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Leishmaniasis is a common parasitic disease seen in many parts of the world, especially in areas where current U.S. and international forces are deployed. Approximately 350 million people are thought to be at risk of cutaneous leishmaniasis (CL) with an annual incidence of 1.5 million cases. Over 90% of cutaneous infections with Leishmania occur in the Middle East, Brazil, and Peru. Outbreaks of CL may occur in military personnel deployed to endemic areas. Since the incubation period for symptomatic CL ranges from weeks to months, symptoms may not appear until well after returning to the United States. As operations continue to expand globally, the exposure and concern for leishmaniasis persists for military physicians. We describe localized CL in a previously healthy male in an effort to help medical personnel identify leishmaniasis on the basis of cutaneous lesions alone, as well as increase diagnostic suspicion when treating patients in nonendemic areas.A previously healthy 30-year-old Saudi Arabian male presented to the emergency department with a 1-month history of four well-demarcated nonhealing, painless ulcers on his left ear, hand, and foot. Symptoms began shortly after arriving in the United States. He had been treated with trimethoprim/sulfamethoxazole, oral clindamycin, mupirocin ointment, and vancomycin for suspected infection without improvement of lesions. Upon presentation to dermatology, physical examination revealed a firm erythematous plaque with central ulceration on his left ear. Two shallow indurated ulcers were also found on his left fourth dorsal finger and left dorsal foot. Biopsy of the foot revealed granulomatous inflammation with predominantly lymphoplasmacytic infiltrate and multinucleated giant cells. Parasitized histiocytes were identified on hematoxylin and eosin stain and focally on Giemsa stain. Polymerase chain was consistent with a diagnosis of leishmaniasis and outpatient treatment was initiated with fluconazole 200 mg daily for 6 weeks. At 2-week follow-up, lesions were noted to be stabilized.CL has a wide variety of presentations. The classic lesion appears as a papule that will enlarge, often developing into a nodule or plaque-like lesion with central ulceration. The lesion may be covered with an eschar or by fibrinous material. This presentation can mimic many disease processes resulting in an extensive differential diagnosis that includes bacterial, fungal, and viral infections, cutaneous malignancy, and insect bites. The clinical course, treatment options, response to therapy, and prognosis are all highly variable and dependent on the causative species. Local therapy options, oral systemic agents, and parenteral agents have all shown varying results in the treatment of leishmaniasis. The difficulty with standardizing treatment options for CL stems from the lack of well-controlled studies and the lack of standardized outcome measures. This deficiency in comparative studies of treatment hinders consensual recommendations. However, the choice of the correct therapy often depends on the experience of the clinician, burden of disease, preferences of patients, and cost-effectiveness considerations for the patient and/or the health care system.

Myeloid leukemia cutis (MLC) is a rare disease characterized by the infiltration of neoplastic myeloid, myelomonocytic, or monocytic precursors into the skin, producing clinically nonspecific-appearing papules, nodules, plaques, or purpura that necessitate biopsy for definitive diagnosis. In general, it is considered an extramedullary manifestation of acute myeloid leukemia (AML) similar to myeloid sarcoma, also known as a chloroma. MLC often develops in patients with an established diagnosis of AML and is only rarely seen before the onset of systemic disease. Even more rarely, some patients are found to have an underlying nonleukemic bone marrow disease, such as a myelodysplastic syndrome (MDS). It is in these latter settings that the somewhat perplexing terminology aleukemic leukemia cutis (ALC) has been used widely. As may be imagined, establishing a diagnosis of ALC can be problematic and typically requires a high index of suspicion with careful integration of clinical, histopathological, and laboratory data. Once a diagnosis of ALC is made, a complete hematologic workup, including assessment of the patient's bone marrow, is essential because a diagnosis of MLC (with or without systemic leukemia) generally indicates a poor prognosis. When discovered in a patient with MDS, MLC has been suggested to herald progression toward more advanced disease. We present a rare case of so-called aleukemic myeloid leukemia cutis in an 82-year-old man subsequently diagnosed as having MDS without progression to overt AML. This case also illustrates a seemingly rare Kikuchi disease-like inflammatory pattern that obscured the underlying leukemic infiltrate in the skin, delaying its recognition.

Background Both vertical and transverse sections are used in the histologic interpretation of alopecia biopsy specimens. Although a combination of the two may be optimal, the pathologist is frequently only provided with a single specimen. Even though the trend in recent years has been toward transverse sections in this setting, we are not aware of any published data directly comparing the two methods. Methods One hundred two consecutive archived hair biopsy accessions that demonstrated comparable vertical and transverse sections were examined twice, each time in a random order. The pathologist's interpretation based only on the vertical sections and an interpretation based only on the transverse sections were compared with the original biopsy report, which had been based on the combination of vertical and transverse sections. Results In 76 cases, all 3 diagnoses were concordant (ie, the diagnosis made with vertical sections alone, the diagnosis made with transverse sections alone, and the original diagnosis were all in agreement). In 2 cases, neither the diagnosis made with vertical sections alone nor the diagnosis made with transverse sections alone were in full agreement with the original diagnosis. In 20 cases, only the diagnosis made with vertical sections was concordant with the original diagnosis. In 4 cases, only the diagnosis made with transverse sections alone was concordant with the original diagnosis. Limitations Our practice is heavily weighted toward scarring alopecia, and the results of our study may not be applicable to practices weighted toward other forms of alopecia. Because the cases had been signed out over a period of several years, the nomenclature for some entities changed. For the purposes of our study, we counted the diagnoses of follicular degeneration syndrome and idiopathic pseudopelade to be subtypes of (and concordant with) a diagnosis of central centrifugal cicatricial alopecia. In some cases, a definitive diagnosis was not possible at the time of the original diagnosis, but rather the pathologist had provided a histologic description and a differential diagnosis. For purposes of this study, an interpretation was considered to be concordant with the original descriptive diagnosis if all of the important histologic features were identified that had been described in the original report. Sampling error could have contributed to discordant diagnoses, but would be expected to affect both vertical and transverse samples in a random manner. Conclusion The combination of vertical and transverse sections is superior to either alone. Although transverse sections have revolutionized the evaluation of alopecia, in this study, the diagnosis made with vertical sections alone had a higher concordance rate with the combination than did transverse sections alone. As there are advantages and disadvantages inherent in either method, when only a single biopsy specimen is submitted, it may be sectioned either vertically or transversely, at the discretion of the pathologist. With either method, serial step sections should be obtained to reduce the risk of missing important histologic findings.

Background Endoscopic band ligation for bleeding small-bowel vascular lesions has been reported as safe and efficacious based on small case series. There have been several other published case reports of band ligators used for bleeding lesions, usually Dieulafoy's lesions, in the stomach, the proximal small bowel, and the colon. In addition, this method has been used for postpolypectomy bleeding stalks. There has never been a critical look at the anatomic consequences of banding in the thinner sections of bowel. Method The purpose of this study is to define the anatomic and histologic consequences of applying band ligator devices to the small and the large bowel. Fresh surgical specimens, both large and small bowel, that were excised because of neoplastic lesions were transported to our endoscopy unit where one end of the intact bowel was sutured shut. A standard upper endoscope was passed via the open end, and the bowel was closed tightly with rubber band ties. The bowel then was insufflated, and band ligators were applied to unaffected mucosa by using a standard technique. Photodocumentation from inside and outside the bowel was obtained. Some of the band polyps were cut above the band, and some were cut below the band in the fresh state. Some were fixed in formalin and examined microscopically. Histologic sectioning occurred at the level of the bands. Results The results were striking in that there were large holes (1 cm) in the fresh ileum specimen. There was gross serosal entrapment manifested by visible puckers on the outer surfaces of the specimens, especially in the small bowel and the right colon. The left colon, anatomically thicker, was less affected. The histologic evaluation revealed inclusion by the band ligator of the muscularis propria and serosa on the small bowel, the muscularis propria in the right colon, and the submucosa in the left colon. Conclusions Based on these findings, we conclude that band ligator devices are not safe in the small bowel and the right colon but probably are safe in the thicker left colon.

Campbell SE, Reed CM, Bui-Mansfield LT, Fillman E 64-year-old woman with a history of sarcoidosis presented with back and abdominal pain and was unresponsive to nonsteroidal antiinflammatory medications. In addition, the patient complained of weakness in her right arm. Physical examination of the abdomen was unremarkable, and examination of the spine revealed normal flexion and extension and no focal tenderness. Neurologic examination revealed slightly decreased strength in the right arm and hand. A posteroanterior chest radiograph showed a bilateral diffuse reticulonodular pulmonary parenchymal pattern, right paratracheal stripe thickening, and bilateral hilar lymphadenopathy (Fig. 1A). CT of the chest confirmed bilateral hilar, right paratracheal, and subcarinal lymphadenopathy and interstitial pulmonary disease. CT also revealed widespread retroperitoneal lymphadenopathy and multiple lytic lesions within the vertebral bodies and posterior elements of the thoracolumbar spine. Subsequent MRI of the spine revealed decreased T1 signal intensity and increased T2 signal intensity scattered throughout the spine (Fig. 1B). After IV sodium gadopentate was administered to the patient, multiple brightly enhancing lesions within the vertebral bodies, pedicles, laminae, and spinous processes were identified. Diffuse leptomeningeal and nerve root enhancement and an enhancing parenchymal spinal cord mass were also present (Fig. 1C). Biopsy of a vertebral lesion revealed noncaseating granuloma consistent with sarcoidosis without evidence of malignancy (Fig. 1D). Gram stains and cultures for fungi, aerobic and anaerobic organisms, and acid-fast bacilli were all negative. The differential diagnosis for diffuse marrow infiltration, enhancing intraaxial spinal cord mass, diffuse meningeal and nerve root enhancement, and mediastinal and retroperitoneal lymphadenopathy includes metastatic disease, lymphoma, leukemia, hematogenous osteomyelitis (tuberculous, fungal), and sarcoidosis [1]. Sarcoidosis is a systemic granulomatous disease of unknown etiology that has been shown to affect nearly every organ system. Osseous involvement occurs in 1–13% of cases, typically in the small tubular bones of the hands and feet [2, 3]. Sarcoidosis may affect either the vertebral column or the spinal cord. Typical vertebral column manifestations are lytic lesions with sclerotic borders that enhance on MRI and enhancement of the intervertebral disk [1, 3–5]. Typical spinal cord manifestations are leptomeningeal enhancement, enhancing spinal cord mass, nerve root “clumping,” and enhancing nerve root [4]. The most common spinal cord manifestation is leptomeningeal disease [4]. Given the variable manifestations of sarcoidosis within the spine, this disease should be considered in the differential diagnosis along with multiple sclerosis [4]; tuberculous meningitis [4]; and widespread vertebral involvement of metastatic disease, infection, or lymphoma [1]. Sarcoidosis is typically treated with corticosteroid therapy, after which clinical symptoms and even MRI findings may completely or partially resolve in 29% of the patients [6]. Prednisone