Merkel Cell Carcinoma

Left: Merkel cell carcinoma recurrence a few months after excision. Right: Progressive increase in size of recurrence over a few months. (Dr. Noorali Bharwani)
Left: Merkel cell carcinoma recurrence a few months after excision. Right: Progressive increase in size of recurrence over a few months. (Dr. Noorali Bharwani)

82 year-old male nursing home resident presented with a subcutaneous lump on the left knee for three to six months. Medical history includes head injury with intra-cranial bleed due to a fall, resulting in permanent physical disability and cognitive deficit.

The lump was about four cm in diameter. The patient and family requested excision biopsy as the patient kept drawing their attention to the lump that progressively turned red, as if it was getting inflamed. My first impression was that this was not a lipoma but probably an inflamed sebaceous cyst. It was excised under local anesthetic without any complications.

Pathology:

Merkel cell carcinoma of the skin, 4 cm in size. Peripheral and deep margins were extensively involved with lymphovascular invasion.


Merkel Cell Carcinoma (MCC)

Merkel cell carcinoma, a rare type of skin cancer, usually appears as a flesh to bluish-red colored nodule on sun-exposed areas, like the face, head and neck.

Merkel cell carcinoma is usually found in older people. Around 80% are caused by Merkel cell polyomavirus. Exposure to sunlight and a weak immune system increase the chance of developing MCC.

The tumor is locally invasive and also spreads rapidly through the body. Early diagnosis and treatment lowers the chance of metastasis.

Since the lesion has no distinguishable features from other skin cancers, the first treatment is surgical excision. Once the pathology report comes back the lesion can be identified as Merkel cell carcinoma. Further therapies like lymph node biopsy, radiation or chemotherapy can be considered if needed, to prevent metastasis and recurrence.


In this case, no further investigation or treatment were planned, as the patient’s quality of life would be extremely poor should he survive recurrence. The family decided it was time to let nature take its course.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Parotid Gland Abscess

Abscess over the left parotid gland area. (Dr. Noorali Bharwani)
Abscess over the left parotid gland area. (Dr. Noorali Bharwani)

46 year-old female presented with a two-week history of an abscess over the left parotid area. The patient reports an abscess in the same location 18 months prior which she had aspirated. She has a medical history of Sjögren’s syndrome.

The patient had finished a course of amoxicillin-clavulanic acid and then was started on a course of a cephalosporin. Incision and drainage was done under local anesthetic and a large amount of pus was drained. The patient healed well.

Culture: Streptococcus anginosus

Streptococcus anginosus is part of the human bacteria flora, but can cause diseases including brain and liver abscesses under certain circumstances.” (Wikipedia)

Pathology: Showed no parotid tissue. There was acute-on-chronic inflammation of subcutaneous tissues.


Salivary Gland

Infection: parotitis, sialandenitis

Symptoms – One-sided salivary gland swelling. Fever and pain will accompany the swelling.

Pathogens – Typically normal bacteria found in the mouth. Viral infections such as mumps often affect the salivary glands. Mumps most often involves parotid salivary gland. Mumps is a rare problem today because of the MMR vaccine.

Dehydration and malnutrition raise the risk of getting a bacterial infection.

Sjögren’s syndrome

This is a chronic autoimmune disease in which cells of a person’s immune system attack the salivary and other moisture-producing glands, leading to dry mouth and eyes. About half of people with Sjögren’s syndrome also have enlargement of the salivary glands on both sides of the mouth, which is usually painless.

Treatment

In some cases, no treatment is needed.

Antibiotics for fever or pus drainage, or if the infection is caused by bacteria. Antibiotics are not useful against viral infections.

Surgery or aspiration to drain abscess.

Self-care steps that can be done at home to help with recovery:

  • Practice good oral hygiene. Brush teeth and floss well at least twice a day. This may help with healing and prevent infection from spreading.
  • Rinse mouth with warm salt-water rinses (1/2 teaspoon of salt in 1 cup of water) to ease pain keep the mouth moist.
  • Stop smoking.
  • Drink lots of water and use sugar-free lemon drops to increase the flow of saliva and reduce swelling.

Prognosis

Most salivary gland infections go away on or are cured with treatment. Some infections will return. Complications are uncommon.

Complications

  • Abscess of salivary gland
  • Infection returns
  • Spread of infection (cellulitis, Ludwig’s angina)

Prevention

In many cases, salivary gland infections cannot be prevented. Good oral hygiene may prevent some cases of bacterial infection.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Pilomatricoma

Pilomatricoma before and after excision. (Dr. Noorali Bharwani)
Pilomatricoma before and after excision. (Dr. Noorali Bharwani)

A 47 year-old male presented with a three-month history of a lump below the right eyelid. It was slowly getting bigger. The lump was excised under local anaesthetic.

Pathology report

Specimen

Cyst right lower eyelid.
The specimen consists of a tan and brown irregularly shaped piece of skin measuring 1.3 x 0.5 x 0.2 cm. Attached is an underlying cyst-like structure measuring 1.0 x 0.5 x 0.5 cm. The cyst-like structure is extremely friable. The margins are marked with blue ink.

Diagnosis

Consistent with proliferating pilomatricoma


Pilomatricoma

Pilomatricoma is a benign cystic new growth.

Clinically, pilomatricoma usually presents in young individuals as a solitary cutaneous nodule with an average size of one cm and rarely exceeds 2 cm in diameter.

Proliferating pilomatricoma was first described in 1997.

The lesions are usually situated mostly on the head and neck.

The differential diagnosis includes classical pilomatricoma, pilomatrical carcinoma, and basal cell carcinoma.

These neoplasms should be excised with adequate surgical margins, and careful follow-up examinations are strongly recommended.

Proliferating pilomatricoma can occur at younger ages and should be considered in the differential diagnosis of solitary lesions in adults and children, even if the lesion is rapidly growing.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Shingles Vaccine may be Viewed as a Quality of Life Vaccine

An example of shingles. (iStockphoto/Thinkstock)
An example of shingles. (iStockphoto/Thinkstock)


A man with shingles of the face.

Shingles is caused by chickenpox virus called varicella zoster virus. The first indications that chickenpox and shingles were caused by the same virus were noticed at the beginning of the 20th century.

The incidence of shingles is mainly in adults. There are approximately four cases per 1000 population per year and a lifetime risk of 20 to 30 per cent.

Chickenpox generally occurs in children. Once the child gets over the illness the virus does not disappear from the body. Virus can settle down in one of the nerve cell bodies and lay dormant for many years.

When your resistance is low and this can be due to any reason, the virus may break out of the nerve cell and travel down the nerve causing viral infection of the skin in the area supplied by that nerve. This can happen decades after the chickenpox infection. Exactly how the virus remains latent in the body, and subsequently re-activates is not understood.

Shingles starts with burning pain, itching and tingling followed by painful rash and blisters in the area supplied by the affected nerve. The pain and rash most commonly occurs on the torso, but can appear on the face, eyes or other parts of the body. If the nerve to the eye is involved then a person may suffer loss of vision. It usually affects one nerve on one side of the body.

The rash and blisters heal within two to four weeks but some sufferers experience residual nerve pain for months or years. This condition is known as postherpetic neuralgia. About 20 per cent of patients with shingles suffer from this.

If the diagnosis of shingles is made early then it helps to start antiviral medications within 72 hours of the appearance of the rash. This reduces the severity and duration of the illness. The antiviral medications should be used for seven to ten days. The blisters crust over within seven to ten days, and usually the crusts fall off and the skin heals. But sometimes after severe blistering, scarring and discolored skin remains.

Until the rash has developed crusts, a person is extremely contagious. During the blister phase, direct contact with the rash can spread the virus to a person who has no immunity to the virus. This newly infected individual may then develop chickenpox, but will not immediately develop shingles.

Since 2008-2009, a vaccine for shingles is available for adults age 60 and over. The vaccine is used to boost the waning immunity to the virus that occurs with aging. The effectiveness of the vaccine is about 60 per cent. It is kind of a “quality of life” vaccine. It does not prevent death from shingles (an extremely rare event) but does help with postherpetic neuralgia (pain).

Booster doses of the vaccine are not recommended for healthy individuals. The efficacy of protection has not been assessed beyond four years and it is not known whether booster doses of vaccine are beneficial. This recommendation may need to be revisited as further information becomes available.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!