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negative computed tomographic scan of the head, absence of systemic eosinophilia, and denial of arthralgias. The mechanism of spread in our patient was likely travel through the dermis, thus explaining the migratory nature of his lesions. The subcutaneous nodules formed as a result of the patient’s foreign body response to the nematode. Presumably, our patient was inoculated with D tenuis from an infected mosquito. Likely mosquito vectors of D tenuis include the black salt-marsh mosquito, Aedes taeniorhynchus, the eastern saltmarsh mosquito, A sollicitans, and the southern house mosquito, A albopictus.5 The most significant risk factor for all forms of human Dirofilaria infections is the density of mosquitoes in that area.6 Mosquito density increases in warm, wet climates, and the majority of D tenuis cases in the United States occur in Florida, Texas, and Georgia.6 Our patient resided in coastal South Carolina.
Fig 1. Whorled bands of erythema with prominent scale at the edges over the trunk and extremities.
Ashley Parks, BA,a Joshua May, MD,a Diana Antonovich, MD,a and John Maize, Jr, MDb Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina,a Charleston, and Maize Center for Dermatopathology,b Mt Pleasant, South Carolina Funding sources: None. Conflicts of interest: None declared. Reprint requests: Diana Antonovich, MD, Medical University of South Carolina, Department of Dermatology and Dermatologic Surgery, 135 Rutledge Ave, PO Box 250578, Charleston, SC 29245 E-mail:
[email protected] REFERENCES 1. Davis BR. Filariases. Dermatol Clin 1989;2:313-21. 2. Skidmore PJ, Dooley DP, DeWitt C. Human extrapulmonary dirofilariasis in Texas. South Med J 2000;93:11-2. 3. Shah MK. Human pulmonary dirofilariasis: review of the literature. South Med J 1999;92:276-9. 4. Corman LC. Acute arthritis occurring in association with subcutaneous Dirofilaria tenuis infection. Arthritis Rheum 1987;30:1431-4. 5. Billups J, Shenken JR, Bracer PC. Subcutaneous dirofilariasis in Nebraska. Arch Pathol Lab Med 1980;104:11-3. 6. Jetliner T, Schulte-Helen J, Lecher T. Human dirofilariasis. Int J Dermatol 1996;35:872-5. doi:10.1016/j.jaad.2010.10.005
Erythema gyratum repens To the Editor: Erythema gyratum repens (EGR) was first described by Gammel1 in 1952, with the case of a 55-year-old woman who presented with a bizarre
Fig 2. Punch biopsy specimen showing superficial perivascular lymphocytic infiltrate with hyperkeratosis, focal parakeratosis, mild acanthosis, and focal spongiosis. (Hematoxylin-eosin stain; original magnification: 3100.)
pruritic eruption of 9 months’ duration associated with adenocarcinoma of the breast and that resolved following removal of the tumor. We report the case of a 66-year-old man with a 2-month history of a progressive pruritic eruption over his body. He had smoked for 50 years and was diagnosed with bronchogenic carcinoma of the right lung 2 months before evaluation. Physical examination was remarkable for multiple concentric erythematous bands with a trailing scale (Fig 1) and a grain of wood-pattern resembling a knotty cypress board and collarette type of desquamation, similar to that originally described by Gammel.1 Histopathologic examination of a lesional skin biopsy specimen ( from the abdomen) revealed hyperkeratosis with focal parakeratosis, mild acanthosis with focal spongiosis, and a superficial perivascular lymphocytic infiltrate. These findings are consistent with EGR (Fig 2). The patient returned 2 weeks later because he developed severe pruritus, erythroderma, and ectropion, even though he was receiving chemotherapy for the lung cancer. At the time of manuscript submission, the patient was still alive. EGR is a rare, but clinically distinctive, figurative erythema associated with an internal malignancy
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more than 80% of the time.2 Approximately one third of patients will have an underlying lung cancer, 8% esophageal cancer, 6% breast cancer, and another 6% do not have an associated internal malignancy.2,3 The non-paraneoplastic cases have been associated with tuberculosis, CREST syndrome, pregnancy, and bullous dermatosis, among others.2,3 The figurate eruption can precede, occur concurrently, or appear after the diagnosis of the neoplasm.3,4 Gyratum means coiled or winding around a central point and repens from the Latin, meaning to crawl or creep; the name itself describes the classic eruption of concentric erythematous rings that develop trailing scale at their edges and advance at a rapid rate ( # 1 cm per day). Males are affected twice as commonly as females, with an average age of 63 years at onset. All cases have been described in Caucasians.2,3 The histologic findings are nonspecific. The disease mechanism is unclear, but it has been proposed that in the case of bronchogenic carcinoma, the neoplasm produces molecules that alter the pulmonary basement membrane, with subsequent induction of antibodies that could cross-react with similar antigens in the basement membrane of the patient’s skin. This theory is supported by the reported granular deposits of IgG and C3 by direct immunofluorescence in both involved and uninvolved skin.4,5 The therapy for this paraneoplastic phenomenon is to identify and treat any underlying malignancy, with resolution of the eruption after surgery, chemotherapy, or radiotherapy.3 If an underlying tumor cannot be identified, careful documentation of the diagnosis and close follow up should be attempted. This present case differs from previously reported cases as the eruption in our patient did not improve, but progressed to erythroderma. This could be due to the advanced disease, resembling the paraneoplastic erythroderma of late-stage solid-organ malignancies. The authors thank Jaime Villa Col on, MD, for referring the patient to them.
Eneida M. De La Torre-Lugo, MD, and Jorge L. S anchez, MD Department of Dermatology, University of Puerto Rico School of Medicine, San Juan, Puerto Rico Funding sources: None. Conflicts of interest: None declared. Correspondence to: Eneida M. De La Torre-Lugo, MD, Department of Dermatology, University of Puerto Rico School of Medicine, PO Box 365067, San Juan, Puerto Rico, 00936-5067 E-mail:
[email protected]
J AM ACAD DERMATOL
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REFERENCES 1. Gammel JA. Erythema gyratum repens. AMA Arch Derm Syphilol 1952;66:494-505. 2. Stone SP. Life-treatening paraneoplastic cutaneous syndromes. Clin Dermatol 2005;23:301-6. 3. Boyd AS, Nelder KH, Menter A. Erythema gyratum repens: a paraneoplastic eruption. J Am Acad Dermatol 1992;26:757-62. 4. Holt PJA, Davies MG. Erythema gyratum repens—an immunologically mediated dermatosis? Br J Dermatol 1977;96:543-7. 5. Caux F, Lebbe C, Thomine E, Benyahia B, Flageul B, Joly P, et al. Erythema gyratum repens. A case studied with immunofluorescence, immunoelectron microscopy and immunohistochemistry. Br J Dermatol 1994;131:102-7.
doi:10.1016/j.jaad.2010.10.006
Acquired, verrucous, gluteal lymphangioma in the setting of Crohn’s disease To the Editor: A 46-year-old man with a history of Crohn’s disease was referred for evaluation of a large verrucous plaque on the superior gluteal cleft that was concerning for condyloma acuminatum. He had noted a small papule at the site 1 year earlier, which slowly enlarged to form a large plaque that frequently oozed clear fluid. The lesion was otherwise asymptomatic. The patient denied a history of anogenital warts or antecedent trauma. He was married and monogamous with his wife, who also denied a history of genital warts. His medical history was significant for Crohn’s disease that had been quiescent for the past 10 years after a partial colectomy. He had not taken immunosuppressive medication for several years and was otherwise healthy. Physical examination revealed a 10-cm exophytic, pink plaque with a cobblestonelike appearance on the superior gluteal cleft (Fig 1). There were no other lesions in the anogenital region. An 8-mm punch biopsy specimen showed verrucous epidermal hyperplasia with a few scattered lymphangiectases and was interpreted by a local pathologist as condyloma acuminatum. After further review by a dermatopathologist who raised the possibility of a verrucous lymphangioma, a proposed surgical excision was cancelled and the patient underwent a large wedge biopsy for further diagnostic evaluation. This larger biopsy showed marked expansion of the papillary dermis in a verrucous configuration with dilated lymphatics and mild overlying acanthosis. Prominent fibrosis of subjacent reticular dermis was noted with a patchy lymphoplasmocytic infiltrate (Fig 2). There was no evidence of cutaneous Crohn’s disease. After consultation with multiple dermatopathologists, a consensus diagnosis of acquired lymphangioma was made.
