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Letters to the Editor

of primary with metastatic lesion can be done followed by adjuvant chemotherapy. In spite of the best of treatment, outcome of carcinoma pancreas with skin metastasis is poor as seen in our patient.

K. Pranjali, K. Prabhash, V. N. Karanth, S. Kane*, R. Nair, P. M. Parikh

Departments of Medical Oncology and * Pathology, Tata Memorial Hospital, Parel, Mumbai, India. Address for correspondence: Dr. K Prabhash, Room no-22, Medical Oncology Department of Tata Memorial Hospital, Parel - 400012. Mumbai, India. E-mail: kp_prabhash@

Figure 1: Reddish smooth surfaced umbilical nodule

Figure 2: FNAC: Clusters of adenocarcinoma cells (Papanicolaou, x200)

genitourinary tract (12-35%) while in 15-30% of the patients the primary site is unknown.[3] The umbilical nodule is usually a painful lump with ulcerated surface and irregular margins unlike our case and is hard in consistency.[4]

The exact mechanism for spread of umbilical metastasis is not known. It has been postulated that it may occur either due to direct spread or through arterial, venous or lymphatic vessels or via the umbilical ligament. The most common form of umbilical involvement is the direct invasion of peritoneal metastasis.[1,3] The so-called Sister Mary Josephs nodule is formed by localization of metastatic tumors to the umbilicus.[5] FNAC is a useful diagnostic intervention with 92.8% sensitivity and 100% positive predictive value. Once metastatic lesion is confirmed the primary lesion should be looked for with the help of clinical examination and further investigations. Being a metastatic disease, the treatment remains palliative. Patients may be treated with chemotherapy, radiotherapy or both. In some patients if the primary lesion is resectable and umbilical metastasis is the only lesion then resection

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1. 2. 3. 4. 5.

Crescentini F, Deutsch F, Sobrado CW, Araujo S. Umbilical mass as the sole presenting symptom of pancreatic cancer: A case report. Rev Hosp Clin Fac Med S Paulo 2004;59:198-202. Lookingbill D, Spangler N, Sexton FM. Skin involvement as the presenting sign of internal carcinoma. A retrospective study of 7316 cancer patients. J Am Acad Dermatol 1990;22:19-26. Gabriele R, Conte M, Egidi F, Borghese M. Umbilical metastasis: Current viewpoint. World J Surg Oncol 2005;3:13. Barrow MV. Metastatic tumors of the umbilicus. Chron Dis 1966;19:1113-7. Inamdar CA, Mavarkar L. Sister Mary Josephs nodule as presenting sign of ovarian carcinoma. Indian J Dermatol Venereol Leprol 1995;61:383.

Pityriasis rosea occurring during acyclovir therapy

Sir, Pityriasis rosea is an acute self-limiting disease, probably infective in origin, affecting mainly children and young adults and characterized by distinctive skin eruptions and minimal constitutional symptoms. Second attacks of pityriasis rosea are said to occur in about 2% of cases after an interval of a few months or many years. Multiple recurrences have rarely been reported.[1] The cause of pityriasis rosea is yet not known. Many studies have focused on human herpes virus 6 (HHV-6) and HHV-7 as causative agents for pityriasis rosea.[2-4] But they are not demonstrable in all individuals with pityriasis rosea.[5-6] Use of high dose acyclovir (800 mg given five times a day) has been shown in one study to hasten the clearance of the lesions, when compared with placebo.[7] A 28-year-old male patient presented with pink-colored scaly skin lesions over the trunk for a period of two weeks. A single
Indian J Dermatol Venereol Leprol| May-J une 2007| Vol 73| Issue 3

Letters to the Editor

The search for a microorganism in pityriasis rosea continues. Earlier suspicions about fungi, streptococci and spirochaetes have not been confirmed and most speculation now centers on a viral etiology. Successful transmission by scale, infiltrate or blister fluid has been claimed in isolated cases, but many more attempts have failed. A possible picornavirus was detected on culture of scale or of skin biopsy from a minority of patients, but other attempts to culture virus from affected skin have been fruitless. Viruslike particles have been detected ultrastructurally in a few patients. But recently many studies focus on HHV-6 and HHV-7 as causative agents for this condition. Acyclovir is one of the commonly used drug to treat human herpes virus group of infections. Some studies claim that the use of this drug hastens the clearance of lesions, when compared with a placebo.[7] Hence, pityriasis rosea developing during treatment with acyclovir is unlikely to be caused by HHV-6

Indian J Dermatol Venereol Leprol| May-J une 2007| Vol 73| Issue 3

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2. 3. 4. 5. 6. 7.

big patch appeared first and later he developed tiny lesions over the trunk. There was history of mild itching. There were no other symptoms. Enquiry revealed that the patient was on acyclovir 400 mg twice daily, as a suppressive therapy for his herpes genitalis for the past five months. On examination, there were multiple dull pink colored patches with peripheral scaling over the trunk with typical distribution. Serum VDRL, TPHA and HIV did not reveal any abnormalities. A 10% potassium hydroxide (KOH) test for fungus was also negative. Diagnosis of pityriasis rosea was entertained and he was treated with topical fluticasone propionate cream 0.05%. The lesions cleared over a period of four weeks.

and HHV-7. Hence an alternative etiological possibility may also to be considered.

Laxman Mavarkar
Department of Dermatology, Apollo Hospital, Colombo, Sri Lanka. Address for correspondence: Dr. Laxman Mavarkar, Apollo Hospital, Colombo-05, SriLanka. E-mail: fmlaxman@

1. Singh SK, Singh S, Pandey SS. Recurrent pityriasis rosea. Indian J Dermatol Venereol Leprol 1998;64:237-7. Drago F, Ranieri E, Malaguti F, Losi E, Rebora A. Human herpes virus 7 and Pityriasis rosea. Lancet 1997;349:1367-8. Watanabe T, Kawamura T, Jacob SE, Aquillino EA orenstein JM, Black JB, et al. Pityriasis rosea is associated with systemic active infection with both human herpes virus-7 and human herpes virus-6. J Invest Dermatol 2002;119:793-7. Broccolo F, Drago F, Careddu AM, Foglieni C, Turbino L, Cocazza CE, et al. Additional evidence that pityriasis rosea is associated with reactivation of HHV-6 and HHV-7. J Invest Dermatol 2005;124:1234-40. Kempf W, Adam V, Kleinhans M, Burg G, Panizzon RG, Campadelli-Fiume G, et al. Pityriasis rosea not associated with human herpes virus -7. Arch Dermatol 1999;135:1070-2. Chuh AA, Chu SS, Peiris JS. Human herpes virus 6 and 7 DNA in peripheral blood leukocytes and plasma in patients with pityriasis rosea by polymerase chain reaction: A prospective case control study. Act Derm Venereol (Stockh) 2001;81:28990. Drogo F, Vecchio F, Rubora A. Use of high dose acyclovir in pityriasis rosea. J Am Acad Dermatol 2006;54:82-5.