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Dear Editor, Paraneoplastic dermatomyositis is a distinct clinical variant of dermatomyositis (DM) in which the typical cutaneous features and muscle weakness appear before, simultaneously, or after the diagnosis of an internal malignancy. It occurs in approximately one-third of patients with DM, predominantly adults, after the age of 40 (1). Different neoplasms have been described in association with DM, the most common of which are lung, breast, ovarian, gastrointestinal, prostate, and bladder cancers. The gender distribution of cancer type corresponds roughly to that of the general population (1,2). We report the case of a 58-year-old man who presented with facial heliotrope erythema, periorbital edema, Gottron's papules over the interphalangeal and metacarpophalangeal joints, and Gottron's sign on the elbows (Figure 1). The patient also exhibited some less frequent skin signs of DM, such as shawl sign on the upper back and shoulders and V-sign on the neck and chest. Apart from the rash, he complained of weight loss, adynamia, dysphagia, cough, and scant expectoration, which he reported experiencing over a 3-month period. The muscle involvement consisted of proximal muscle weakness and had appeared a month after the skin rash. The histology of the skin lesion revealed epidermal atrophy, vacuolar degeneration of the basal keratinocytes, and perivascular and periadnexal lymphocytic infiltrate in the upper dermis (Figure 2). Laboratory examination found increased creatine kinase (2822 U/L) and liver enzymes, anemia, and leukocytosis. Screening for antinuclear antibodies and anti-Jo1 autoantibodies were both negative. The diagnosis of trichinosis was excluded via serologic examination. The impaired general condition of the patient led to a prompt paraneoplastic screening. Abdominal sonography detected hepatomegaly. Computed tomography (CT) of the abdomen and pelvis visualized a mass in the distal part of the esophagus, narrowed lumen of the gastric cardia, enlarged gastric lymph nodes, lung and liver metastases, and ascites (Figure 3). The diagnosis of paraneoplastic DM in association with an advanced, metastatic, primary gastric carcinoma was established. Palliative surgery and chemotherapy were proposed to the patient, but he refused both. A systemic therapy with methylprednisolone 60 mg/daily and azathioprine 100 mg/daily was initiated, aiming to alleviate the progressively worsening muscle weakness, but proved ineffective. The patient died two months later of combined respiratory and heart failure. There are multiple prediction factors, such as cutaneous signs, laboratory data, and disease progression, which may direct the physician towards the possibility of paraneoplastic DM. Some atypical cutaneous lesions, such as cutaneous necrosis or vasculitis, hyperkeratotic follicular papules, vesiculo-bullous lesions, and flagellate erythema, are seen more frequently in cancer-associated DM (3,4). None of these were present in our patient. Pruritus is also described as a paraneoplastic sign (5). Some authors consider the increased erythrocyte sedimentation rate and C-reactive protein to be of predictive value for malignancy. Myositis-specific autoantibodies anti-TIF1-γ and anti-NXP-2, among the numerous novel serological markers for DM, are clearly associated with the presence of neoplasia (6,7). Unfortunately, we were unable to test for those autoantibodies. The symptom of dysphagia is a hallmark of paraneoplastic dermatomyositis and usually represents a manifestation of muscle weakness (8). In our case, it was rather a reflection of the endoluminal tumor, although it may also be a combination of both factors. In their study, Bowerman et al. investigated the risk of cancer development in different DM subtypes (9). They included 201 patients with adult-onset DM, 142 of with classic DM and 59 with the clinically amyopathic type. The estimated prevalence of malignancy-associated classic and clinically amyopathic DM were 9.9% and 1.7%, respectively. The authors concluded that older age and classic DM represent independent risk factors for malignancy-associated DM within 2 years of disease onset. Given that early diagnosis significantly impacts prognosis in patients with cancer-associated DM, recent studies support blind screening for internal malignancy (10). Leatham et al. performed a retrospective analysis of 400 patients with DM, finding a total of 53 cancers in 48 patients (some of the patients had two separate neoplasms). Among the group of paraneoplastic DM cases, 17 cancers were diagnosed via purely blind screening in patients with a lack of concerning history or physical examination. The authors claimed that the most informative tests were mammography and CT scanning. The above-mentioned predictive factors for paraneoplastic DM represent a useful tool for the clinician. Although it is generally accepted that patients with DM should undergo some type of cancer screening, there is no consensus regarding methods or frequency. New data suggest that blind screening in asymptomatic patients might be of great importance for early diagnosis and treatment of patients with cancer-associated DM.

Dear Editor, Rowell's syndrome is a rare disease, characterized by the appearance of erythema multiforme (EM)-like lesions in patients with lupus erythematosus. It was initially reported by Rowell (1) in 1963 and its existence as a separate clinical entity is currently under debate (2,3). A few cases may have been induced by drugs such as systemic antimycotics, antibiotics, anticonvulsants, and more recently proton pump inhibitors (PPIs). CASE REPORT We present the case of a 67-year-old woman with subacute cutaneous lupus erythematosus (SCLE) and EM-like lesions who fulfilled all the criteria for Rowell's syndrome. The patient had lupus arthritis for two years and was treated with oral methylprednisolone 8 mg/day and hydroxychloroquine 200 mg/day. She started receiving 20 mg of omeprazole daily for gastroprotection. The patient also had arterial hypertension with no current treatment, osteoporosis, and an L1 vertebral fracture. The dermatological examination revealed multiple erythematous infiltrated plaques involving mainly the sun-exposed areas (neck, chest, upper back, and shoulders). Cutaneous lesions had an annular or target pattern and a tendency to form hemorrhagic crusts and scales at the margins (Figure 1, A). The mucous membranes were unaffected. Histological examination (hematoxylin and eosin ×200) found epidermal atrophy, vacuolar degeneration of the basal layer, and sparse perivascular lymphocytic infiltrate in the dermis - features corresponding to lupus erythematosus (Figure 2, A). Single eosinophilic necrotic keratinocytes characteristic for erythema multiforme were observed in the epidermis (Figure 2, B). Direct immunofluorescence (IF) from lesional skin showed granular deposits of C3 on the dermo-epidermal junction. Lupus band test from sun-protected, nonlesional skin was negative. On indirect IF a speckled pattern antinuclear antibodies (ANA) with >1:1280 titers were detected. Anti-Ro (>200 U/mL) and anti-La (>200 U/mL) antibodies were also positive. The blood cell count and differential analysis were within reference ranges. The 24-hour urine protein test showed a non-significant proteinuria - 0.36 g/24h. Photo-testing was impossible considering the extent of the skin lesions. The therapeutic approach consisted of increasing the hydroxychloroquine dose to 400 mg/day, substituting PPI with famotidine 20 mg/day p.o. and ceftriaxone 2 g/day for the superinfection with Ps. aeruginosa, which led to a clinical improvement (Figure 1, B). The methylprednisolone dose remained unchanged due to already existing severe adverse effects. DISCUSSION The diagnosis was based on Zeitouni et al.'s classification (4). The three main criteria are as follows: lupus erythematosus, EM-like lesions, and speckled pattern of ANA. Our patient met all three major and one minor criteria, namely the presence of anti-Ro and anti-La antibodies. As for the other minor criteria, RF was negative and no chilblains were found. Although there was a continuous time lapse (more than 1 year) between the initiation of omeprazole intake and the diagnosis of Rowell's syndrome, we suggest that the connection is probable. For instance, the latency differs depending on the incriminated medication in drug induced SCLE. Longer periods are reported for diuretics and calcium blockers, while the time interval is shorter for chemotherapeutic drugs and antimycotics (5). Our suspicions were further confirmed by the fact that the lesions improved promptly within a month after discontinuation of omeprazole and doubling the dose of hydroxychloroquine. PPIs are reported to be a major cause of drug-induced SCLE (6,7). According to Laurinaviciene et al., the most common drugs involved are PPIs, thiazide diuretics, antifungals, chemotherapeutics, statins, and antiepileptics (6). However, very few cases of Rowell's syndrome are found to be drug-related. The culprit drugs include: oral terbinafine (8,9), norfloxacin (10), sodium valproate (11) and esomeprazole (12) (Table 1). CONCLUSION Despite the common clinical and immunological features shared between SCLE, drug-induced SCLE and EM, Rowell's syndrome seems to be a separate entity rather than a coincidental association. Finally, according to our knowledge this case would be the second of Rowell's syndrome due to PPIs.

Acute generalized exanthematous pustulosis is a rare disorder characterized by an acute onset of generalized, nonfollicular, pustular eruption associated with fever. It is usually drug-induced and is uncommon in children. We report a 12-year-old girl with acute generalized exanthematous pustulosis induced by oral ketoconazole. To our knowledge, in spite of its relatively frequent use, acute generalized exanthematous pustulosis due to ketoconazole has not been previously reported.

Few patients with systemic lupus erythematosus have features of verrucous (hypertrophic) lupus erythematosus. A 29-year-old Caucasian woman with a 7-year history of systemic lupus erythematosus developed painful verrucous plaques on the nose. Erythematous, raised, indurated, hyperkeratotic plaques localized on the dorsa of the distal parts of the toes and over the interphalangeal joints of her fingers were also noted. A large, dull-red, indurated plaque with rolled borders on the bridge of the nose was most characteristic. Rapid therapeutic effect was obtained by systemic corticosteroid regimen. This verrucous variant of lupus erythematosus, sometimes clinically resembling actinic keratosis, keratoacanthoma and squamous cell carcinoma, is reviewed.