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Background Integration of disease-specific programmes into the primary health care (PHC) service has been attempted mostly in clinically oriented disease control such as HIV/AIDS and tuberculosis but rarely in vector control. Chagas disease is controlled principally by interventions against the triatomine vector. In Honduras, after successful reduction of household infestation by vertical approach, the Ministry of Health implemented community-based vector surveillance at the PHC services (health centres) to prevent the resurgence of infection. This paper retrospectively analyses the effects and process of integrating a Chagas disease vector surveillance system into health centres. Methods We evaluated the effects of integration at six pilot sites in western Honduras during 2008–2011 on; surveillance performance; knowledge, attitude and practice in schoolchildren; reports of triatomine bug infestation and institutional response; and seroprevalence among children under 15 years of age. The process of integration of the surveillance system was analysed using the PRECEDE-PROCEED model for health programme planning. The model was employed to systematically determine influential and interactive factors which facilitated the integration process at different levels of the Ministry of Health and the community. Results Overall surveillance performance improved from 46 to 84 on a 100 point-scale. Schoolchildren’s attitude (risk awareness) score significantly increased from 77 to 83 points. Seroprevalence declined from 3.4% to 0.4%. Health centres responded to the community bug reports by insecticide spraying. As key factors, the health centres had potential management capacity and influence over the inhabitants’ behaviours and living environment directly and through community health volunteers. The National Chagas Programme played an essential role in facilitating changes with adequate distribution of responsibilities, participatory modelling, training and, evaluation and advocacy. Conclusions We found that Chagas disease vector surveillance can be integrated into the PHC service. Health centres demonstrated capacity to manage vector surveillance and improve performance, children’s awareness, vector report-response and seroprevalence, once tasks were simplified to be performed by trained non-specialists and distributed among the stakeholders. Health systems integration requires health workers to perform beyond their usual responsibilities and acquire management skills. Integration of vector control is feasible and can contribute to strengthening the preventive capacity of the PHC service.

Freeze-fractured keratinocyte membrane of the human epidermis revealed a relatively particle(arrows)-rich A-face (A) and a relatively particlepoor B-face (B)(Fig. 1). However, these so-called membrane-associated particles are not numerous even on the A-face, as compared with those of other tissues.When the nexus or gap junctions were fractured, in most cases the B-face showed clustered cobblestone particles (c), instead of pits (Fig. 1). Cobblestone particles were 70-135 A in diameter and 0-25 A in height (Fig. 1). Much taller particles (50-70 A in height) were very often admixed (Fig. 1). In some instances. a macule of cobblestone particles (C) was seen in the neighborhood of a macule of depressed particles (D) showing the same dimensions (Fig. 2).

In recent years the epidermal Langerhans cell has been considered to belong to histiocytic rather than melanocytic lineage. However, the functional significance of the Langerhans cell granule, which has also been called Bribeck's granule or racket body, has not been settled. In this study, 0.1 ml of horseradish peroxidase solution (25 mg in 1.0 ml normal saline) was injected intradermally into six sites on the back of a normal adult guinea pig. The injected sites were biopsied at 10, 30, 60, 120, 180 and 300 minutes and later at 22, 120 and 142 hours. The epidermis was minced with sharp razor blades into 1 mm blocks and fixed in 5% glutaraldehyde in 0.1 M cacodylate buffer (pH 7.2) for 3 hours at 4°C. After overnight rinse in the same buffer, tissue blocks were minced again into smaller pieces to facilitate the penetration of benzidine and hydrogen peroxide. Benzidine reaction was done according to the method of Schneeberger-Keeley and Karnowsky.

Diagnostic Electron Microscopy in Practical Dermatology by Daroczy and Racz is a collection of clinical, histologic, and electron microscopic pictures of miscellaneous dermatoses. The paucity of this type of publication makes this volume a handy reference book. Although these authors state that "no textbook on this subject [electron microscopy of dermatoses] has appeared as yet," there are a few recent reference sources (eg, The Clinical Use of Electron Microscopy in Dermatology , Minneapolis, Bolger Publications, 1985; Skin Pathology by Light and Electron Microscopy , New York, Igaku-Shoin Medical Publishers Inc, 1983; and Electron Microscopy in Human Medicine , New York, McGraw Hill International Book Co, 1985, vol 11a: The Skin ) that they should not neglect. Of over 40 entities discussed in this book, only about eight conditions could use electron microscopic analysis for diagnosis (Hand-Schuller-Christian disease, cutis laxa, hyalinosis cutis et mucosae, Fabry's disease, primary systemic amyloidosis, lichen amyloidosis, metastatic carcinomas, and Sezary

• Long-term use of a nylon brush for back scratching by a 53-year-old white woman was associated with the development of typical macular amyloidosis. EKH4 monoclonal antikeratin antibody, which recognizes 50-kd neutral and acidic keratin species, labeled this amyloid. Confirmation of amyloid substance in the lesion included positive staining with Dylon and thioflavin T; immunohistochemical reactions with monoclonal and polyclonal antibodies against elastic fiber microfibrils (NKH1 and anti-P component), immunoglobulins (IgG, IgM, and IgA), and complement (C3); and electron microscopic identification of 6- to 10-nm straight filaments. Type IV collagen staining demonstrated a breakage and/or thickening of the dermoepidermal basement membrane above the amyloid deposition in the papillary dermis. Electron microscopic findings confirmed this phenomenon. (Arch Dermatol1987;123:633-637)

To the Editor.— The association of lithium and psoriasis, acne and acneiform eruptions, and folliculitis is relatively well known. There have been other rare and isolated reports of the association of lithium with alopecia, exfoliative dermatitis, maculopapular rash, ulcer, stomatitis, ichthyosis, xerosis, eczema, and pruritus, and a single case of dermatitis herpetiformis.1The last case was reported by Posey in 19722; in his short report he described an adult woman who had been taking lithium carbonate for a manicdepressive illness and in whom an intensely pruritic papular dermatitis developed that appeared on the elbows and resembled dermatitis herpetiformis clinically. This diagnosis was not histologically confirmed. Sulfoxone sodium therapy was started with cessation of symptoms, but lithium therapy could not be reinstituted without new lesion formation. Report of a Case.— A 26-year-old man presented with a six-month history of blisters involving his arms and hands, left lower leg and

Basal Cell Epitheliomas Treated by Mohs Chemosurgery. Presented by Rex A. Amonette, MD, Richard H. Shereff, MD. Case 1.— A 78-year-old black woman had a large (6.5×5.5 cm) basal cell epithelioma in the postauricular sulcus. Infiltrating tumor extended over the posterior surface of the ear and onto the posterolateral area of the scalp. There was no history of trauma or evidence of scar in this area. The epithelioma was surgically removed using Mohs technique. Seven stages of chemosurgery and 72 frozen tissue sections were required to reach a tumor-free plane. The surgical defect healed by spontaneous granulation. Case 2.— A 78-year-old white woman had a 1.0×1.0-cm nodule over a 2×2-cm sclerotic area of the right tip of the nose. Biopsy revealed this lesion to be an infiltrating basal cell epithelioma. To remove the entire tumor, a 4.3×3.8-cm surgical defect was created. This required nine stages

• Elastic fibers account for 2% of dermal volume and are responsible for normal skin resiliency. We investigated a disorder of the dermal elastic component as the mechanism for the decreased elasticity of skin in myxedema. Skin biopsy specimens were obtained from patients with thyroid diseases and normal subjects matched for age, sex, and biopsy location. Elastic fiber concentration, determined by computerized morphometric analysis of Verhoeff-van Gieson–stained sections, was significantly lower than normal in hypothyroid and pretibial myxedema. The decreased elastin concentration was not a consequence of the glycosaminoglycan infiltration. Ultrastructural studies of myxedematous skin showed wide variability of elastic fiber diameter and decreased microfibrils. Myxedema (hypothyroid and pretibial) is consistently associated with quantitative and qualitative defects of dermal elastic fibers. ( Arch Intern Med 1985;145:117-121)

Pityriasis rubra pilaris (PRP) is a rare papulosquamous disease characterized by erythroderma, acuminate follicular papules, with so-called islands of sparing, follicular hyperkeratosis, palmoplantar keratoderma and occasional lymphadenopathy, hair loss, mucosal lesions (white or blue lines or erythematous lesions transversed by white streaks), and eye lesions (corneal opacities, conjunctivitis, keratitis). Pityriasis rubra pilaris can be widespread and very distressing to the patient, because limitation of motion and painful fissuring of palmar and plantar surfaces can occur. Among the many treatment modalities that have been used are vitamin A alone1or in combination with vitamin E,2topical aminonicotinamide,3azathioprine,4methotrexate,5isotretinoin,6etretinate,7PUVA,7and systemic steroids.8Anecdotal reports indicate that ascorbic acid or penicillin might also be of benefit. Lamar and Gaethe,8in their review of PRP, documented the effects of old remedies, such as arsenic, foreign protein injections, pilocarpine, pituitary extract, carotene

Pseudopseudohypoparathyroidism and pseudohypoparathyroidism have been thought to represent variants of the same disease process, Albright hereditary osteodystrophy. A 31-year-old woman with the characteristic features of pseudopseudohypoparathyroidism, such as shortened metacarpals and metatarsals, round facies, and normal serum calcium values, was studied. Underdeveloped metacarpal and metatarsal heads produced an important diagnostic sign, Albright dimpling sign, which dermatologists can use to make the correct diagnosis. The presence of this sign, together with roentgenographic evidence, will usually exclude other diagnostic possibilities. Our patient had a normal response to parathyroid hormone infusion, including increased urinary adenosine 3′,5′ cyclic monophosphate excretion. Radiological, light microscopic, and electron microscopic studies of the mandible showed fibrous dysplasia, a disease commonly reported to be present with hyperparathyroidism, but, to our knowledge, never before reported in association with any variant of hypoparathyroidism.

• A 24-year-old woman noted a depigmented halo around a pigmented lesion that had been present on her abdomen since birth. The halo and the central pigmented zone showed no change during the following year. Light and electron microscopic studies disclosed an uninflamed nevus extending to the deep reticular dermis; peripherally, the basal layer of the epidermis was depigmented. These findings indicate that a halo may develop about an uninflamed nevus that does not involute, and that the nevus may show the specific histopathology of congenital nevus. ( Arch Dermatol 113:1572-1575, 1977)

Seven new cases of dermatofibrosarcoma protuberans were studied. Most tumors were asymptomatic, multinodular, protuberant masses; five were on the trunk or abdomen and two on a thigh. Clinical diagnoses included dermatofibrosarcoma protuberans, dermatofibroma, metastasis, and lymphoma. Histologic examination showed a cartwheel or storiform pattern in each lesion; short fascicles of spindle-shaped tumor cells coursed in various directions and intersected at different angles. Melanocytes were present deep in one lesion. Electron microscopically, the tumor cells showed extensive cytoplasmic processes, moderately dense cytoplasmic matrix, elaborately convoluted nuclei, few profiles of rough-surfaced endoplasmic reticulum and Golgi lamellae, spotty basal laminalike material, and fibrous long-spacing collagen; conspicuously absent were intracellular lysosomes and lipid, and prominent cytoplasmic filamentation. The findings are sufficiently distinctive to be of diagnostic utility and suggest origin from a modified neural supporting cell, such as the endoneural or perineural cell.

Generalized pustular psoriasis is a rare form of psoriasis characterized by the following four clinical patterns: Zumbusch, annular, exanthematic, and localized. 1 In contrast to the Zumbusch variety, the annular type is less severe and benign. It consists of gyrate, annular lesions with an erythematous, scaly, pustular margin. A history of psoriasis vulgaris is usually absent. Subcorneal pustular dermatosis (SPD) is frequently confused with annular pustular psoriasis (APP). 1,2 We report a case of APP in a 3-year-old girl who had a previous diagnosis of SPD. Report of a Case A 3-year-old girl was referred to Children's Medical Center, Dayton, Ohio, in January 1979, with an exacerbation of a pustular eruption that began at 3 weeks of age. A skin biopsy done in January 1977 was read as "psoriasiform dermatitis." A second biopsy specimen in October 1977 showed a subcorneal pustule. A diagnosis of SPD was made and dapsone therapy

• Studies of early progressive vitiligo, Vogt-Koyanagi syndrome, and incontinentia pigmenti achromians were made by electron microscopy. At the periphery of the depigmented lesions, the melanocytes had several subcellular abnormalities, ie, vacuolization of the cytoplasm, aggregation of melanosomes, autophagic vacuoles, fatty degeneration, pyknosis or homogeneous cytoplasmic degeneration, and others. Numerous nerve endings were seen in close contact with the basal lamina of the epidermis or even within the epidermis. Direct continuities between Schwann cell basal lamina of nerve endings and the basal lamina of the melanocytes were observed. Nerve endings could be associated with either normal or abnormal melanocytes. ( Arch Dermatol 113:755-766, 1977)

Two new cases of colloid milium were studied by several methods to examine if collagen is the source of colloid. Woundhealing experiments in the lesion revealed that colloid is reproduced de novo with possible interaction with epidermal cells. Unfixed, native colloid did not contain collagen and salt extraction did not alter the ultrastructure of colloid. Tissue culture of colloid fibroblasts produced colloid-like substance. These results suggest that colloid is not a degeneration product of collagen. Disc electrophoresis of extracted colloid produced a distinct band, which is absent in the normal skin control. Amino acid analysis of colloid suggests that colloid may contain the recently described class of glycoprotein, called "structural glycoprotein" that is not related to collagen because it does not contain hydroxyproline and hydroxylysine and contains only a small amount of glucose. These biochemical data support the conclusion reached in electron microscopical studies.

Numerous tubuloreticular structures were seen on electron microscopic examination of involved and uninvolved skin of a neonate with lupus erythematosus. The patient had characteristic lupus skin lesions at birth that worsened for three months, and then gradually subsided. Their course was associated with systemic illness. Skin biopsy specimen was diagnostic. Direct immunofluorescence of the skin showed no abnormalities. Abnormal serological findings were noted in the mother, who had no overt clinical disease. The significance of these virus-like structures in lupus erythematosus is emphasized by the present case. (JAMA235:2743-2744, 1976)

In a case of chronic, severe urticaria and intermittent episodes of anaphylaxis due to an iophendylate injection (Pantopaque) given in the course of myelography, almost complete relief was obtained from the removal of approximately 8 ml of residual iophendylate from the spinal canal. Data obtained from direct skin testing, Prausnitz-Kustner testing, peptide inhibition of Prausnitz—Kustner testing, and IgE levels quantitated before and after removal of iophendylate indicate that these symptoms were mediated via an IgE anti-iophendylate reaction. (JAMA236:1495-1497, 1976)

With the use of new material, lichen amyloidosus was reexamined with improved techniques. Island formation of amyloid in a close spatial relation to fibroblasts and absence of amyloid in perivascular spaces were reemphasized. As new findings, segregation of cytoplasmic material of fibroblast by budding and ballooning of the peripheral cytoplasm, desmosome-like and half-desmosome-like structures of fibroblasts, intracellular amyloid of dermal fibroblasts, and amyloid-like intracellular filaments of keratinocytes were described.

The second genetically significant report of urticaria pigmentosa in closely related individuals is presented. The hereditary pattern seems to be that of an incompletely penetrant autosomal dominance.

SURGICAL GLOVE TALC can cause granulomas in various intestinal and pelvic organs.1In the skin, localized silica granulomas due to the glove talc have been observed in surgical scars2,3and as the result of the impregnation of the skin by silicious particles, such as glass or sand, following an injury.' 5Extensive talc granulomas of the skin have not been reported, to our knowledge. Report of a Case A 45-year-old woman was admitted to the hospital because of the development of increasing numbers of lumps on her shoulders, buttocks, and thighs. These nodules had been developing for the past two years and were at sites where she has had as many as 500 boils over the past eight to ten years. Many of these boils were treated by incision and drainage. The nodules have not appeared on areas of the body where she has not had furuncles. She also

Eruptive hidradenoma, a rare type of syringoma, was studied histologically, histochemically, and electron microscopically in two patients. In spite of its peculiar clinical differences, such as occurrence of numerous lesions with limited distribution to anterior surfaces of the body, it showed features identical to the eyelid type syringoma. Direct connections were found between the lesions and epidermis and between individual lesions, but not between the lesions and underlying eccrine secretory segments. Also, cystic or tubular spaces were lined with an "immature eccrine intra-epidermal type" of epithelium which possessed a periluminal tonofilament band, lysosomes, keratohyaline granules, and often underwent complete keratinization. No secretory epithelium was found in the lesion. Dermal histiocytes with typical Langerhans cell granules and collagen fiber bundles were seen in parenchyma. It seemed that the lesion was undergoing constant destruction and regeneration.

To the Editor.— It has previously been suggested 1 that lichenoid and macular amyloidosis may represent the same basic disease process; the important difference between these conditions is not the amount of amyloid deposited but the presence of epidermal hyperplasia in the former condition and its absence in the latter. During the past few months, we have had the unique opportunity to study two Puerto Rican women with lichen amyloidosus of one leg and macular amyloidosis of the other. The first patient manifested a pruritic lichenoid eruption of the right leg and barely discernible speckles of brown macular pigmentation on the left side. A biopsy specimen from the right limb disclosed epidermal hyperplasia and amyloid deposits in the papillary dermis, confirming the clinical impression of lichen amyloidosus. The lower portion of the left limb had been deformed, and sensation had been impaired since birth. Light and electron microscopic examination

Ruthenium red staining demonstrated the intercellular cement substance more distinctly and specifically than staining with uranyl acetate and lead citrate. The intercellular cement substance was seen in direct contact with the outer leaflet of the plasma membrane. In the acantholysis of pemphigus vulgaris the cement substance underwent dissolution first in nondesmosomal areas and later in desmosomal areas and at intermediate junctions where the cement substance was present as a thicker layer and appeared condensed. Occluding zonules persisted even in degenerated acantholytic cells, indicating a high degree of resistance against separation. In separated desmosomal areas and separated intermediate junctions, the trilaminar structure of the plasma membrane remained intact. In early acantholyzed cells, the attachment plaques and tonofilaments appeared normal. Thus, acantholysis in pemphigus is initially an extracellular phenomenon. Fine fibrillar structures were found crisscrossing the space between the basal plasma membrane of the basal cell and the basal lamina. The presence of these fibrils partially explained why acantholysis does not occur in this space.

Electron microscopic examination showed varying numbers of typical Langerhans cells in the dermis in normal human skin, pityriasis rosea, reticulum cell sarcoma, and Letterer-Siwe disease as well as among the stromal and parenchymal cells of several benign appendage tumors. Langerhans cells were observed crossing the basement membrane and an epidermal Langerhans cell in mitosis was seen. These findings suggest that Langerhans cells are not directly related to epidermal melanocytes and may constitute a self-perpetuating "intraepidermal phagocytic system" to which histiocytes from the dermis are added from time to time.

To the Editor.— We would like to point out to Dr. Fusaro that we are not in disagreement with him that cylindroma is probstraightably, but not definitely, an apocrine type of tumor. We were only cautious about straightforward classification of cylindroma into the apocrine group. We have repeated and confirmed the work by Fusaro and Goltz 1 as such and one of us quoted it in a standard textbook. 2 Obviously, in a general review, 3 we could not include his master's thesis. 4 The PAS reaction with picric acid counterstain, combined with negative Alcian blue stain, may identify neutral carbohydrate or carbohydrate protein complexes. However, the conclusion that cylindroma is an apocrine tumor because PAS( + ), DR and AB ( - ) substance was found in common in globules of apocrine secretory cells, cylindroma and hyaline materials of cylindroma needs some comments. First, although we also believe that some constituents of the hyaline

Biopsy specimens of cutaneous lesions from two patients with histiocytosis X of the infantile type (Letterer-Siwe disease) were examined with the electron microscope. More than one half of the dermal macrophages in both specimens contained organelles identical to epidermal Langerhans' cell granules. These organelles appear to arise during the process of endocytosis of extracellular material and are ultimately found in various stages of degradation within Iysosomelike granules. The ultrastructural identity of these dermal macrophages to epidermal Langerhans' cells supports the hypothesis that the epidermal Langerhans' cell is a macrophage.

HISTOCHEMICAL .ISTOCHEMICAL and electron microscopic investigations have been useful in the determination of the histogenesis of many appendage tumors for two reasons. First, the immature cells of appendage tumors, like immature cells of cutaneous appendages of the human embryo, contain certain enzymes that are quite specific for each cutaneous appendage. Second, the electron microscopic examination of the appendage tumors reveals details which are not recognizable on examination with the light microscope. With these new methods, many conventional viewpoints of the light microscopist have been confirmed, whereas, some were disproved. 1-4 In this review, the histogenesis of eccrine poroma, syringoma, eccrine spiradenoma, cylindroma, and calcifying epithelioma will be discussed. Materials and Methods All histochemical methods and materials used were the same as those used previously. 5-12 Original electron micrographs used for Fig 2, 3, 6, 8, and 10 were taken with a high resolution electron microscope (Hitachi HU-11C) at accelerating voltage

One case of congenital, multicentric reticulohistiocytoma of the skin was followed up for more than a year. All lesions disappeared within 31/2 months, and there was no recurrence. Electron microscopic examination revealed typical histiocytic proliferation. Characteristically, the majority of the tumor cells contained numerous dense bodies, many of which showed myelin-like laminations. About 10% of the tumor cells contained Langerhans' cell granules. Some of these cells also contained myelinated dense bodies. These features, which are not commonly seen in Langerhans' cells of histiocytosis X, and the benign course of the disease were emphasized as differentiating points of this entity from histiocytosis X. No cell exhibited a resemblance to ganglioneuronal cells.

Tubular structures similar to paramyxoviruses were observed in the skin lesions of ten consecutive patients with discoid lupus erythematosus. Two lesions from each case, one representing the most recently developed and the other the oldest one, were examined. Fifty dermal blood vessels consisting of arterioles, capillaries, venules, and small veins were examined in each lesion, totaling 100 blood vessels from each case. The detection rate of paramyxovirus-like inclusion or inclusions in either endothelial cells, perivascular histiocytes, or fibroblasts was 100% in new lesions (defined as up to six months' duration), whereas in old ones (older than six months) the mean detection rate was 70% on average. Very old scarred lesions did not contain the structure. Similar structures have been found also in dermatomyositis, scleroderma, and the congenital rubella syndrome. Since these inclusions were found mostly in so-called autoimmune disorders and, with the exception of congenital rubella syndrome, not in other groups, we hypothesized that, if proven to be a virus, they may be causally related to these diseases or, if not, they may represent a common reaction pattern in the autoimmune responses of tissue.