Cameo
TINEA PEDIS MASKING A KAPOSI'S SARCOMA ROBERT R. WALTHER, M-D., GREGORY L. ZALAR, M.D. AND MARC, b. GROSSMAN. M.D.
A 67-yetr-old white man presented with bilateral blan( hing erythema and scale of the sec ond through fifth toes extending on to thednrsa and moccasin areas ol the fi'et for Iwo years. The right great tcje had subungual debris. No cultures or KOH studies were recorded. A ( ourse of tnlnaftate cream therapy was initiated. Two years later, ihe patient returned and c omplained of no c hange i i his condition. Previously recorded descriptions and diagrams In the medical record confirmed his report. At this time, KOH preparations from the •jkin and nail were pfisitive for hyphae. He refused to accept medi( al retommendatfons for a fungal < ullure and griseofulvin therapy. He, therefore, w.is instructed to use miconazole cream twice daily as alternative treatment. One year later, physical examination was unchanged (Fig. 1|. KOH preparations and fungal cultures of the skin were twice legative. A 4-mm punch skin biopsy specimen of the erythematous patt h on thedorsum of the fool Wds performed. Hematoxylin and c'osin-stained sections revealed a :iroliffc'rating vascular process in the cutis. Many spindle-shaped cells formed vascular slits and endothelial-'ined spaces in which there were erythrocytes (Fig. 2i. No hyphae were seen. One year after the biopsy specimen was taken, the erythema ol his feet persists, and d few nonblanching nodules are visible. He declined fur her studies.
From Ihc Dcpdrlmcnl ot Dcrma/o/o^y, Columhij-Fn'sbyhTidn Mediisl Center. New York, New Ynrk
Kaposi's sarrnma is well recoj;nizcd as both a cutaneous and systemic disease, but the presenting signs usually have been localized to the skin and are varied. The usual clinical presentation is a purfilish maculethat may progress to a plaque or tumor with tissue edema. Lesions evolve slowly and occasionally will resolve spontaneously leaving scars and hyperpigmentation. While the initial presentation is often typical, the differential diagnosis includes angioma, angiosarcoma, angiokeratoma, pyogenic granuloma, glomus tumor, lymphoma, malignant melanoma, sar-
Discussion
In his original description, "Idiopathic Multiple Pigmented 5arcoma of the Skin,"' Kaposi recognized the common presence of a nonblanching component in the skin lesions. A patient with Kaposi's sarcoma who lacked this pigment has been followed in the Dermatology Clinic of the Columbia-Presbyterian Medical Center. His only lesions were on the feet and for years he was diagnosed as having chronic tinea pedis. Address foi- reprlnls: Robert R. Walther, M.D., Department of Dermatology, Columbia-Presbylerian Medical Center, 622 West 168th Street, New York, NY 10032.
Fig. I. Scaling, erythematous patches m a mc>ccasin distribution on both feet.
0011-90S9/79/1100/075I/$00.6U (c) International Society of Tropical Dermatology, Inc.
751
752
INTERNATIONAL lOURNAL OF DERMATOLOGY
Fig. 2. Biopsy specimen showing a [Koliferative processof vascular and spindle cells with the presence of slits containing erythrocytes (H&E, original magnification X 1601-
coidosis, leprosy, syphilis, metastatic nodules and drug eruption. The histologif findings of Kaposi's sarcoma are the definitive diagnostic aid. In keeping with Kaposi's original description of the purpuric or pigmented nature of the early macule, plaque or nodule of Kaposi's sarcoma, the lack of clinically visible pigment, totally blanching erythema and missed diagnosis lor several years makes this patient unusual. Several other cases of Kaposi's sarcoma without clinically evident pigment aro reported. Bluefarb recounts a patient with a twenty-year history of blanching "rose spot" on the hand before extension of typical Kaposi's sarcoma.^ Farberet al.'' reported two patients presenting as stasis dermatitis with erythema and scale about the ankles. Close
November 1979
Vol. 18
inspection however, revealed pigment in the usual area of the dorsa of the feet, which suggests a different diagnosis. Wolf^ described a patient with typical morphologic lesions of Kaposi's sarcoma without pigment and erythema. Most unusual was a patient reported by Howard, et al.' who was originally thought to have an exfoliative erythroderma of Sezary's syndrome; multiple biopsy specimen results of erythrodermic skin were compatible with Kaposi's sarcoma. Since the large number of patients with Kaposi's sarcoma are elderly and often die of other organic diseases, it is possible that other cases of Kaposi's sarcoma presenting without pigment are not being diagnosed. Biopsy of persistent erythema unresponsive to treatment is suggested. Drug Names miconazole: Micatin tolnaftate: Tinactin
References 1. Kaposi, M.: Idiopathisc hes multiples pigmentsarkom dcr haul. Arch. DermatoL Syphilol. 4:26.5, 1H72. 2. Bluefdrb, S. M.: Kaposi's Sarcoma. Springfield, Charles C Thomas, 1957. 3. Farber, E. M., Schmidt, O. E. L,, and Weber, W. E.: Kaposi's sarcoma simulating stasis ulcers of the legs. Stan. Med. Bull. 7;79, 1949. 4. Wolf, C: Idiopathic multiple hemorrhagic sarcoma ofKaposi.Arch.Dermatol.Syphilol. 36:1252, 1937. 5. Howard, W. R., Roenigk, H. H., and Bergtietd, W. F.: Ka|K)si's hemorrhagic sarcoma. Cutis 21:503, 1978.
Erratum In the January, 1979 issue (18:231, the Drug Names listing in the article entitkni "Steroid Addiction" by Altx'rl M. Kligman, M.D., Ph.D. and Peter !. Frosch, M.D. misidentified hydrocortisone 17-butyrdte as Westcort. The correct source of hydrocortisone 17-butyrate, which is not available in the United States, is Gist-Brocades Ltd., United Kingdom.
TINEA PEDIS MASKING A KAPOSI'S SARCOMA ROBERT R. WALTHER, M-D., GREGORY L. ZALAR, M.D. AND MARC, b. GROSSMAN. M.D.
A 67-yetr-old white man presented with bilateral blan( hing erythema and scale of the sec ond through fifth toes extending on to thednrsa and moccasin areas ol the fi'et for Iwo years. The right great tcje had subungual debris. No cultures or KOH studies were recorded. A ( ourse of tnlnaftate cream therapy was initiated. Two years later, ihe patient returned and c omplained of no c hange i i his condition. Previously recorded descriptions and diagrams In the medical record confirmed his report. At this time, KOH preparations from the •jkin and nail were pfisitive for hyphae. He refused to accept medi( al retommendatfons for a fungal < ullure and griseofulvin therapy. He, therefore, w.is instructed to use miconazole cream twice daily as alternative treatment. One year later, physical examination was unchanged (Fig. 1|. KOH preparations and fungal cultures of the skin were twice legative. A 4-mm punch skin biopsy specimen of the erythematous patt h on thedorsum of the fool Wds performed. Hematoxylin and c'osin-stained sections revealed a :iroliffc'rating vascular process in the cutis. Many spindle-shaped cells formed vascular slits and endothelial-'ined spaces in which there were erythrocytes (Fig. 2i. No hyphae were seen. One year after the biopsy specimen was taken, the erythema ol his feet persists, and d few nonblanching nodules are visible. He declined fur her studies.
From Ihc Dcpdrlmcnl ot Dcrma/o/o^y, Columhij-Fn'sbyhTidn Mediisl Center. New York, New Ynrk
Kaposi's sarrnma is well recoj;nizcd as both a cutaneous and systemic disease, but the presenting signs usually have been localized to the skin and are varied. The usual clinical presentation is a purfilish maculethat may progress to a plaque or tumor with tissue edema. Lesions evolve slowly and occasionally will resolve spontaneously leaving scars and hyperpigmentation. While the initial presentation is often typical, the differential diagnosis includes angioma, angiosarcoma, angiokeratoma, pyogenic granuloma, glomus tumor, lymphoma, malignant melanoma, sar-
Discussion
In his original description, "Idiopathic Multiple Pigmented 5arcoma of the Skin,"' Kaposi recognized the common presence of a nonblanching component in the skin lesions. A patient with Kaposi's sarcoma who lacked this pigment has been followed in the Dermatology Clinic of the Columbia-Presbyterian Medical Center. His only lesions were on the feet and for years he was diagnosed as having chronic tinea pedis. Address foi- reprlnls: Robert R. Walther, M.D., Department of Dermatology, Columbia-Presbylerian Medical Center, 622 West 168th Street, New York, NY 10032.
Fig. I. Scaling, erythematous patches m a mc>ccasin distribution on both feet.
0011-90S9/79/1100/075I/$00.6U (c) International Society of Tropical Dermatology, Inc.
751
752
INTERNATIONAL lOURNAL OF DERMATOLOGY
Fig. 2. Biopsy specimen showing a [Koliferative processof vascular and spindle cells with the presence of slits containing erythrocytes (H&E, original magnification X 1601-
coidosis, leprosy, syphilis, metastatic nodules and drug eruption. The histologif findings of Kaposi's sarcoma are the definitive diagnostic aid. In keeping with Kaposi's original description of the purpuric or pigmented nature of the early macule, plaque or nodule of Kaposi's sarcoma, the lack of clinically visible pigment, totally blanching erythema and missed diagnosis lor several years makes this patient unusual. Several other cases of Kaposi's sarcoma without clinically evident pigment aro reported. Bluefarb recounts a patient with a twenty-year history of blanching "rose spot" on the hand before extension of typical Kaposi's sarcoma.^ Farberet al.'' reported two patients presenting as stasis dermatitis with erythema and scale about the ankles. Close
November 1979
Vol. 18
inspection however, revealed pigment in the usual area of the dorsa of the feet, which suggests a different diagnosis. Wolf^ described a patient with typical morphologic lesions of Kaposi's sarcoma without pigment and erythema. Most unusual was a patient reported by Howard, et al.' who was originally thought to have an exfoliative erythroderma of Sezary's syndrome; multiple biopsy specimen results of erythrodermic skin were compatible with Kaposi's sarcoma. Since the large number of patients with Kaposi's sarcoma are elderly and often die of other organic diseases, it is possible that other cases of Kaposi's sarcoma presenting without pigment are not being diagnosed. Biopsy of persistent erythema unresponsive to treatment is suggested. Drug Names miconazole: Micatin tolnaftate: Tinactin
References 1. Kaposi, M.: Idiopathisc hes multiples pigmentsarkom dcr haul. Arch. DermatoL Syphilol. 4:26.5, 1H72. 2. Bluefdrb, S. M.: Kaposi's Sarcoma. Springfield, Charles C Thomas, 1957. 3. Farber, E. M., Schmidt, O. E. L,, and Weber, W. E.: Kaposi's sarcoma simulating stasis ulcers of the legs. Stan. Med. Bull. 7;79, 1949. 4. Wolf, C: Idiopathic multiple hemorrhagic sarcoma ofKaposi.Arch.Dermatol.Syphilol. 36:1252, 1937. 5. Howard, W. R., Roenigk, H. H., and Bergtietd, W. F.: Ka|K)si's hemorrhagic sarcoma. Cutis 21:503, 1978.
Erratum In the January, 1979 issue (18:231, the Drug Names listing in the article entitkni "Steroid Addiction" by Altx'rl M. Kligman, M.D., Ph.D. and Peter !. Frosch, M.D. misidentified hydrocortisone 17-butyrdte as Westcort. The correct source of hydrocortisone 17-butyrate, which is not available in the United States, is Gist-Brocades Ltd., United Kingdom.
