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Multilobated T-cell lymphoma is a malignancy of the lymphoid tissue characterized by abnormal immune T-cells, which contain nuclei with many lobes. The chromatin, or structures within the nucleus, tend to be fine, whereas the nucleoli (round structures made up of dense fibers and granules) tend to be very small or undetectable. The multilobated form of peripheral T-cell lymphoma (PTL) often affects sites other than the lymph nodes, such as the skin and bone. Twenty-eight percent of patients with multilobated PTL have skin complications. However, the skin is rarely the primary tissue involved in multilobated PTL, and less than 20 cases of cutaneous (skin-related) multilobated T-cell lymphoma have been reported. Cutaneous multilobated T-cell lymphoma (CMTCL) is usually a chronic disease with a favorable outcome. A case is described of a 74-year-old man who developed CMTCL, which progressed rapidly to death within two years after the onset of disease. The patient had a history of diabetes and severe disease of the coronary arteries, the major blood vessels supplying the heart. A large ulcer on the right leg and enlarged lymph nodes in the right groin area were noted. Microscopic examination of tissue samples from the ulcer and affected lymph nodes confirmed the diagnosis of CMTCL, which was successfully treated with radiation. However, five months later, the patient developed fever, night sweats, and enlargement of the lymph nodes and spleen. He was diagnosed with angioimmunoblastic lymphadenopathy, a disease of the lymph nodes, and was treated with cyclophosphamide, vincristine, and prednisone. Violet-colored, solid, round skin lesions on the right thigh developed, which resolved after radiation treatment. A year later, the patient developed reddish patches on his body and enlarged lymph nodes in the groin area. Despite treatment with cyclophosphamide, vincristine, and prednisone, the disease spread to the lungs, liver, spleen, bones, and bone marrow, and the patient died five months later. This case shows that CMTCL can progress rapidly to a fatal outcome. (Consumer Summary produced by Reliance Medical Information, Inc.)

Syphilis is a sexually transmitted disease caused by the spirochete Treponema pallidum. It develops in three stages, with the formation of skin lesions and enlargement of lymph nodes in the primary stage. Further development of skin lesions, the onset of systemic symptoms such as headache, fever, and malaise, and enlargement and hardening of the lymph nodes occur in the secondary stage. The heart, blood vessels, and central nervous system become involved in the tertiary stage. Late benign syphilis occurs in 17 percent of patients; cardiovascular syphilis in 10 percent; and neurosyphilis, or syphilis affecting the nervous system, in 8 percent. Late benign syphilis frequently involves the skin and bones and rarely affects the mucous membranes, muscle, abdominal organs, and eye structures. The skin lesions in late benign syphilis can be grouped into two types: the superficial noduloulcerative form, characterized by the formation of node-like lesions and ulcers; and the more damaging gummatous form, which is characterized by the formation of soft, granular tumors. A case is described of a 57-year-old woman with noduloulcerative late benign syphilis of the face with unusual features. The patient was not diagnosed with syphilis for 30 years. When treated with penicillin, she developed a low-grade fever, headache, and chills with worsening of the lesions. This reaction is commonly observed in the treatment of early syphilis. Although most of the facial lesions resolved after penicillin treatment, several granular tumors persisted, suggesting the persistence of the infecting spirochete. However, tests for T. pallidum were negative, and the lesions may result from a hypersensitivity reaction to the drug triamcinolone, which was injected directly into the lesions. (Consumer Summary produced by Reliance Medical Information, Inc.)

• Differences in skin pigmentation may significantly affect light penetration during photodynamic therapy. This study evaluated the effect of skin pigmentation on dermatotoxic reaction to photodynamic therapy utilizing the photosensitizer dihematoporphyrin ether. Black and white guinea pigs were given 10 mg/kg of dihematoporphyrin ether, depilated, and treated 48 hours after injection with 30 mW/cm2 of 514-nm light. Eschar formation was observed on white skin at an average light dose of 26 J/cm2, whereas black skin showed similar changes at 58 J/cm2. Microscopically, superficial necrosis corresponded to the gross changes noted. Our results agree with data describing the difficulty of treating pigmented lesions such as malignant melanoma with photodynamic therapy. This further suggests that higher light doses may be required to treat superficial lesions and produce skin photosensitivity in dark-skinned individuals.(Arch Dermatol. 1990;126:1303-1307)

• Nevus cell nests were seen histologically within the upper levels of the epidermis in biopsy specimens obtained from three patients with clinically banal-appearing nevi. Although the presence of melanocytes arranged as solitary units or grouped in nests in the upper layers of the epidermis is one histopathologic feature of malignant melanoma, we believe this finding represents transepidermal elimination of nevus cells and may be one mechanism of nevus involution.(Arch Dermatol 1987;123:1371-1374)

The Cutting Edge: Challenges in Medical and Surgical Therapeutics REPORT OF A CASE An 18-year-old Hispanic woman presented with a slowly progressive and cosmetically disfiguring dystrophy of her fingernails that began at 4 years of age and that recently began to involve her toenails. Her medical history was significant for several episodes of oral candidiasis, hypoparathyroidism, adrenocortical failure (Addison's disease), and ovarian failure. She was receiving replacement therapy with hydrocortisone, fludrocortisone acetate, estrogen, calcium, and vitamin D for her endocrinopathies. There was no family history of skin, hair, or nail disease or endocrinopathy.The findings from her physical examination revealed severely dystrophic fingernails with some proximal nail fold hyperpigmentation (Figure 1). Also noted was dystrophy of the left great toenail and early involvement of the left second toenail. Patchy hyperpigmentation of the buccal mucosa and hard palate with superficial whitish plaques were observed (Figure 2). The dentition appeared normal. Cultures