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We encountered a patient who complained of many small papules on the neck, shoulders, upper chest and upper back. Biopsy specimens showed complete loss of elastic fibers in the upper dermis including papillary dermis, whereas those of the mid dermis were intact. Electron microscopy revealed that assembly of component fibrils of elastic fibers was loose, and electron dense substance was aggregated in the spaces between these loosely bound subunit Fibrils or along the periphery of abnormal fibers. Dermal phagocytes engulfed abnormal as well as normal elastic fibers. Upper dermal elastolysis is a clinical and histopathological entity different from mid-dermal elastolysis. Ultrastructural changes of the former are essentially similar to those of the latter but much more severe. It is suggested that activated elastophagocytosis of dermal phagocytes may play a role in this disease. Hashimoto K, Tye MJ. Upper dermal elastolysis: A comparative study with mid-dermal elastolysis.

A new case of typical mid dermal elastolysis was studied with electron microscopy. Elastic fibers were irregularly branched or lumpy, but subcomponents of these fibers were often normal. In some fibers, loose assembly of skeleton fibrils and aggregation of dense substances were observed. Phagocytosis of normal and abnormal elastic fibers by dermal macrophages was observed.

The cell-surface glycoprotein CD44 is found on a wide variety of cells including epidermal cells. It is involved in cell to cell adhesion. Desmoplakin I & II are important components of the attachment plaque of desmosomes. In this study, we compared the distribution patterns of anti-CD44 and anti-desmoplakin I & II in Hailey-Hailey's disease and Darier's disease. In the normal skin, anti-CD44 stained the entire periphery of epidermal keratinocytes while anti-desmoplakin I & II produced dotted staining patterns along the periphery of epidermal keratinocytes. In Hailey-Hailey's disease and Darier's disease, the staining pattern of anti-CD44 on acantholized keratinocytes did not change, but anti-desmoplakin I & II lost their peripheral, dotted patterns and stained diffusely in the cytoplasm in most acantholytic cells. These results suggest that, in Hailey-Hailey's disease and Darier's disease, CD44 may be intact even in acantholytic cells but abnormalities of desmoplakin exist in such cells.

The presence of human Merkel cells in the eccrine ridges and eccrine germs was studied, using antibodies to simple epithelial keratins, in separated epidermal sheets with attached eccrine ducts. The localization of Merkel cells could be analysed three-dimensionally in the wet, whole-mount of the stained sheets. In the plantar skin of a 12-week-old human fetus, immunoreactive (ir-) Merkel cells were randomly located in the flattened epidermis. In the plantar skin of a 15-week-old human fetus, there was early development of eccrine germs, and Merkel cells were concentrated in eccrine gland ridges. In the plantar skin of a 20-week-old human fetus, eccrine germs were well formed and ir-Merkel cells were located within the developing eccrine ridges and ducts. In the plantar skin of adults, the eccrine concentration of Merkel cells was markedly reduced. Concentration of Merkel cells on the eccrine structures was also observed in the scalp skin of human fetuses. This tendency continued into adult life, although there was a marked reduction in the total number of Merkel cells. These findings suggest that epidermal Merkel cells move down into the eccrine ducts as eccrine germs extend into the mesenchyme. Alternatively, they may develop de novo from the keratinocytes of the eccrine duct. In view of the expression of nerve growth factor receptor in fetal Merkel cells, it is postulated that these eccrine gland Merkel cells play a role in the formation of the periglandular nerve plexus.

Suppressor oncogene p53 is expressed more frequently in the nodular portion than the superficial spreading portion of the same melanoma. PCNA expression follows the same pattern but it is strongly expressed already in the superficial spreading portion. CD34 is found to label dermatofibrosarcoma protuberans. There is the mixture of negative strands but the immunostains are predominantly positive in the three cases studied. Neurogenic tumors are reactive but the intensity of staining is only moderate. Fibrous histiocytoma, dermatofibroma and other fibrohistiocytic tumors are non-reactive. CD34 is expressed in the outer root sheath of hair follicle below the sebaceous gland level. A case of piloepidermal cyst is CD34 positive. CD34 is expressed in vascular endothelial cells; not only hemangiomas but also lymphangiosarcoma is CD34 positive. A case of indeterminate cell histiocytosis following scabies and superficial variant of clear cell sarcoma are discussed as examples of new entities.

The Bronsted acid catalyzed formal [3 + 3] cycloaddition reaction of allene sulfonamides 1 with phenols 2 provides functionalized chromanes. This formal [3 + 3] cycloaddition reaction is proposed to proceed via a stepwise process involving intermolecular hydroarylation followed by intramolecular cyclization.

A case of harlequin ichthyosis was studied with electron microscopy. From the basal cell to granular cell layers, keratinocytes contained giant mitochondria (860 nm) which exhibited vesicular cristae. Typical lamellar granules were absent; instead, numerous dense cored granules (DCG) and particles containing cored granules (PCG) were produced. Some of these were discharged into the intercellular spaces of granular cells, but the majority failed to be released from the cytoplasm. These retained DCG and PCG coalesced to form large vacuoles and cavities in the stratum corneum. In the hair follicle, keratinized cells failed to loosen and desquamate into the hair canal; instead, they formed concentric keratin rings surrounding hair, a diagnostic feature of this disease. It is suggested that the abnormal lamellar granule underlies the pathogenesis of this disease and that giant mitochondria may be related to an abnormal lipid metabolism of keratinocytes which may affect lipid composition of lamellar granules.

A comparative histopathologic study is made between the hypopigmented and hyperpigmented skin lesions of pityriasis versicolor and normal skin areas utilizing histochemical stains and electron microscopy. There were no differences found between the population of Dopa-positive melanocytes within the hypopigmented and hyperpigmented lesions and the normal skin areas. The total epidermal pigmentation was diminished in hypopigmented lesions. The keratin layer was found to be significantly thicker in hyperpigmented lesions and contained more organisms. In hypopigmented lesions, melanocytes contained fewer and smaller melanosomes and exhibited signs of degenerative cellular changes.

Although there is a decreasing number of gastric cancer patients in Japan, the number of patients over 80 years of age is increasing. Forty patients over 80 years of age (from 80 to 88 years) with gastric cancer (Group 1) during the 10 years from 1980 to 1989 were retrospectively investigated and compared with those 70-79 years of age (Group 2). The resectability rate was 80% in Group 1 and 89% in Group 2. Early gastric cancer was observed at a rate of only 25% in Group 1 and 39% in Group 2. Pathologically, the differentiated type occurred in 78% of those in Group 1 and 68% of Group 2. Total gastrectomy was performed in only 6% of the resected cases in Group 1 and in 25% of Group 2. A combined resection including such operations as pancreatico-splenectomy or splenectomy (PS) was employed in none of the total gastrectomy cases in Group 1 and in 30% of Group 2. R3 gastrectomy was performed in none of the patients in Group 1 and in 21% of those in Group 2. Postoperative complications occurred in 25% of Group 1 patients and in 12% of Group 2 patients. Anastomotic leakage occurred in 3% of those in Group 1 and in 4% of those in Group 2. The 5-year survival rate was 47% for all the resected cases in Group 1 and 68% for Group 2. The 5-year survival rate was 61% for those who underwent a curative (radical) gastrectomy in Group 1, and 84% for those in Group 2.

A case of a massive advanced gastric cancer of the Borrmann type III in a patient with the rare blood group of negative Gregory antigen (Gregory (a-)) is reported. On admission, he was found to have a severe anemia (Hb 6.1 g/dl) requiring a direct blood infusion. He had never received a blood infusion, previously. In blood crossmatching tests, his blood was agglutinated by all the antisera for the common antigens, and he was discovered to have a rare blood type of Gregory (a-). There was no appropriate blood donor in his family. Before the operation, only 600 ml (6 i.u.) of frozen red blood cells could be found in storage from only 2 people with Gregory (a-), O blood type and Rh (+) in Japan. To increase the RBC, erythropoietin (3000 i.u.) was administered 6 times; and the Hb increased to 7.4 g/dl. However, the anemia remained and 200 ml (2 i.u.) Gregory (a-) blood was infused, preoperatively. The final preoperative Hb was 7.8 g/dl and the RBC was 283 x 10(4)/mm3. A massive gastric cancer directly infiltrated the pancreas, the transverse colon and the mesocolon. A palliative subtotal gastrectomy with combined resection of the transverse colon was performed. The intraoperative blood loss was 460 ml and the volume of blood infused was 400 ml (4 i.u.). The postoperative Hb was 7.9 g/dl, and more blood was needed. However, there was no more Gregory (a-) donor blood in storage in Japan.(ABSTRACT TRUNCATED AT 250 WORDS)

The best surgical procedure to treat a carcinoma in the gastric cardia remains a controversy because the carcinoma is often advanced and there are other unknown factors. In this article the incidence of invisible metastasis from cardia cancer to the diaphragm will be analyzed using an experimental cardia cancer model and clinical studies. An experimental cardia cancer was induced by an endoscopic injection of VX2 cancer cells into the submucosal layer of the esophago-gastric junction in rabbits using a 27G needle and an Olympus BF-4B2 bronchofiberscope. A total of 26 cardia cancer models for Borrmann type 2 or 3 were produced. Of these, six (23%) had visible cancer metastases in the diaphragm, including 4 cases with direct invasion and 2 cases with peritoneal dissemination on the surface of the diaphragm. Four (20%) of the remaining 20 were histologically found to have macroscopically-invisible cancer metastases mainly in the lymph vessels of the left hemidiaphragm. From 1985 to 1988, 22 clinical cases of cardia cancer were managed by a combined total gastrectomy with a partial diaphragm resection through a left thoracoabdominal approach. When widely resected, reconstruction was performed using a latissimus dorsi muscle flap. Six (27%) of these 22 were also histologically found to have macroscopically-invisible cancer metastases to the diaphragm, including 1 (11%) of the 9 well-differentiated type and 5 (39%) of 13 poorly-differentiated type adenocarcinomas. For patients with stage II, III or IV cardia cancers with no hepatic metastasis and no peritoneal dissemination, the 2-year survival rate was 64% for those who underwent a combined resection of the diaphragm and 42% for those who underwent a non-combined resection. The postoperative mortality in this series was zero. This is the first report of invisible cancer metastases from cardia cancer to the diaphragm.

A 48-year-old white woman, skin type III, had a slate-gray discoloration of the face and dorsa of both hands after ingesting imipramine, 150 mg/day for 5 years. Her iris color was also darkened. One year after cessation of the therapy, the discoloration became lighter. Sun-protected skin showed no discoloration. Light microscopy revealed an accumulation of doubly refractile golden yellow granules in the papillary dermis, mostly scattered, with some concentration around the blood vessels but not in the endothelial cells. Electron micrographs showed numerous amorphous electron-dense inclusion bodies in histiocytes, phagocytes, fibroblasts, and dermal dendrocytes. Melanosomes were phagocytosed in the same cells but in separated locations. Imipramine is structurally related to ehlorprornazine and can cause slate-gray discoloration. However, the color of the granules deposited in the papillary dermis is golden-yellow and they are not deposited in endothelial cells.

Diffuse neonatal hemangiomatosis is a rare, frequently fatal disease characterized by multiple cutaneous and visceral hemangiomas. The skin, liver, lungs, intestines, and central nervous system are the most commonly affected organs. Death can result from high-output cardiac failure as a result of arteriovenous shunting. In this report we present a new constellation of findings in a patient with diffuse neonatal hemangiomatosis, namely, an absent corpus callosum, ectopia cordis (sternal agenesis) with median abdominal raphe, and tricuspid atresia.

Two rare cases involving distal gastrectomies for gastric cancer after an earlier gastrojejunostomies without gastrectomy for duodenal or gastric stricture due to a duodenal or pre-pyloric ulcer are reported. The time interval between the initial gastrojejunostomy and the resection of the distal stomach with gastrojejunal stoma were 17 and 36 years. One patient underwent reconstruction by Billroth II and the other by Roux-en-Y end-to-side gastrojejunostomies, both retrocolically without any peri or postoperative complications. The histological classification was confirmed for both as type IIc mucosal early gastric cancer. Only 6 other primary early gastric cancers following gastrojejunostomies without gastrectomy have been reported in the Japanese literature.

From 1979 to 1988, a total of 1083 patients with gastric cancer underwent resection at Kurume University Hospital. Among these cancers, 183 (16.8%) were located in the upper third of the stomach. Of these, 56 (5.2%) were adenocarcinomas in the esophagogastric (E-G) junction. Cancer in this area was designated as cardia cancer when the focus of the cancer was macroscopically located within 2 cm of the E-G junction line and the tumor was less than 8 cm in diameter. The incidence of early gastric cancer in the cardia was only 13%, while the incidence for stage III advanced cancer was high at 46%, and the positive lymph node metastasis rate was 59%. Thirty-nine (70%) were cured by resection with a 5-year-survival rate of 64%, while for non-curative resection, this was only 10%. Twenty-two cases of either advanced cardia or advanced CE cancer underwent combined resection of the diaphragm. The rate of invisible metastasis to the diaphragm was 20% in our experimental study. The two year-survival rate for a combined resection of the diaphragm was 64%, while the rate for those who did not undergo a required combined resection was 42%.

Twenty-four cases of resected remnant cancers following partial gastrectomy were retrospectively investigated for benign gastroduodenal disease. The time interval between the initial gastrectomy and the remnant gastrectomy was more than 10 years in 19 (79%) patients and less than 10 years in 5 (21%) patients. There were 2 cases with remnant cancer at stage I, 1 at stage II, 3 at stage III and 13 at stage IV for the all cases with a time interval of more than 10 years. Early-type remnant gastric cancer has a frequency of only 5%. The proportion of positive lymph node metastases was high, in 84%.

The expression of a cell proliferation-associated human nuclear antigen was immunohistochemically studied in human anagen hair and hair follicles using the monoclonal antibody Ki-67. The reaction of Ki-67 in mature anagen hair follicles was observed in the hair matrix cells and outer root sheath (ORS) cells. Nuclear staining was seen in a small number of matrix cells and in some ORS cells; this finding corresponded to the thymidine or bromodeoxyuridine labeling studies previously reported. In addition, there were two different patterns of cytoplasmic staining in the ORS: strong staining of the innermost cells (IMC) and weaker staining of the other ORS cells in the isthmus. Ki-67 reactivity of the IMC layer was observed at each stage of anagen and was regularly seen from the upper bulb to the isthmus. Ki-67 is a commercially available antibody that detects cycling cells. However, the IMCs in anagen hair follicles showed cytoplasmic labeling by Ki-67 from the matrix cells in the upper bulb to the distal portion of the isthmus.

Immunohistochemical localization of S-100 protein alpha and beta subunits in the cells of melanocytic nevi and malignant melanomas was studied by using monoclonal antibodies directed against each subunit. Although polyclonal anti-S-100 reactivities have been demonstrated uniformly in all nevus cells and melanoma cells, monoclonal anti-S-100 alpha and anti-S-100 beta reactivities were either absent or rarely found in ordinary junctional nevi or junctional nests of ordinary compound nevi. However, in the junctional nests of dysplastic junctional nevi and junctional components of dysplastic compound nevi, monoclonal anti-S-100 alpha reactivity become more frequent, whereas monoclonal anti-S-100 beta reactivity remains negative. In the superficial variety of melanomas such as superficial spreading melanoma and lentigo maligna melanoma, monoclonal anti-S-100 beta is nonreactive until vertical growth or invasiveness begins. Most nodular melanomas are positively stained with both monoclonal anti-S-100 alpha and anti-S-100 beta. It is suggested that monoclonal anti-S-100 alpha can be an indicator of active junctional nevus of melanocytic nevi and the reactivity with monoclonal anti-S-100 beta may be related to vertical progression of superficial spreading melanomas and lentigo maligna melanomas.

A typical case of infantile digital fibromatosis (IDF) was studied with antibodies raised against actin, vimentin, desmin and several species of cytokeratin. Strong reactions were observed for desmin, cytokeratin and CK-5, and moderate reactions for vimentin and actin. The diagnostic intracytoplasmic inclusion bodies within the tumor cells were ultrastructurally composed of aggregations of dense microfilaments. Immunoelectron microscopy showed that these filament aggregations are positively stained with anti-actin antibody. From these results, we suggest that the large tumor cell of IDF is a myofibroblast and may originate from or differentiate toward vascular smooth muscle cells, because only this type of smooth muscle can coexpress desmin, vimentin and cytokeratin.

When Congo red stain was the only criterion, "amyloid" was considered to be a single substance. With the advent of electron microscopy, this idea was further strengthened because unfortunately the ultrastructure of all amyloids including those of the skin was found to be uniform. Clinical dermatologists knew that there were two types of skin amyloidoses; one manifesting itself in the skin as well as in various internal organs, the other being exclusively limited to the skin. The first group included amyloidoses associated with multiple myeloma (now termed AL amyloid), infections (now termed AA amyloid), and familial hereditary disease (of chemically variable composition). The second group consisted of truly cutaneous diseases such as lichen amyloidosus, macular amyloidosis, and cutaneous epithelioma-associated amyloidoses. Nodular amyloidosis was thought to be the link between these two groups because occasionally it can become systemic disease; it turned out to be a systemic disease of immunoglobulin light-chain production with a limited skin manifestation. Today we realize that this clinical division was more important than histologic and ultrastructural analyses of amyloid deposits: the second group of amyloidoses occur exclusively in the skin because the amyloid substances come from a special degeneration of keratinocytes of the epidermis and its derivatives.

Polyglycolic acid elastic mesh was tailored and wrapped around the entire surface of experimentally injured spleens in 11 dogs, while carefully avoiding the splenic hilum, like a “hair-net”, to achieve complete hemostasis by compression. All 11 dogs survived the experiment with no postoperative bleeding observed. Histological examination, performed 6 weeks postoperatively, revealed histiocytes, fibroblastic proliferation with collagen and cellular collagenized fibrous tissue forming a neocapsule covering the spleen. Hematologically, the platelet count was increased at 2 weeks postoperatively, but subsequently decreased to within the normal levels by 4 weeks. We employed this splenic capping method clinically in four cases to avoid splenectomy and sufficient hemostasis with ultimate splenic recovery was achieved in each case without any abscess formation, postoperative bleeding, or complications related to the use of the mesh. These experimental and clinical results thus indicate the efficacy and safety of the splenic capping method for preserving the injured spleen.

From 1985 to 1989, a total of 598 gastric cancer patients underwent gastrectomies in the First Department of Surgery at Kurume University School of Medicine. Of these, 24 patients (4.0%) incurred a subphrenic abscess, postoperatively. Subphrenic abscesses occurred most frequently after total gastrectomies at a rate of 17 of 197 (8.8%) cases. Leaking gastrointestinal anastomoses were responsible for 12 of the 17 (70.5%) abscesses. In 384 cases of distal gastrectomy, only 6 (1.6%) cases with a subphrenic abscess occurred, and only 3 were due to anastomotic leakage. Among the total of 24 cases with subphrenic abscesses, 16 (67%) were related to an anastomotic leakage including a pancreatic fistula, while the other 8 (33%) showed no leakage by contrast roentgenography. When chest roentgenography shows a pleural effusion and an elevation of the diaphragm, then a subphrenic abscess must be suspected. The majority of patients were treated by replacing the intraabdominal drainage catheter inserted during the gastrectomy with a larger catheter. The overall operative mortality rate was 4.1% due to a death in only one (MOF) patient.

The mechanism of the protection by human epidermal growth factor (hEGF) against the gastric mucosal lesions induced by acidified ethanol was studied in rats. At different times following the subcutaneous administration of hEGF (30 μg/kg), intragastric acidified ethanol (EtOH : 0.125 M HCl = 50 : 50 v/v%) was administered to induce an experimental gastric mucosal lesion. Mean length of the lesion in the gastric mucosa was used as a lesion index. Extravasation of intraveneously injected Evans blue into the gastric wall and gastric contents was used as an indicator of vascular permeability. Pretreatment with hEGF decreased both the gastric mucosal lesions and the increase of vascular permeability caused by acidified ethanol with similar time profiles relative to pretreatment with hEGF. Maximal protective actions of hEGF occured about 10 to 30 min after the observed peak plasma concentration of hEGF. Indomethacin and N -ethylmaleimide, but not iodoacetamide, blocked the protective action of hEGF, indicating that endogeneous prostaglandins and/or sulfhydryls may participate in the protective action of hEGF. The content of endogeneous nonprotein sulfhydryls in the gastric mucosa decreased markedly after acidified ethanol. However, pretreated hEGF did not restore the sulfhydryl contents. Thus, it seemed that endegeneous prostaglandins, but not sulfhydryls, are the probable mediators for protection against gastric mucosal injury caused by acidified ethanol.

Acantholytic foci have been reported several times in pityriasis rubra pilaris (PRP). Lichenoid tissue reactions were also mentioned in the literature regarding PRP. We report a 58-year-old patient who, after having colon cancer, had PRP with biopsies showing acantholytic lesions and a heavy lichenoid lymphocytic infiltration. Investigation by serial sectioning of the acantholytic lesion suggested an involvement of the intraepidermal eccrine duct and further investigation with carcinoembryonic antigen (CEA) staining demonstrated a CEA-positive eccrine duct in the acantholytic foci. We suggest that acantholysis in PRP is induced by proteolytic enzymes, urea, and other substances in eccrine sweat in keratin-plugged acrosyringia. This patient had a combination of three relatively rare features of PRP-acantholysis, lichenoid reaction, and a cancer background.

Basal cell carcinoma (BCC) occasionally arises from the preexisting lesions of multiple familial trichoepithelioma (MFT). 1 The gene for BCC has been assigned to chromosome 9q22.3-q31, 2 and the gene for Bazex-Dupre-Christol syndrome, characterized by the early onset of multiple BCCs, has been mapped to chromosome Xq24-q27.1. 3 Recently, we carried out a linkage analysis in 3 families with MFT and mapped the gene for MFT to chromosome 9p21. 4 Therefore, trichoepithelioma does not seem to be allelic with BCC despite their histological similarities. To assess the involvement of the BCC genes in the development of BCC in MFT lesions, we examined the possibility of loss of heterozygosity in 2 different BCC specimens from the same patient using microsatellite markers of chromosomes 9q22-q31, Xq24-q27, and 9p21. Only the markers of chromosome 9q22-q31, the locus for sporadic BCCs and nevoid BCC syndrome, showed loss of heterozygosity in 1 of the 2

Objective: To elucidate the geographic and genospecific association of Borrelia with morphea and lichen sclerosus et atrophicus (LSA). Design: The association of Borrelia burgdorferi with morphea and LSA has been reported, but is still controversial. We conducted a retrospective survey of Borrelia DNA in skin biopsy specimens. Settings: The samples were collected from the outpatient clinic of university hospitals and a dermatopathology laboratory. Patients: Skin biopsy specimens (19 morphea and 34 LSA) were obtained from patients in the United States, Japan, and Germany. DNA samples were subjected to amplification with polymerase chain reaction for B burg-dorferi flagellin gene, and for the genotype-specific detection of B burgdorferi sensu stricto, Borrelia garinii , and Borrelia afzelii . Results: Five cases of morphea and 2 cases of LSA in Germany and Japan yielded positive signals for B garinii or B afzelii , the European species. None of the American samples were positive for Borrelia polymerase chain reaction. Borrelia burgdorferi sensu stricto was not detected in any of the specimens. Conclusion: Morphea and LSA in Germany and Japan can be related with European genotypes of Borrelia. Arch Dermatol. 1997;133:41-44

REPORT OF A CASE A 41-year-old black woman presented with a 3-year history of a plaque on her chin. This asymptomatic lesion developed in an area of scarring that had resulted from grease splattering while the patient was cooking. There is no family history of similar lesions. Physical examination revealed an oval, violaceous, 1-cm, annular plaque with a depressed center and an elevated indurated rim studded with tiny, white milia on the chin (Figure 1andFigure 2). A biopsy specimen was obtained from the rim of the lesion (Figure 3andFigure 4). What is your diagnosis? DIAGNOSIS: Desmoplastic trichoepithelioma. HISTOPATHOLOGIC FINDINGS AND CLINICAL COURSE On hematoxylin-eosin—stained sections (Figures 3 and 4), focal irregular thickening and elongation of rete ridges were seen in the center of the specimen. The dermis in these areas showed several masses and cords of epithelial cells in a desmoplastic stroma.

REPORT OF A CASE A 19-month-old Albanian girl developed yellow-red papules in both eyelids at age 6 months. Over the past year, new lesions developed on her head and upper trunk. She was asymptomatic and otherwise healthy. The examination revealed multiple scattered 2- to 3-mm yellow-red papules over the scalp and face (Figure 1). A few were present on her upper chest. A complete blood cell count, serum protein electrophoresis, and chemistry panels were normal. Bone marrow aspirate, skeletal survey, chest radiograph, and computed tomographic scan were normal. Histologic findings from a typical lesion are shown (Figure 2). Special stains for CD1 and S100 were positive in a few dermal cells; HLA-DR was strongly positive. Electron microscopy was performed (Figure 3andFigure 4). What is your diagnosis? DIAGNOSIS: Benign cephalic histiocytosis. HISTOPATHOLOGIC FINDINGS The epidermis was slightly atrophic. The dermis contained large histiocytic cells with ground-glass cytoplasm, a few multinucleated giant cells

REPORT OF A CASE A black child was born to a 14-year-old primagravida during week 35 of gestation. On delivery, the boy was in respiratory distress and required intubation. The patient manifested multiple scars, erosions, ulcerations, and constricting bands of his scalp, trunk, and extremities. There was no maternal history of drug or alcohol use during the prenatal period. Cutaneous examination revealed a ring constriction extending deep into the subcutaneous tissue on the left thigh (Figure 1). Distal to the constriction, the limb was abducted with a club foot. Trunk exami- nation revealed a linear erosion (1.0×1.0 cm) across the back (Figure 2). The right foot showed a ring constriction of the third metatarsal. Craniofacial defects included multiple shallow ulcerations with scarring over bilateral frontotemporal regions and vertex of the scalp. In addition, there were multiple superficial erosions and atrophic scars (1.0×1.0 cm) over the shoulders, knees, hips, and right

An emergency dermatology consultation was requested by the medical intensive care staff for evaluation of a patient admitted an hour earlier from the emergency department with a diffuse skin eruption in conjunction with respiratory distress, hypotension, pyrexia, hepatitis, and renal failure. The patient was a 64-year-old black man who developed a faint rash 2 weeks prior to admission that dramatically worsened 4 days prior to admission. The rash was accompanied by fever, chills, and anorexia. There was no medical history except for a recent seizure treated with 200 mg/d of phenytoin over the past month and a half. Phenytoin was reportedly discontinued 2 to 3 weeks prior to admission. The patient was a retired baker, taking no other medications, with no known allergies, and no recent travel. On presentation in the hospital emergency department, his oral temperature was 40.6°C, his pulse was 160 beats per minute, and his blood pressure