J AM ACAD DERMATOL

VOLUME 67, NUMBER 3Letters e113

immunohistochemical stains to detect loss of DNAmismatch repair genes. In conclusion, we present theyoungest case of SC developing in NS and the onlycase to develop in pregnancy.

Michael Crandall, MD,a,* Elizabeth K. Satter, MD,MPH,b,* and Mary Hurt, MDc

MAG39 Medical Department,a Camp Pendleton;Department of Dermatology,b Naval MedicalHospital, San Diego; and Department ofDermatology,c Camp Pendleton, California

*Approximately equal contribution to the articlewas made by these authors.

Funding sources: None.

Conflicts of interest: None declared.

The views expressed in this article are those of theauthors and do not reflect the official policy orposition of the Department of the Navy, Depart-ment of Defense, or the United States government.

Correspondence to: Elizabeth K. Satter, MD, MPH;Department of Dermatology, Director of Dermat-opathology; Naval Medical Center, San Diego,California; 34520 Bob Wilson Dr, Suite 300, SanDiego, CA 92134-2300

E-mail: elizabeth.satter@med.navy.mil

REFERENCES

1. Matsuda K, Doi T, Kosaka H, Tasaki N, Yoshioka H, Kakibuchi M.

J Dermatol 2005;32:641-4.

2. Akbari D, Naraghi Z, Emadi N, Ghaninejad H. Extraocular

sebaceous carcinoma arising from nevus sebaceous. Acta

Medica Iranica 2005;43:227-9.

3. de Giorgi V, Massi D, Brunasso G, Mannone F, Soyer HP, Carli P.

Sebaceous carcinoma arising from a nevus sebaceus: a case

report. Dermatol Surg 2003;29:105-7.

4. Izumi M, Tang X, Chiu CS, Nagai T, Matsubayashi J, Iwaya K,

et al. Ten cases of sebaceous carcinoma arising in nevus

sebaceous. J Dermatol 2008;35:704-11.

5. Kazakov DV, Calonje E, Zelger B, Luzar B, Belousova IE,

Mukensnabl P, et al. Sebaceous carcinoma arising in nevus

sebaceous of Jadassohn: a clinicopathological study of five

cases. Am J Dermatopathol 2007;29:242-8.

6. Miller CJ, Ioffreda MD, Billingsly EM. Sebaceous carcinoma, basal

cell carcinoma, trichoadenoma, trichoblastoma and syringocys-

tadenoma papilliferum arising within a nevus sebaceus. Der-

matol Surg 2004;30:1546-9.

7. Misago N, Kodera H, Narisawa Y. Sebaceous carcinoma,

trichoblastoma and sebaceoma with features of a trichoblas-

toma in nevus sebaceous. Am J Dermatopathol 2001;23:

456-62.

8. Rinaggio J, McGuff HS, Otto R, Hickson C. Postauricular seba-

ceous carcinoma arising in association with a nevus sebaceous.

Head Neck 2002;24:212-6.

http://dx.doi.org/10.1016/j.jaad.2011.09.019

Pedunculated manifestations of infectiousmononucleosis

To the Editor: We report the case of a previouslyhealthy 15-year-old male who was referred becauseof the appearance 1 week earlier of a painless lesionon the posterolateral surface of the tongue. At thetime of referral he had pharyngitis with palpablelymphadenopathy, but no hepatosplenomegaly; hewas receiving treatment with amoxicillin-clavulanicacid. Physical examination of the lesion showed a1-cm, pedicled, firm lesion that was covered innormal mucosa with two small whitish ulcerationsat the base (Fig 1).

The results of the laboratory studies were withinnormal ranges: leukocytes, 9000 cells/�L (referencerange, 3200-10000 cells/�L), but with 59% lympho-cytes, 2% band neutrophils, and frequent stimulatedlymphocytes.

The lesion was excised and the histologic studyshowed an oropharyngeal lingual mucosa with ton-sillar crypts and lymphoid follicular hyperplasia, withareas of ulcerated epithelium, and lymphoid expan-sion with numerous B- and T-cell immunoblasts, andReed-Sternbergelike cells. Immunohistochemicalstudy showed a dual population of B and T lympho-cytes with a predominance of CD20-positive, MUM-positive, CD30-positive activated lymphoid cells.Study for Epstein-Barr virus (EBV) (immunohisto-chemistry for LMP-1) revealed intense positivity inactivated lymphocytes (Fig 2).

Three days after excision of the lesion, the patienthad ageneralizedmacular rashwhichwas interpretedas secondary to the amoxicillin treatment during thecourse of infectious mononucleosis. A diagnosis ofinfectious mononucleosis was established.

Primary infection with Epstein-Barr virus, both inyouths and adults, is often associated with infectiousmononucleosis, characterized by the classic triad offever, cervical adenopathy, and pharyngitis. It is alsooften accompanied by peripheral blood lymphocy-tosis with abundant atypical lymphocytes.1 Otherassociated symptoms include general malaise, head-ache, and joint pain. Physical examination may showpalatine enanthem, lymphadenopathy, splenomeg-aly, and hepatomegaly. A macular-papular rash istypical in patients treated with ampicillin or amox-icillin about 5 to 7 days after starting the antibiotictherapy. Other less usual cutaneous manifestationsinclude palpebral edema, cold urticaria, or jaundice.

Diagnosis is made by the presence of a compat-ible clinical picture and confirmed by the detectionin serum of EBV heterophile antibodies (IgM).2 Thepresence of more than 10% ‘‘atypical lymphocytes’’in peripheral blood is also characteristic.

Fig 2. Immunohistochemical study of EBV-induced lin-gual papule for CD20 (original magnification 340); CD30(3200) and Epstein-Barr virus (immunohistochemistry forLMP-1) (3400) showed intense positivity in activatedlymphocytes.

Fig 1. EBV-induced lingual papule. A pedicled lesion withtwo small whitish ulcerations at its base on posterolateralsurface of the tongue.

J AM ACAD DERMATOL

SEPTEMBER 2012e114 Letters

EBV is transmitted via the saliva. The target withinthe mouth is the oral lymphoid tissue B cells. Oncethe B cells are infected, proliferation takes place inthe germinal centers3 with later dissemination.

We are unaware of any previous reports of apedicled tumor at the tongue as the manifestation ofinfectious mononucleosis, though the pathologicalchanges of EBV in our patient were identical to thosedescribed in involvement of the palatine tonsils bythis virus.4 This is to be expected, given that thelingual tonsil forms part of Waldeyer’s tonsillar ring,where the EBV enters the organism and startsreplicating.

Pathologically, the differential diagnosis includeslymphoproliferative processes (high-grade B lym-phoma or Hodgkin’s lymphoma). From a clinical

point of view, it must be differentiated from certainpapillomatous lesions secondary to humanpapillomavirus infection, traumatic fibromas, Abrikossoff’s tu-mor, exophytic epidermoid carcinomas, pyogenicgranuloma, and sialadenoma papilliferum.5

Leticia Sempau, MD,a Luis Miguel Valladares, MD,a

Jes�us Lomas-Garc�ıa, MD,b Nieves Alonso-Orcajo,MD,b Jos�e Mar�ıa Garc�ıa Ruiz de Morales, MD,PhD,c and Manuel �Angel Rodr�ıguez-Prieto, MDa

Departments of Dermatology,a Pathology,b andImmunology,c Complejo Asistencial Universitariode Le�on, Altos de Nava SN, 24071 Le�on, Spain

Funding sources: None.

Conflicts of interest: None declared.

Correspondence to: Leticia Sempau, MD, Depart-ment of Dermatology, Complejo Asistencial deLe�on, Altos de Nava SN, 24071 Le�on, Spain

E-mail: leticiasempau@gmail.com

REFERENCES

1. Mendoza N, Diamantis M, Arora A, Bartlett B, Gewirtzman A,

Tremaine AM, et al. Mucocutaneous manifestations of

Epstein-Barr virus infection. Am J Clin Dermatol 2008;9:

295-305.

2. Ebell MH. Epstein-Barr virus infectious mononucleosis. Am Fam

Physician 2004;70:1279-87.

3. Macsween KF, Crawford DH. Epstein-Barr virus-recent advances.

Lancet Infect Dis 2003;3:131-40.

4. Kutok JL, Wang F. Spectrum of Epstein-Barr ViruseAssociated

Diseases. Annu Rev Pathol Mech Dis 2006;1:375-404.

5. Wood NK, Goaz PW, editors. Maxillo-differential diagnosis of

oral and maxillofacial lesions. Philadelphia: Mosby-Year Book,

Inc; 1997.

http://dx.doi.org/10.1016/j.jaad.2011.09.020

Alopecia-associated pseudocyst of the scalp

To the Editor: Pseudocyst of the scalp is a rarelydescribed condition that has only been reported inthe Japanese and European literature. The author hasdocumented 11 cases observed over the last 10 years(Table I), two of which are detailed below.

A 19-year-old man presented for the first timewitha 2-week history of a tender and tense slightlyerythematous cystic swelling at the vertex (Fig 1).He noted hair loss at the onset of the swelling. Abacterial culture of the slightly viscous yellow fluidaspirated was sterile. The cyst was treated withintralesional triamcinolone acetonide (2.5 mg/mL)and the swelling resolved after 2 days. Early hairgrowth was noted 5 weeks later without any evi-dence of scarring.