Hifu no kagaku
Online ISSN : 1883-9614
Print ISSN : 1347-1813
ISSN-L : 1347-1813
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Clinico-pathological notes by Dr.Murata
  • Yozo Murata
    2019 Volume 18 Issue 4 Pages 193-203
    Published: 2019
    Released: December 13, 2019
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    Epidermal collarette, a characteristic pathological finding of granuloma pyogenicum, is generally thought to be formed from the surrounding epidermis or appendages after hemangioma formation. However, by careful observation, following findings can be obtained ; first, the epidermis collarette is composed of upper and lower lobes of epidermis ; second, there are frequently seen skin appendages such as sweat apparatus and hair follicles under the lower lobe, but not seen above the upper lobe ; third, delicate elastic fibers exist only in the connective tissue facing the lower lobe. So, it can be said that the lower lobe of epidermal collarette had been existing before the onset of hemangioma, and that pyogenic granuloma is an upward proliferation of capillaries from the gap of the epidermis. In other words, pyogenic granuloma can be described as“a flake flower blooming in the empty sky”. From this perspective, ligation treatment is recommended as most appropriate treatment modality. Skin Research, 18 : 193-203, 2019

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CASE REPORT
  • Takashi Hosomoto, Nozomi Yoshioka, Yoko Yamamoto, Rieko Isogai, Hideka ...
    2019 Volume 18 Issue 4 Pages 204-210
    Published: 2019
    Released: December 13, 2019
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    Primary focus resection and sentinel lymph node biopsy were performed on a 50-year-old female under the diagnosis of primary malignant melanoma of the left lower abdomen (stage IIC T4bN0M0). In the extirpated left inguinal lymph node, metastasis from malignant melanoma was detected and the postoperative stage was evaluated as IIIC T4bN3M0. As postoperative chemotherapy, 5 courses of DAV-Feron therapy were administered and nivolumab (2mg/kg, every 3 weeks) was started. Computed tomography (CT) after the 8th course of nivolumab therapy revealed 9th right costal bone and multiple skin metastases. Topical radiotherapy at the site of bone metastasis and vemurafenib were started. Edematous erythema with vesiculation, which was consistent with the irradiated site,developed 10 days after starting vemurafenib, and diffuse systemic stigmas and red papules appeared thereafter. Considering drug exanthema, a steroid was administered. At the irradiated site, there was marked histological change, which is not routinely observed at a standard radiation dose,suggesting the radiation-enhancing effects of vemurafenib. Skin Research, 18 : 204-210, 2019

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  • Yuki Saito, Sayuri Onishi, Hideaki Tanizaki, Teruo Kurokawa, Shinichi ...
    2019 Volume 18 Issue 4 Pages 211-215
    Published: 2019
    Released: December 13, 2019
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    A man in his 50s was diagnosed with alcoholic acute pancreatitis three months before the rst visit to our hospital. A painful erythema appeared on both legs two months ago. A month ago, an infectious pseudo-pancreatic cyst was observed and he was referred to the department of gastrointestinal internal medicine at our hospital. The same day, he was referred to our department for the skin lesions on both legs. At the rst visit, multiple painful indurated erythemas were observed on the medial center of both legs, accompanied by severe edema on his lower legs and feet. Laboratory examination revealed an increase in CRP and a marked increase in several pancreatic enzymes. Histopathological ndings included both septal panniculitis and lobular panniculitis, with degenerative necrosis of adipocytes, including ghost-like fat cells. Based on these ndings, this case was diagnosed as subcutaneous fat necrosis due to acute pancreatitis. The incidence of this disease is very rare, accounting for 0.1 to 0.3% of all pancreatic diseases, and the relationship between this condition and pancreatic disorders has not yet been elucidated. More cases should be examined in order to clarify the pathogenesis of subcutaneous fat necrosis related to pancreatic disorder. Skin Research, 18 : 211-215, 2019

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  • Eri Yonezawa, Nao Kusutani, Koji Sugawara, Masahiko Ohsawa, Shinzoh Ku ...
    2019 Volume 18 Issue 4 Pages 216-221
    Published: 2019
    Released: December 13, 2019
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    Tuberculosis verrucosa is warty plaque-like form of cutaneous tuberculosis resulting from the invasion of Mycobacterium tuberculosis into theskin in a previously M. tuberculosis-sensitized person. Cutaneous tuberculosis is classied into four subtypes by infection pattern : direct inoculation, direct inltration from internal lesion, hematogenous dissemination and tuberculid. We report a case of tuberculosis verrucosa that developed on a burn scar. A 67-year-old man presented with nodules and reddish plaqueon a burn scar on theright forearm. Hewas burned by a hot asphalt mixturesix years prior and treated the wound without medical intervention, but pruritic nodules developed on the burn scar later. He visited his previous doctor and received a topical steroid, which provided limited relief of pruritus, and he was referred to our hospital one year later. On physical examination, a 12×16 cm-sized reddish plaque on the right forearm with nodules arranged in a horseshoe shape was observed on the margin of the lesion. Skin biopsies were performed from the nodules, and the histopathological ndings were consistent with epithelioid cell granuloma without caseation necrosis. M. tuberculosis complex was detected in the mycobacterium culture of the biopsy specimen. As there was no tuberculous lesion other than the skin based on whole-body examination, we diagnosed him with tuberculosis verrucosa cutis caused by direct inoculation of M. tuberculosis. We started combination therapy with anti-tuberculosis drugs and the lesion was cured six months later. There have been 38 reported cases of tuberculosis verrucosa cutis in Japan in the past 35 years, and only 2 cases exhibited caseous necrosis histopathologically. This suggests that tuberculosis cannot be excluded by the absence of caseous necrosis in a biopsy specimen. Tuberculosis verrucosa cutis should be considered as a differential diagnosis of intractable warty lesions and we should perform mycobacterium culture in addition to pathological tissue examination. Skin Research, 18 : 216-221, 2019

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  • Haruka Goda, Naotomo Kambe, Kaori Kusabiraki, Fumikazu Yamazaki, Hiroy ...
    2019 Volume 18 Issue 4 Pages 222-225
    Published: 2019
    Released: December 13, 2019
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    A-70-year old man had a 30-year history of numerous skin colored papules on the extensor of the forearms. Similar papules were observed on the extensor sides of the lower legs, but not on the face and trunk. Histopathologically, deposition of a mucin-like substance was observed from the upper to middle layer of the dermis. These deposits, which were stained with alcian blue, disappeared after hyaluronidase digestion. No underlying diseases or complications causing mucin deposition were found. Based on the distribution of the eruption, we diagnosed this case as discrete papular lichen myxedematosus in lichen myxedematosus. As the eruption distributed at the sun-exposed parts and solar elastosis surrounded bythe lesion was histopathologicallynoted in the dermis, we speculate ultraviolet exposure to be one of the etiologies of this disease. Skin Research, 18 : 222-225, 2019

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  • Hiraku Kokubu, Noriki Fujimoto, Takeshi Kato, Takeshi Nakanishi, Yasuh ...
    2019 Volume 18 Issue 4 Pages 226-230
    Published: 2019
    Released: December 13, 2019
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    A Japanese woman presented with joint pain in both ankles, diffuse skin sclerosis, general malaise,and muscle weakness. We initially diagnosed her with overlap syndrome of polymyositis and systemic sclerosis. Although we administered oral prednisolone up to 1 mg/kg a day, her serum creatinine kinase level remained high. We added tacrolimus and intravenous immunoglobulin treatment, which improved the serum creatinine kinase level and muscle weakness. Her serum precipitated 50kDa doublets by protein-immunoprecipitation assay and was positive for antiRuvBL1/2 antibody. We then diagnosed her with anti-RuvBL1/2 antibody-positive systemic sclerosis. The review of previous reports suggests that patients with systemic sclerosis with antiRuvBL1/2 antibody often require combination treatment with corticosteroids. Skin Research, 18 : 226-230, 2019

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  • Koji Muranishi, Reiko Mita, Yoko Adachi, Keigo Matsumoto
    2019 Volume 18 Issue 4 Pages 231-236
    Published: 2019
    Released: December 13, 2019
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    The patient was a 64-year-old man with a history of diabetes, cerebral infarction, status epilepticus seizure, lower extremity venous thrombosis, and old myocardial infarction. Approximately 3 months before his rst visit, he had continuous high fever and bilateral swollen inguinal lymph nodes,and was diagnosed with Hodgkin lymphoma. Two months after this diagnosis, cyanosis developed on the left 5th digitus pedis, and chemotherapy was started. After two courses, cyanosis of the toe and skin ulcer of the left 5th digitus pedis were conrmed. Angiography suggested no stenosis in the lower extremity artery, and paraneoplastic syndrome was considered based on exclusion diagnosis. As antiplatelet or anticoagulant drugs had been administered, we continued chemotherapy for Hodgkin lymphoma. In addition to the administration of opioid analgesics, spinal cord stimulation therapy was performed to improve pain and microcirculation by inhibiting the efferent sympathetic nerve. However, the effects of this therapy were insufcient. Although complete remission of Hodgkin lymphoma was conrmed on imaging upon completion of the therapy, necrosis of the right 1st and 4th digitus pedis, and left 3rd, 4th, and 5th digitus pedis developed, accompanied by fever. Improvement was conrmed after prednisolone was administered at a dose of 30 mg/day for 19 days. Ischemic symptoms in the distal portion of the extremities associated with malignant tumor are referred to as paraneoplastic acral vascular syndrome, and these symptoms improve when the malignant tumor is treated in approximately 50% of patients. However, aggravation may occur in some patients and careful attention should be paid to this condition. In our case, steroids were effective, suggesting an immunological mechanism. Skin Research, 18 : 231-236, 2019

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  • Kasumi Kakuda, Yuki Takehara, Yukiko Shoda
    2019 Volume 18 Issue 4 Pages 237-240
    Published: 2019
    Released: December 13, 2019
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    A 78-year-old woman developed asymptomatic erythema on the right knee 1 year ago. She received antibiotic therapy, but it was unsuccessful. At the initial visit, she exhibited elevated indurated erythema with nodules on the lateral side of her right knee. Skin biopsy from the nodule demonstrated leukocytoclastic vasculitis with dense neutrophilic cell inltration into the dermis. Based on the clinical and histopathological ndings, the diagnosis of erythema elevatum diutinum (EED) was made. Dapsone (DDS) at 50 mg/day orally was started, but she discontinued it due to side effects. We tried nicotinamide at 200 mg/day orally and noted clearance of her skin lesion after 4 weeks. Dapsone is the rst-line therapy for EED, but it often causes mild to severe side effects. On the other hand, nicotinamide is a physiological nutrient and is therefore relatively safe to use. Nicotinamide therapy can be a promising option as a second-line treatment for EED when DDS cannot be used. Skin Research, 18 : 237-240, 2019

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