Leslie, Kieron

A woman in her 70s with well-controlled HIV on antiretroviral therapy presented with a several-month history of an asymptomatic perianal lesion. Skin examination showed a 0.5–1 cm red-pink, shiny, exophytic papule with visible telangiectasias near the anal verge. The differential diagnosis was most concerning for Kaposi sarcoma. A shave biopsy with electrodessication was performed for both diagnostic and therapeutic purposes. Histology revealed a dome-shaped lesion with a diffuse inflammatory infiltrate composed of lymphocytes and eosinophils. The vessels in the superficial and mid-dermis showed cuboidal-to-columnar endothelial cells with nuclear enlargement, conspicuous nucleoli, and ample cytoplasm. These findings were consistent with angiolymphoid hyperplasia with eosinophilia (ALHE). Only 2.4% of ALHE occur on the genitals and fewer than 1% on the buttocks. Additionally, few of these are reported in female patients and none in female patients with HIV. At 12 months post-treatment, the patient remains without evidence of recurrence.

AbstractA 44‐year‐old male presented with a 2‐month history of erythematous ulcerative papules and plaques on the scalp, face, and bilateral lower legs. He had a 5‐year history of well‐controlled HIV on antiretroviral therapy and recurrent syphilis infections. His face had violaceous plaques, while bilateral ankles and calves had ulcerative lesions with necrotic centers and purple borders. The morphologies clinically mimicked pyoderma gangrenosum on the lower extremities and cutaneous lymphoma on the face. Biopsy and reactive rapid plasma reagin confirmed a diagnosis of lues maligna, and the patient was successfully treated with penicillin G benzathine.

Abstract Melanotan II (MT2) is an injectable melanocortin agonist advertised as a tanning agent, despite not being approved by the Food and Drug Administration. Sold online as a ‘research peptide’, individuals can purchase and reconstitute the lyophilized (freeze-dried) form with bacteriostatic water to inject with insulin needles. While MT2 has been previously studied for erectile dysfunction treatment, its potential adverse effects (dysplastic naevi, renal infarction) and lack of ongoing clinical trials limit scientific research on its effects (Habbema L, Halk AB, Neumann M, Bergman W. Risks of unregulated use of alpha-melanocyte-stimulating hormone analogues: a review. Int J Dermatol 2017; 56: 975–80; Peters B, Hadimeri H, Wahlberg R, Afghahi H. Melanotan II: a possible cause of renal infarction: review of the literature and case report. CEN Case Rep 2020; 9: 159–61). This study aims to understand MT2 users’ motivations, hesitations, side-­effects and tanning effects, and their relationship with healthcare providers. Participants were recruited for this qualitative study through online forums such as Reddit.com, as well as snowballing via personal contacts. Virtual interview audio was recorded, transcribed into text, and coded using thematic analysis with two coders. Twenty-eight participants have been interviewed, aged 18–64 years (mean 38.4, SD 10.2); gender breakdown is 21 cisgender men, 6 cisgender women, and 1 transgender man. Three participants identify as LGBTQ+. Two of the 28 participants identify as Hispanic; all identify as White, with one who also identifies as Native American. All participants started MT2 for tanning, but some emphasized burn prevention as a motivator. Commonly reported side-effects include nausea, reversible darkening of moles, and an increase in libido or erections. All participants had darkening of skin tone, but their sun-exposure habits varied from none to dedicated, timed sun tanning. Dosage and dosage frequency also vary widely. Common topics that emerged include participants being introduced to MT2 through the bodybuilding community and frustration with the lack of available scientific research or medical knowledge regarding MT2. While physicians have reported dysplastic naevi in people using MT2, some participants perceive that MT2 is protective against skin cancer through preventing sunburns. Many patients regularly visit doctors or even dermatologists, but do not openly discuss their MT2 usage due to general distrust or doubt that their providers are knowledgeable enough to help. This provides an opportunity for dermatologists to build trust with patients and encourage harm reduction.

Abstract A 44-year-old man was referred for 2 months of erythematous ulcerative papules and plaques on the scalp, face and lower legs. The lesions started as painful ‘pimples’. He also reported fever and chills. He had a 5-year history of well-controlled HIV on antiretroviral therapy since diagnosis and a prior history of recurrent syphilis. Exam showed a large violaceous plaque on the right cheek with surrounding erythematous papules and an additional erythematous papule on the left ear. On the bilateral ankles and calves were four ulcers with necrotic centres and purple borders. The differential diagnoses included pyoderma gangrenosum and cutaneous lymphoma. A punch biopsy of the right zygomatic area showed dermatitis with a dense, diffuse plasma cell infiltrate suggestive of syphilis. The acid-fast bacteria (AFB), periodic acid–Schiff with diastase (PAS-D), and spirochete stains were all negative. Rapid plasma regain (RPR) was reactive at 1 : 4096. HIV was detected at < 30 copies per mL. Absolute CD4 T-cell count was 529 cells per μL. AFB and fungal cultures were negative, and bacterial culture showed rare Staphylococcus aureus. Although the spirochete stain was negative, it is only 70% sensitive and the positive RPR with histopathology supportive of syphilis in a patient who was positive for HIV confirmed the diagnosis of lues maligna. The patient received one dose of 2.4 million units of intramuscular penicillin G benzathine. He continued empiric doxycycline 200 mg daily, which had previously been initiated, and continued doxycycline postexposure prophylaxis after diagnosis. The patient reported healing with no new lesions 3 weeks after treatment. A new question brought on by this case is whether prior history of recurrent syphilis infection has a role in developing lues maligna. This patient in particular required syphilis treatment four times in the 3 years leading up to his presentation. Current literature describes a patient who was treated for secondary syphilis, then reinfected with malignant syphilis. However, further research is needed to elicit whether recurrent syphilis infections increase the chances of severe infection or malignant syphilis.

Abstract The terminology for human papillomavirus (HPV)–associated squamous lesions of the lower anogenital tract has a long history marked by disparate diagnostic terms derived from multiple specialties. It often does not reflect current knowledge of HPV biology and pathogenesis. A consensus process was convened to recommend terminology unified across lower anogenital sites. The goal was to create a histopathologic nomenclature system that reflects current knowledge of HPV biology, optimally uses available biomarkers, and facilitates clear communication across different medical specialties. The Lower Anogenital Squamous Terminology (LAST) Project was cosponsored by the College of American Pathologists and the American Society for Colposcopy and Cervical Pathology and included 5 working groups; 3 work groups performed comprehensive literature reviews and developed draft recommendations. Another work group provided the historical background and the fifth will continue to foster implementation of the LAST recommendations. After an open comment period, the draft recommendations were presented at a consensus conference attended by LAST work group members, advisors, and representatives from 35 stakeholder organizations including professional societies and government agencies. Recommendations were finalized and voted on at the consensus meeting. The final, approved recommendations standardize biologically relevant histopathologic terminology for HPV-associated squamous intraepithelial lesions and superficially invasive squamous carcinomas across all lower anogenital tract sites and detail the appropriate use of specific biomarkers to clarify histologic interpretations and enhance diagnostic accuracy. A plan for disseminating and monitoring recommendation implementation in the practicing community was also developed. The implemented recommendations will facilitate communication between pathologists and their clinical colleagues and improve accuracy of histologic diagnosis with the ultimate goal of providing optimal patient care.