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Mirjana Paravina

Abstract

Lichen planus is an immune, infl ammatory reaction with characteristic clinical and histological lesions. It is a benign disorder, often chronic or recurrent, characterized by fl at-topped, pink to purple, shiny pruritic polygonal papules on the skin, or milky white reticular papules on the visible mucous membranes. Hypertrophic lichen planus is a chronic form of lichen planus with marked epidermal hyperplasia and intense pruritus. It is characterized by symmetrical hypertrophic plaques, usually located on the pretibial or perimalleolar regions. Lesions are often resistant to treatment.

This paper presents a patient with a giant form of verrucous lichen planus on the lower extremities, with a chronic course and resistance to various forms of therapy (keratolytics, local and intralesional corticosteroids, radiotherapy, systemic antibiotics, cryotherapy). Significant improvement was seen after 8-month treatment with etretinate (initial dose of 75 mg per day, with progressive reduction to 10 mg per day). Etretinate therapy resulted in a significant regression of the disease.

Open access

Mirjana Paravina

Abstract

Cheilitis is an inflammatory condition of the vermilion border of the lips, which is the junction between the skin and the mucosa. Cheilitis may arise as a primary disorder of the vermilion zone; the inflammation may extend from the nearby skin, or less often from the oral mucosa. Primary cheilitis lesions are either superficial or deep. Deep types include cheilitis glandularis (inflammatory changes and lip gland swelling), and granulomatous cheilitis (chronic swelling of the lip due to granulomatous inflammation mostly of unknown origin). Cheilitis glandularis is a rare condition that mostly affects the lower lip and it is characterized by nodular enlargement, reduced mobility and lip erosion. Based on clinical presentation, cheilitis glandularis may be classified into three subtypes: simplex (described as Puente and Acevedo), superficial suppurative (described by Baelz-Unna), and the most severe type - deep suppurative, also known as cheilitis glandularis apostematosa (Volkmann’s cheilitis) characterized by deep-seated inflammation forming abscesses and fistulous tracts. This is a case report of a female patient with a deep suppurative type of cheilitis affecting both lips. Treatment with systemic antibiotics (using antibiogram tests), corticosteroids and topical therapy resulted in significant improvement.

Open access

Mirjana Paravina and Dragana Ljubisavljević

Abstract

Malignant acanthosis nigricans is a rare obligate paraneoplastic dermatosis which accounts for 20% of all acanthosis nigricans cases. The clinical features of the disease are the same as in the benign forms: symmetrical, hyperpigmented, velvety papillomatous lesions mostly involving the axillae, neck, groins, periumbilical cubital and popliteal areas, mammary areolae and less often mucous membranes. However, unlike other forms, it is characterized by sudden onset and rapid spread, commonly (80%) after the age of 40, which may be a marker of malignancy and a key to early diagnosis, indicating the need for a detailed examination. It is a disorder that has no gender differences. Most cases are detected at the moment of cancer diagnosis (61.3%), in fewer cases (about 20%) prior to cancer diagnosis, and in 21% at a later stage of malignant disease. Acanthosis nigricans is usually associated with one of the three or all three forms of paraneoplastic lesions: florid cutaneous papillomatosis, acanthosis palmaris (tripe palms, pachydermatoglyphia) involving the palms and soles, as well as multiple seborrheic keratosis (sign of Leser-Trélat).

We report on a female patient with clinically established three paraneoplastic syndromes: malignant acanthosis nigricans, florid cutaneous papillomatosis, and acanthosis palmaris, which appeared before the diagnosis of advanced gastric adenocarcinoma, leading to fatal outcome.

Open access

Mirjana Paravina, Milenko Stanojević, Mirjana Veličković, Stanoje Petrović and Mirjana Milosavljević

Abstract

A classical triad of extrathyroidal manifestations of Graves’ disease known as EMO syndrome (exophthalmos, pretibial myxedema and osteoarthropathy) is a rare condition. This paper presents a 39-year old male patient who underwent chemo- and radiation therapy of the supradiaphragmatic area due to Hodgkin’s disease at the age of 35 and 36 leading to remission. Two years later, the patient developed general symptoms of Graves’ disease and ophthalmopathy, with high thyroid stimulating hormone levels. Four months later, the patient presented with pretibial myxedema. Thirteen months after the onset of the disease, higher levels of thyroxine and decreased levels of thyroid stimulating hormone were registered. The diagnosis of EMO syndrome was confirmed by radiologic and histopathological analyses. Thiamazole and intralesional corticosteroid therapy were administered, resulting in euthyreosis and decrease of pretibial myxedema. The question is whether the autoimmune thyroid disease was triggered by the previous disease, or by chemo- and radiation therapy..

Open access

Milica Stepanović, Mirjana Paravina and Danica Janjić Spasić

Abstract

Disseminated superficial actinic porokeratosis is the most common form of porokeratosis in adults, which develops in the third or fourth decade of life, but may also occur later or earlier, more frequently in females, particularly in countries with high sun exposure. Lesions are numerous, uniform, superficial with central atrophy, demarcated by a distinct peripheral ridge, and usually found on sun exposed areas or elsewhere. The disease is inherited as an autosomal dominant condition. We present a 57-year-old retired woman. Her initial skin changes, affecting the face, developed in her thirties, and they have not changed their features since. In the following years, changes developed on the extensor surface of her arms and legs, with more prominent erythema, and then also on other parts of the body, including palms and soles, presenting as dark brown pigmented patches. Her mother had similar changes, and her daughter, who lives abroad, also has them. On examination, the patient presented with facial lesions, patches 2-3 mm wide, with peripheral hyperpigmentation and a pale center. There were multiple, 2-3 mm wide, dark brown lesions on the extremities and trunk. The lesions were either flat or with atrophic center with darker filiform corneal rim. Pathohistolgical examination revealed a "cornoid lamella", which is pathognomonic for the diagnosis of porokeratosis. Auxiliary diagnostic methods were also used - dermoscopy and Gentian violet staining. The patient was advised to avoid sun exposure and to apply photoprotective sunscreens. In conclusion, this is a case report of a disseminated superficial actinic porokeratosis that affected three generations of a family. Our patient developed lesions on palms and soles as well. A review of available world literature shows that this is the second case report of disseminated superficial actinic porokeratosis with palmoplantar involvement.

Open access

Mirjana Paravina, Milanka Ljubenović, Ivana Binić, Mirjana Milosavljević, Milenko Stanojević and Ljiljana Nikolić

Abstract

Pityriasis rubra pilaris (PRP) is an idiopathic inflammatory hyperproliferative chronic dermatosis characterized by: perifollicular coalescing papules with central keratotic acuminate plugs gradually submerged in sheets of erythema; perifollicular erythema with islands of unaffected skin; palmoplantar keratoderma; diffuse desquamation which typically spreads from the head down to the feet. The cause of the condition is unknown, but possible etiological factors include: vitamin A deficiency, trauma, infections, autoimmune mechanisms, and malignancies. Taking into account different age of onset, clinical course, morphology and prognosis, there are six different types of the disease: two in adults (classical and atypical); three in children (classical, circumscribed and atypical); one in individuals infected with human immunodeficiency virus.

This paper presents two male patients with clinical symptoms of classical PRP, 53 and 69 years of age at the onset of the disease, with rapid generalized involvement, typical erythematous perifollicular papules, islands of unaffected skin, palmoplantar hyperkeratosis with a waxy appearance and nail changes. The diagnosis was based on clinical findings and histopathologic analysis. Apart from topical therapy with emollients, corticosteroids and keratolytics, they received systemic retinoids and corticosteroids, which resulted in improvement of skin lesions.

It is extremely important to consider the possible triggering factors, establish the diagnosis as soon as possible and begin proper treatment.

Open access

Milica Stepanović, Mirjana Paravina, Goran Janković and Danica Janjić Spasić

Abstract

Keratitis, ichthyosis and deafness (KID) syndrome is a rare congenital ectodermal dysplasia characterized by ichthyosiform hyperkeratosis of the skin, neurosensory hearing loss and vascularizing keratitis. It is inherited as an autosomal dominant trait, now known to be due to mutations in the connexin gene.

This paper presents a case of a 20-year-old male patient with erythrokeratodermia and mild scaling since birth. He presented mild hearing impairment at the age of two and often suffered from eye inflammations. On admission, his clinical picture was typical of KID syndrome with erythrokeratodermia, neurosensory deafness, vascularizing keratitis, alopecia, palmoplantar keratosis, and nail dystrophy. The patient also had a history of recurrent infections, especially bacterial and candidal infections of the skin, auditory canals and eyes. Despite extensive skin, ocular, ear and hair manifestations, his physical and psychomotor growth and development were normal.

Adjuvant balneotherapy in Prolom Spa, along with emollient creams, significantly reduced cutaneous manifestations in our patient.

Open access

Mirjana Paravina, Ivana Binić, Danijela Popović and Dragana Ljubisavljević

Abstract

Yellow nail syndrome is a rare disease of unknown etiology. It is clinically characterized by a triad of yellow nails, lymphedema at one or more sites, and chronic respiratory disease (bronchitis, bronchiectasis and rhinosinusitis). All nails may be affected, but some may be spared. The nail plates are yellowish green, thickened, occasionally with transverse ridging and onycholysis, with increased longitudinal and transversal over-curvature, with partial or complete separation of the nail plate from the nail bed, without lunula and cuticle and slow nail growth rate. The lymphedema is usually peripheral, affecting the lower limbs, or in the form of pleural effusion.

This is a case report of a 47-year-old female patient who presented with nail changes at the age of 40; two years later the patient developed lymphedema of the lower limbs, and a year later a chronic respiratory disease. The affected nails were yellow to yellow-gray, with thickened nail plates separated from the nail bed, ingrown in the perionychium, without lunula. At the same time, additional examinations revealed the following associated conditions: edema of talocrural joints in both legs, chronic obstructive bronchitis, bronchial asthma, chronic rhinitis with bilateral nasal polyposis, labile arterial hypertension. Apart from the management of chronic respiratory disease, oral vitamin E capsules (200 mg 3 times a day) and topical vitamin E solution were administered over 15 months. The nails began to grow, and the newly grown nails were of normal pigmentation.

In conclusion, we present a case of an adult female patient with yellow nail syndrome, and a recognized association of peripheral edema and chronic pulmonary disease. The patient had a typical clinical picture, all the nails were affected, but showed a favorable response to systemic and topical vitamin E therapy.

Open access

Khair Fadel Merei Al Junidi, Mirjana Paravina, Vuka Katić and Pasxalina Mitsa

Abstract

Basal cell carcinoma (BCC) is the most common malignant tumor of the skin. This study was conducted to analyze patients with BCC, their age and sex distribution, occupation, site distribution of tumors, clinical types, and histopathological characteristics of lesions. Based on the data obtained from the Histopathological Registry, a clinical and histopathological analysis of the surgically excised BCCs was performed.

The study included 100 randomly selected patients out of 263 consecutive patients with histopathologically diagnosed BCC at the Institute of Pathology of the Clinical Center in Niš in the period of 15 months. The sex ratio was 1.4:1 in favor of men (p<0.05). Two thirds of patients were over the age of 60 (p<0.0001). The average age of patients was 66.6 ± 12.2 years (range 23 - 90). In agreement with the age distribution, 53 patients were retired (mostly retired farmers), 12 were workers, 14 farmers, 12 without permanent employment, 5 were housewives, and 4 clerks. A substantial majority of 61% of examinees lived in the country (p<0.001). The employment status was related to the age of examinees, but also with the altered demographic structure in the country: many workers lived in the country, or returned to the country after retirement.

BCC was commonly found on the face (77%), and rarely on the trunk (11%) and extremities (2%).

There were no data about exposition to X-rays or chemicals (except for pesticides and insecticides), scars resulting from burns or genodermatoses. In 87% of cases, BCC was significantly most often found at sites continually exposed to the sun (head including face and scalp, and neck). The most commonly diagnosed was the nodular type (57%), then the superficial (7%), ulcerative (5%), ulcero-sclerotic (4%), pigmented (1%), and morpheaform (1%). In 27% of cases, there were no data about the histopathological type of BCC in the Histopathological Registry, based on which accurate histological type of BCC could have been established. Based on histopathological analysis, apart from the nodular (40%), other types were rarely diagnosed, like the adenoid (12%) (p<0.0001), mixed types (nodular-adenoid, nodular-adenoid-fibroblastic and mixed) (9%), superficial (7%), fibroblastic (2%), infiltrative (1%), pigmented (1%), and morpheaform (1%). Surgical excision is the gold standard in the treatment of BCC: conventional, conducted in our patients, and Mohs micrographic surgery, which takes an important place in the treatment of high-risk BCCs. In 6% of cases, the tumor process was found in the margins of the excision.

In conclusion: Basal cell carcinoma was more common in males than in females. Significantly more patients with excised basal cell carcinoma lived in the country. An age-related increase in the number of patients with BCC has been established, and most patients with excised basal cell carcinomas belonged to the age group of 61 to 81 years of age. In most patients the tumor site was on the face, whereas clinically and histopathologically, nodular type was the most common.

Open access

Dragana Ljubisavljević, Zorana Zlatanović, Radmila Milenković, Danijela Popović and Mirjana Paravina

Abstract

Verrucous epidermal nevi are noninflammatory, congenital, cutaneous hamartomas composed of keratinocytes, abnormal clone(s) of cells that reflect genetic mosaicism arising from different somatic mutations. Some of these mutations are well recognized, but some are still unidentified. Molecular techniques are used for identification and classification of molecular causes of certain epidermal nevi, whereas all verrucous epidermal nevi are divided into epidermolytic and non-epidermolytic types. They are typically present at birth, but may appear during childhood, even later. Their prevalence in adults ranges from 0.1 to 0.5%, equally affecting both sexes, and about 1 in 1000 newborns.

Warty, brown papules without inflammation distinguish verrucous nevi from other epidermal nevi, while presence at birth and persistance distinguish verrucous epidermal nevi from linear viral warts. Epidermolytic and non-epidermolytic verrucous epidermal nevi are almost always hard to distinguish, except by histology. As a rule, verrucous epidermal nevi are asymptomatic, they have a benign course, except occasionally, and therapy is mostly used for cosmetic reasons. Simple excision is usually the treatment of choice. Topical agents are rarely curative, as well as surgery which is associated with relapses, unless both epidermis and the underlying dermis are removed or destroyed at the same time.

We present a case of an otherwise healthy 21-year-old female patient, who presented with a solitary congenital verrucous cauliflower-like lesion in the right zygomatic region of the face. The lesion was present from birth. Due to its gradual growth during years, the lesion became a great esthetic and functional problem for this young patient. There was no family history of similar or any other tumorous skin lesions in the family. On examination, the patient had a solitar unilateral, well defined yellowish cauliflower-like verrucous lesion confined to the right malar side of the face. The lesion was distributed along the lines of Blaschko extending horizontally, from its wider 1.5 cm cauliflower-like part on the right zygomatic region, towards its tail-like 0.5 cm thick end on the preauricular region, in approximately 3 cm long tail-like manner without crossing the midline. Since the patient refused biopsy, no exact differentiation between epidermolytic and non-epidermolytic nevi was possible. The diagnosis of verrucous epidermal nevus was based on history and clinical presentation, as a diagnosis of exclusion. Due to the fact that patients with epidermolytic verrucous epidermal nevi are at risk of parenting a child with bullous ichthyosiform erythroderma, the patient was counseled on this risk, and on the possibility of first-trimester antenatal diagnosis. The lesion was successfully treated by radio-wave surgery.