Melanonychia Striata

An otherwise healthy 23-year-old black man was concerned about a dark line, 1 mm in width, arising from the nail bed of his right thumb (Panels A and B). The finding had been present for approximately 2 years and had not changed. The line originated in the lunula and stretched to the distal end of the nail in the axis of normal nail growth, an appearance consistent with the descriptive term melanonychia striata. The line did not extend into the cuticle, and the patient had noted no recent change in its width or color. There was no overlying nail dystrophy, no history of trauma, no family history of melanoma, and no involvement of other nails. Subungual melanoma is difficult to rule out on clinical grounds alone and remained an important diagnostic consideration, despite several reassuring features. However, the patient was concerned about the possibility of dystrophic scarring and declined a biopsy of the nail bed. After 2 years, the dark line remains unchanged, and the patient reports no new medical problems.

Marcos de Almeida Santos, M.D.
Tiago Osternack Malucelli, M.D.
Hospital de Clinicas da Universidade, Federal do Parana – Internal Medicine, Curitiba, Brazil
marcos.sjr@gmail.com

Podoconiosis

A 36-year-old man presented to an Ethiopian clinic with a 20-year history of skin nodules, pain, and edema involving his legs and feet. He was otherwise healthy and worked as a farmer. Circulating filarial antigen tests for the presence of Wuchereria bancrofti were negative; he was not tested for other types of filaria. This clinical presentation prompted a diagnosis of probable podoconiosis (also known as nonfilarial elephantiasis or mossy foot). This locally endemic, noninfectious condition is caused by the long-term exposure of susceptible persons to irritant volcanic soil. Colloid particles are thought to be absorbed through the skin and taken up by macrophages, leading to lymphatic fibrosis and elephantiasis. Affected persons are typically barefoot agricultural workers in the highland tropics. Social stigma associated with this condition is widespread; patients are banned from schools, churches, and marriage. Economic productivity is often impaired. Podoconiosis is preventable with fastidious shoe wearing and foot hygiene. Treatment is limited to compression bandaging and elevation. The patient was instructed to wear shoes, but additional nodules continued to develop on uncovered areas of his sandaled feet.

Whitney Lapolla, M.D.
Stephen K. Tyring, M.D., Ph.D.
Center for Clinical Studies, Webster, TX
whitneylapolla@gmail.com

Coral-Red Fluorescence

A 66-year-old man presented to a dermatologist with a pruritic, erythematous, scaly, and mildly hyperpigmented rash of 2 weeks’ duration that involved the scrotum and both inguinal creases (Panel A). Under examination with ultraviolet A light from a Wood’s lamp, the rash exhibited coral-red fluorescence (Panel B), a finding pathognomonic for erythrasma. This common disorder results from overgrowth of Corynebacterium minutissimum in the superficial stratum corneum of moist intertriginous and interdigital regions. The coral-red fluorescence is a result of the production of coproporphyrin III by C. minutissimum, and it helps to distinguish this disorder from dermatophytoses, candidal intertrigo, and psoriasis. Skin scrapings show gram-positive filamentous rods, which may be helpful in assessing for concurrent dermatophytic and candidal infection. After a short course of oral erythromycin, this patient’s rash and pruritus resolved completely.

Ivana Binic, M.D., Ph.D.
Aleksandar Jankovic, M.D., Ph.D.
Clinical Center Nis, Nis, Serbia

Amalgam Tattoo

A 64-year-old man was referred for evaluation of an asymptomatic pigmented lesion on the buccal mucosa (Panels A and B). After 15 pack-years of smoking, he had quit smoking more than 30 years earlier and had no other risk factors for oral cancer. A biopsy of the lesion revealed interstitial accumulation of brown and black particles within the submucosa, a finding that was compatible with a diagnosis of amalgam tattoo. Amalgam dental fillings contain mercury, silver, and other metals that may inadvertently be implanted into adjacent gingival, buccal, palatal, or lingual mucosa at the time of tooth restoration. This produces black, blue, or gray macules that are asymptomatic and change little over time. Although amalgam tattoos are common and benign, they may mimic pigmented oral lesions with more worrisome causes, such as melanoma or Kaposi’s sarcoma. Only a minority of amalgam tattoos are radioopaque on plain radiography. A biopsy can be performed without difficulty and is effective in ruling out cancer, although it is usually unnecessary when the lesion is typical and has been evaluated by an experienced practitioner.

Patrick Dubach, M.D.
Marco Caversaccio, M.D.
Department of Otorhinolaryngology, Head and Neck Surgery, University of Bern Inselspital, Bern, Switzerland
patrickdubach@insel.ch

Keloidal Morphea

A 44-year-old woman presented with a 2-year history of multiple enlarging, painful nodules. Physical examination revealed several irregularly shaped, firm nodules with hyperpigmentation and induration on the trunk and upper arms (Panel A). She reported no other concerns about her health, and physical examination showed no other abnormal findings. Neither she nor her family had a history of keloidal scars or systemic sclerosis. The results of laboratory investigations, including assays for antinuclear and anti-dsDNA antibodies and screening for extractable nuclear antigens (including anti-Jo-1, anti-SSA, anti-SSB, anti-Scl-70, anti-Sm, and anti-RNP antibodies) were unremarkable. Findings on examination of a specimen from a skin biopsy were consistent with a diagnosis of keloid formation, except for the presence of perieccrine lymphocytic infiltration. On the basis of these clinical and pathological features, the nodules were diagnosed as keloidal morphea, a rare form of localized cutaneous scleroderma. Despite multiple treatments, the lesions enlarged over a 10-year period (Panel B).

Hsien-Yi Chiu, M.D.
Tsen-Fang Tsai, M.D.
National Taiwan University Hospital, Taipei, Taiwan
tftsai@yahoo.com

Diabetes mellitus presented with an ulcerating rash

A 63-year-old woman with a 4 1/2-year history of diabetes mellitus presented with an ulcerating rash, primarily on the shins, groin, and face (Panel A); cheilitis (Panel B); and glossitis. Her symptoms had been worsening for 4 years despite specialized wound care. In addition, she noted concurrent weight loss, depression, abdominal pain, and intractable nausea. She was taking 500 mg of metformin daily. Given her history of diabetes mellitus and the skin findings, abdominal computed tomography was performed, and glucagon levels were measured. An enhancing, lobulated mass measuring 7 cm in diameter was found in the tail of the pancreas, and the patient’s fasting glucagon level was elevated, at 890 pg per milliliter (normal range, 0 to 80). The mass was resected, and pathological examination of the specimen confirmed a diagnosis of glucagonoma. Glucagonomas are rare neuroendocrine tumors that can cause diabetes and a rash known as necrolytic migratory erythema, which has a characteristic annular pattern of erythema with central crusting and bullae. The prognosis correlates with the stage of tumor development and the potential for resection. In this patient, 1 day after resection, the rash had faded significantly. Four weeks after discharge, the patient had normal glucose levels (while taking no medication), and the necrolytic migratory erythema had completely resolved.

Ostraceous Psoriasis

A 47-year-old woman presented to our hospital with a 2-week history of widespread, painful lesions on her trunk and limbs (Panels A and B). Her medical history included hypercholesterolemia, diabetes, and a 10-year history of psoriasis that had been treated with corticosteroids, calcipotriene, and methotrexate. Five months before presentation, the patient’s psoriasis went into remission, and treatment was discontinued. Physical examination revealed sharply demarcated, erythematous, well-defined limpetlike plaques covered with scales and crust. Laboratory testing revealed hyperglycemia and hypercholesterolemia. A diagnosis of ostraceous psoriasis was made. The patient was treated with topical petrolatum containing 20% salicylic acid and mometasone furoate cream, resulting in improvement of the lesions after 3 weeks. Adalimumab was then added, with complete resolution of the lesions after an additional 14 weeks.

Hands, chronic rheumatoid arthritis – Clinical presentation

This image illustrates the destructive nature of chronic, severe rheumatoid arthritis. Subluxation and fusion of joints are apparent. Ulnar deviation of the digits is common. Note that the lesion is polyarticular and symmetrical. The most common deformity of the thumb is flexion with hyperextension at the interphalangeal joint.

Liver, cirrhosis from chronic viral hepatitis – Gross

The surface of this liver, which has become cirrhotic from viral hepatitis, has irregular depressed areas. These are due to bands of fibrous scar tissue that separate nodules of regenerating liver parenchyma.

Lung, tuberculosis, secondary (reactivation) – Gross, cut surface, and radiograph

The cavities in the upper lobes are the pathologic and radiographic findings in secondary, or reactivation, tuberculosis. The major bronchi have been opened to reveal mucosal hyperemia, which indicates congestion or inflammation of the bronchial mucosa. In addition, patchy consolidation is present in the upper lobe; this may represent either superimposed bronchopneumonia or progressive spread of tuberculosis.