720 Correspondence Journal of the

American Academy of Dermatology

Case report. An 83-year-old man had had the onset of typical dermatitis herpetiformis at the age of 75. The disease had been satisfactorily controlled for several years by avoidance of iodides and the ingestion of dap- sone, 100 mg daily. Several hours after receiving a topical fluoride dental treatment he developed swelling of his lips and blisters on his hands and forearms. When he consulted me 2 days later the lip swelling had sub- sided but he still had vesicles on his hands and forearms. He had had similar fluoride treatments in the past with- out trouble but believed that the recent treatment had taken longer. The reaction gradually subsided after in- creasing his dapsone dosage to 200 mg daily. Neither patch testing nor oral challenge was performed.

His dental hygienist was contacted. She believed each of his treatments had been similar. She had used a product that contains 1.23% sodium fluoride with added hydrofluoric and phosphoric acids to reach a pH of 3.6. The material is incorporated in an apple-cin- namon-flavored thixotropic gel. After cleansing the teeth, the gel is placed in a cup held in contact with the teeth for 4 minutes. The cup is then removed and the patient expectorates. No drinking or eating is al- lowed for 30 minutes. Correspondence with the man- ufacturer revealed no other cases of this type had been reported to them.

Comment, A patient is reported who had a sugges- tive but not proved exacerbation of dermatitis herpeti- formis from a dental fluoride treatment, presumably through both local and systemic absorption. It seems reasonable that fluorides can produce a reaction similar to the one well established for their close relatives, the iodides. Physicians caring for persons with dermatitis herpetiformis should be aware of this possibility.

Dan A. Bovenmyer, M.D. Spring Medical Park, Ste. 102

3319 Spring St, Davenport, IA 52807

REFERENCE

1. Pillsbury DM, Shelley WB, Kligman AM: Dermatology. Philadelphia, 1956, W. B. Saunders Co., p. 796.

Cytomegalovirus infection in an immunosuppressed man

To the Editor: I would like to comment on the case report of

Bhawan et al (J AM ACAD DERMATOL 11:743-747, 1984) in which vesicobullous lesions in an immuno- suppressed man were ascribed to cytomegalovirus (CMV) infection. This man, who had known CMV

pneumonia, developed scattered vesicobullous lesions that were felt to be caused by CMV on the basis of viral culture. I suggest that this conclusion is premature and that the lesions may have been caused by herpes- virus for the following reasons:

1. The lesions in this case were coalescent, grouped ves- icles that are characteristic of herpes infection. Previous re- ports of documented cutaneous CMV infection have described localized ulcers or transient exanthems.~ A report cited in which vesicles were ascribed to CMV infection was an un. confirmed case. ~

2. The Tzanek smear in this case showed many multinu- cleate giant cells characteristic of herpes infection.

3. The skin biopsy specimen in this case showed an in- traepidermal vesicle, multinucleate giant cells, and retleular and spongiotic degeneration of the epidermis, again charac- teristics of herpes infection. Previous reports of documented cutaneous CMV infection have shown specific involvement of endothelial cells of blood vessels.

4. Electron microscopy in this case showed viral particles having the appearance of CMV in the keratinocytes; however, CMV and herpesvirus are indistinguishable by electron mi- croscopy.

5. Culture of vesicle fluid yielded growth in 22 days on human lung fibroblasts and not on human amnion cells. This behavior is characteristic of CMV, and on this finding rests the conclusion of the authors that these lesions were caused by CMV.

Another explanation that seems equally plausible is that the lesions were caused by herpesvirus that simply failed to grow in their culture system. There are a num- ber of potential technical pitfalls in the culture of vi- ruses. 3 The fact that an isolate with cultural character- istics of CMV was found in the patient 's skin lesions could simply reflect a CMV viremia that can occur in patients with CMV pneumonia. Inadvertent finding of CMV in normal skin in patients with. systemic CMV infection has been reported. 1

Before the authors' conclusion that the vesicobullous lesions were caused by CMV is fully acceptable, one or more of the following criteria should be fulfilled: (1) proof that the particular batch of amnion cells used could support growth of a known inoculum of herpes- virus; (2) skin biopsy cultures of the patient's normal skin showing that CMV could not be found; (3) im- munoperoxidase studies of the skin biopsy showing the presence of CMV antigens and the absence of herpes- virus antigens in the keratinocytes; (4) specific nuclear inclusions of CMV in the keratinocytes,

Robert J. Pariser, M.D. Departments of Medicine (Dermatology) and Pathology

Eastern Virginia Medical School 902 Medical Tower, Norfolk, VA 23507

Volume 12 Number 4 April, 1985

Correspondence 7 2 1

REFERENCES 1, Pariser RJ: Histologieally specific skin lesions in dissem-

inated eytomegalovirus infection. J AM AcAD DI~RMATOL 9:937-946, 1983.

2. Blatt J, Kastner O, Hodes DS: Cutaneous vesicles in con- genital cytomegalovirus infection. J Pediatr 92:509, 1978.

3. Prier JE: Laboratory cultivation of viruses, in Prier JE, editor: Basic medical virology. Baltimore, 1966, Williams & Wilkins, pp. 38-77.

Reply

To the Editor: Dr. Pariser suggests that our conclusion that ve-

siculobullous eruption was due to cytomegalovirus (CMV) in the patient reported by us is premature. We disagree with him for the following reasons:

1. The lesions in our patient were isolated, scattered le- sions and not grouped as pointed out by Dr. Pariser. Fur- thermore, the report cited in our paper in which vesicles were ascribed to CMV infection was not an unconfirmed case; rather, it showed characteristic cytopathic effects of CMV, in WI-38 cells, in culture studies done on the blister fluid.'

2. The Tzanck smear in our patient showed multinucleate giant cells, a phenomenon characteristic of herpes infection, but well recognized in varicella infections. Since CMV be- longs to the same group of viruses as herpes simplex, herpes zoster, and varicella, it is not surprising that we find similar phenomena in CMV. In fact, multinucleate giant cells have been seen occasionally in CMV-infected cell culture. 2

3. It is well known that ultrastructurally CMV and her- pesvirus are indistinguishabl e and the only way to differentiate between them is by viral culture studies. This was precisely done in our investigation. Dr. Pariser, without evidence, as- sumes that our positive culture may be due to a technical pitfall. One of us (T. C.) ha s many years' experience in do- ing viral culture studies, particularly the herpes group, and is quite familiar with technical pitfalls. The particular batch of amnion cells employed at the time of our investigation yielded herpesvirus from other cases in our laboratory.

4. Specific intranuclear inclusions of CMV, though char- acteristic, are not always seen. 3 No convincing intranuclear inclusions characteristic of CMV were seen in the cutaneous lesion in the published photographs of Dr. Pariser's case. 4

5. Dr. Pariser, in his excellent review of skin lesions in disseminated CMV infection, suggests that a "cytomegalic vasculitis" is a specific feature? We also observed leuko- cytoclastic vasculitis, albeit without typical intranuclear in- clusions. The absence of endothelial inclusions could be ex- plained by the small size of the biopsy specimen or the age of the lesion.

We are unable to carry out immunohistochemical studies in our patient as no more tissue is available. It is interesting to note that, except for the case reported by Feldman et al, 5 none of the cases cited by Dr. Pariser,

including his case, were confirmed by viral culture or immurtohistochemical studies of the skin tissue. Al- though our case is unusual, we have presented con - vincing evidence that the cutaneous lesions were caused by CMV. It is hoped that our report will stimulate o the r investigators to suspect CMV in proper setting and con- firm it by culture and immunologic studies.

Jag Bhawan, M.D.* Departments of Pathology and Medicine

University of Massachusetts Medical Center* 55 Lake Avenue North, Worcester, MA 01605

Stephen Gellis, M.D.,** Angelo Ucci, M.D., Ph.D.,*** and Te-Wen Chang, M.D.****

Departments of Dermatology,** Pathology,*** and Microbiology, **** Tufts University

School of Medicine, Boston, MA

REFERENCES I. Blatt Y, Kastner O,/-lodes DS: Cutaneous vesicles in con-

genital cytomegalovirus infection. J PedJatr 92:509, 1978. 2. Stagno S, Pass RF, Reynolds DW, Alford CA: Diagnosis

of cytomegalovirus infection, in Nahmias AJ, Dowdle WR, Schinazi RE, editors: The human herpes viruses. New York, 1980, Elsevier Science Publishing Co. Inc., pp~ 365-373. Browning JD, More I, Boyd JF: Adult pulmonary eyto- megalic inclusion disease: Report o fa case. J Clin Pathol 33:11-18, I980. Pariser RJ: Histologically specific skin lesions Jn dissem- inated cytomegalovirus infection, J AM ACAD DERMATOL 9:937-946, 1983. Feldman PS, Walker AN, Baker R: Cutaneous lesions heralding disseminated cytomega/ovirus infection. J AM ACAD DERMATOL 7:545-548, 1982.

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4.

5.

One-step procedure for earlobe surgical repair and ear post replacement

To the Editor: A laceration of an earlobe sometimes is caused b y

stress placed on ear posts. Wounds that are not repa i red immediately often result in a hole or a wedge-shaped defect extending through the edge of the lobe. O the r surgicalIy produced ear lobe defects occur fo l lowing removal of cysts, tumors, or scar tissue. Conversat ion with surgical colleagues leads me to believe that the usual approach is surgical repair first followed b y re- piercing of the lobe several weeks or months later. Th is delay often is upsetting to the person who wishes to continue to wear pierced earrings.

The following describes a one-step repair and p ie rc - ing procedure. Fig. i shows an earlobe that had been