarely, a fibrohistiocytic proliferation. Ultrastructural examination of one case showed histiocytes with myelin figures and intracellular lipid and cholesterol.
Miescher, in 1947 and 1951, described peculiar radial nodules in erythema nodosum (EN). They consisted of relatively small histiocytes, radially placed around a central cleft. In early lesions, these nodules occurred in association with edema and infiltration of polymorphonuclear leukocytes; later, giant cells originated from the outer borders of the granuloma. Miescher's radial granulomas (MRGs) are mainly located in the interlobular septa and in the deeper layers of the cutis. Although Miescher considered this structure as being specific for EN, it has largely been ignored in the subsequent literature. We have studied 79 biopsy specimens of EN and 182 biopsy specimens of other types of panniculitis. Sixty (76%) of the 79 biopsy specimens of EN disclosed some MRG whereas none was found in the other types of panniculitis. MRG is a characteristic and easily recognizable structure, even at low magnification, and appears to be a useful marker of EN. A detailed study has also been made of the histologic features of EN. Its variations, as well as those of MRG, are related to the chronology of the nodule.
Erythema induratum of Bazin (EIB) is a chronic, recurring panniculitis that is found predominantly on the legs of women with tuberculin hypersensitivity. A causal relationship between EIB and Mycobacterium tuberculosis remains elusive because of the absence of demonstrable organisms in skin lesions. We reviewed the clinicopathological features of 20 patients (all women) with positive Mantoux tests (1:10,000 dilution) and characteristic skin lesions of EIB that cleared up with combined antituberculous treatment. Histological examination of skin lesions confirmed panniculitis with varying combinations of granulomatous inflammation, primary vasculitis, and necrosis. Sections from 20 formalin-fixed, paraffin-embedded skin biopsies obtained from the 20 patients were submitted for polymerase chain reaction (PCR) using oligonucleotide primers for the detection of a 123-bp DNA fragment specific for the M. tuberculosis complex. M. tuberculosis DNA was identified in five of the 20 biopsies. Meticulous care was taken to prevent contamination as a source of false-positive results. Mycobacterial DNA was absent in all negative controls and in normal skin biopsies from purified protein derivative-positive patients with and without EIB. These results provide direct evidence that mycobacterial components are present in EIB lesions and strongly suggest that M. tuberculosis is involved in the pathogenesis of EIB.
The bcl-2 gene family plays a significant role in the propagation of cell survival and tissue modeling. Bcl-2 was originally described in follicular lymphomas and is associated with the suppresion of cellular apoptosis. Evaluation for this protein has been performed for a variety of benign and malignant cutaneous tumors but not to any significant extent on inflammatory disorders. Therefore, we stained biopsy specimens from diseases with interface inflammation (lichen planus, acute graft-versus-host disease, and erythema multiforme) for Bcl-2. Epidermal expression of this protein was minimal for all three diseases; however, lymphocytes stained prominently in lichen planus. The data suggest that Bcl-2 is not prominently involved in the epidermal changes in these diseases. The role of other members of this oncogene family in interface dermatitis still needs to be elucidated.
Erythema elevatum diutinum (EED) is a rare cutaneous condition that initially presents as leukocytoclastic vasculitis (LCCV) of the skin and later resolves with fibrosis. In addition to the LCCV, EED may show features reminiscent of other entities. For example, it may mimic lesions of dermatofibroma, granuloma annulare, granuloma faciale, or dermatitis herpetiformis. For this study, we reviewed the clinical records and 13 skin biopsies in eight patients with EED. One of the patients had concurrent pityriasis rubra pilaris, and another developed lesions of EED following and at the sites of mosquito bites; these associations have not been noted previously. In addition to such typical histopathological features as diffuse dermal involvement by neutrophils, eosinophils, and leukocytoclastic vasculitis, we also found two unusual patterns. The first was characterized by palisaded necrotizing granulomas, as previously described and associated with Churg-Strauss granuloma; the second condition simulated a pyogenicgranuloma--like lesion.
Erythema elevatum diutinum (EED) and granuloma faciale (GF) are chronic, localized forms of cutaneous leukocytoclastic vasculitis that result in patterned (storiform or concentric) fibrosis. EED often occurs in systemically ill patients as bilaterally symmetrical plaques, papules, or nodules, often over the dorsa of joints. GF occurs as one or a few plaques on the face. Eosinophils and plasma cells are prominent in GF, whereas neutrophils are plentiful in EED. Rarely, extrafacial lesions accompany facial ones in GF, and there are a few reports of upper respiratory tract masses with GF-like histologic features. We report on eight patients with solitary cutaneous lesions with histologic features similar to those of EED or GF, but whose clinical picture was not that of either disease. One, whose histology resembled GF, had a large multinodular dermal and subcutaneous mass that persisted despite attempted resection. Unusual histologic findings in other cases included storiform fibrosis with dense infiltrates of plasma cells, branching nerve fascicles admixed with EED-like changes, and EED-like areas adjacent to zones mimicking a sclerotic fibroma. Chronic fibrosing venulitis can be seen outside the stereotypic settings of GF and EED and is an inflammatory reaction pattern that does not signify a specific diagnosis. Because of transitions between EED or GF-like areas and those of patterned sclerosis with plasma cell-rich infiltrates, we believe that some "inflammatory pseudotumors" of the skin, and perhaps of other sites could be the result of localized vasculitis.
To reduce the erythematous discoloration of donor sites used for split-thickness skin grafts, we applied mild topical hyperthermia to the donor sites in 10 patients. Disposable chemical pocket warmers served as the source of heat and were kept in place for 8 hours daily for 8 weeks. Untreated controls consisted of the application of "used" warmers to another part of the lesion. Results were graded subjectively by physicians and patients as effective or ineffective. Quantitative evaluation of the change in the redness of the donor site was used as a system for color analysis. Changes in blood flow were evaluated with the laser Doppler flowmeter, and were evaluated after the application of heat for 8 weeks. Lessening of the erythema and a decrease in blood flow were observed in the affected areas of all subjects. There were no adverse effects.
Cutaneous vasculitis encompasses a highly heterogeneous group of disorders of diverse etiology, pathogenesis, and clinical features. Recent reexamination of clinical pathologic features have yielded no insights assisting our understanding of current clinical classification schemes and strengthening our clinical approach. Erythema nodosum is a common cutaneous disorder for which new etiologies continue to be described. Pyoderma gangrenosum is an uncommon ulcerative cutaneous condition that remains a therapeutic problem.
Leprosy is a disease that is widely distributed in underdeveloped tropical regions, with cases also occurring in the United States. The bone scan findings in a patient with leprosy who had developed a reactional state of the disease, erythema nodosum leprosum, are presented. His scan showed bilaterally symmetrical double stripe signs involving the distal tibias, similar to those seen in hypertrophic osteoarthropathy. Physicians should be aware that this reactive phase of leprosy can also produce the double stripe sign.