Wednesday, May 30, 2012

Skin Cancer in Renal Transplant Patient

The patient is a 64 yo man who received a renal transplant x years ago and is maintained on prednisone and Prograf.  He presented with a 4 cm biopsy proven superficial squamous cell carcinoma on the left parietal scalp.  This lesion would have necessitated a large micrographic surgical procedure with a graft.

An attempt was made to treat with topical chemotherapy.  Imiquimod was inititiated, but there was only minimal response after two weeks.  Five fluorouracil was then added and this achieved a moderate response.  The combination of imiquimod/5FU was continued for a total of six weeks, then stopped.  One month later there appears to be a clinical cure.  He will be followed closely.  

There is a possibility that this combination therapy can help selected transplant patients with low risk superficial nonmelanoma skin cancers.

Clinical Photos:
After Six Weeks Imiquimod/5FU

One month after Stopping Imiquimod/5FU

Comment:  This treatment made me a little nervous, but the surgical approach would have been major for a lesion that had only a small chance of of metastasizing.  The benefits and risks were discussed with the patient; however, his oncologist was unhappy about this approach.

Thursday, May 24, 2012

Interstitial Granulomatous Dermatitis in a Child

Abstract: 8 year-old girl with a one week history of a symmetrical eruption
This patient is presented with permission from her parent.

HPI:  The patient is an otherwise healthy 8 year old girl with a one week history of a mildly pruritic eruption;  No antecedent illnesses.  She has molluscum diagnosed in other areas a few months ago.

O/E:  On May 1, 2012, she had discrete and confluent erythematous papules on both thighs and to a lesser extent on both elbows and abdomen.  There was marked cervical lymphadenopathy (present, by history, for years).  By May 3rd, the lesions had enlarged and coalesced into symmetrical plaques on the thighs, buttocks,  and lower extremities.

Clinical Photos (May 3, 2012)

Labs:  CBC, UA normal

Pathology: There is a superficial and mid-perivascular and interstitial lymphocytic infiltrate with neutrophils and rare eosinophils. (Photomicrographs courtesy of Dr. Marjan Mirzabeigi, Dermatopathology, Boston University Department of Dermatology)
Diagnosis:  Clinically, I considered a viral exanthem or the urticarial phase of Henoch-Schoenlein Purpura.  Histologically, the suggestions were interstitial granulomatous dermatitis (IGD) or an interstitial variant of granuloma granuloma annulare.

Course:  Over the course of two weeks, the lesions completely resolved.  No therapy had been offered.  The child remains well at this time and is at full activity.

Questions:  Have you seen similar cases?  What are your thoughts about "interstitial granulomatous dermatitis."  It is only rarely seen.

Discussion: IGD is a relatively newly described disorder and not much is known about etiology or course.  There may be short-lived variants such as this that are reactions to viral illnesses, drugs or other causes.  Case reports such as this may help to define such rare disorders.

Interstitial granulomatous dermatitis
Hillary Johnson MD PhD, Stephanie Mengden MD, Ronald R Brancaccio MD 
Dermatology Online Journal 14 (5): 18 Free Full Text.