CASE REPORT

A 28-year-old male presented with a 20-year history of asymptomatic, subcutaneous mass on his scalp. He discovered hair loss over the mass several years before and complained of its progressive enlargement as the mass had slowly increased. He denied any history of trauma or chronic irritation. Physical examination demonstrated a 6×3 cm sized, nontender soft mass on the scalp and a 3 X 2 cm sized alopecic patch over the mass (Fig. 1).

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Alopecia has been reported in association with many diseases such as thyroid dysfunction, nutri­tional deficiency, anemia, lupus erythematosus, and various infections. However, hair loss due to the invasion of tumor cells rarely happens. In this report, we present a case of neurofibroma of the scalp which is associated with alopecia. …Read the rest of this article

Clinically, FSCH is an asymptomatic, slow-grow- ing, small papule or nodule usually occurring on the head or neck areas, but other uncommon loca­tions such as the upper back, forearm, labia majora, and the scalp have been reported. The tumor size is usually 0.5-1.5 cm in diameter, but 2 cases of a giant variant have been reported. One was a 7.5 cm in diameter, exophytic, lobulated mass on the back and the other one was a 15 cm-sized multino­dular plaque on the arm.

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INTRODUCTION

FSCH is a rare, distinct, cutaneous hamartoma of follicular, sebaceous and mesenchymal com­ponents. It usually presents as a small, exophytic papule or nodule on the central part of the face. Histopathologically, it is characterized by infundi- bulo-sebaceous cystic proliferation with specific mesenchymal changes including packed fibrillary bundles of collagen, cleft formation between fibroe- pithelial units and surrounding stroma, sparsely distributed adipocytes, and increased numbers of small venules.

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Aluminum intoxication has been long recognized as an independent cause of a microcytic hypochromic anemia in patients with end-stage renal disease who require dialysis. Aluminum seems to interfere with heme synthesis enzymes, resulting in an accumulation of protoporphyrin and interference in iron distribution and metabolism. Not surprisingly, aluminum overload markedly reduces the response to epoetin alfa. Treatment of aluminum overload with deferoxamine has resulted in improvements in hematocrit. Aluminum intoxication is rare because most hemodialysis units deionize the dialysis water used during treatment, thereby eliminating a previously important source of aluminum. Currently, the major causes of aluminum intoxication include the use of aluminum-containing phosphate binders. For patients with identified aluminum intoxication characterized by a serum aluminum level greater than 2300 nmol/L, discontinuation of aluminum-containing phosphate binders and substitution of a calcium-containing phosphate binder such as calcium carbonate or acetate or a noncalcium- containing nonaluminum-containing phosphate binder such as sevelamer is recommended.

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The algorithm developed to guide the investigation and management of chronic dialysis patients with ssuspected epoetin alfa resistance was successfully used to manage 16 patients who did not achieve a target hemoglobin of 110 g/L with epoetin alfa for 3 consecutive months. With the use of the algorithm, these patients were managed in 1 of 5 ways. Patients with iron deficiency received intravenous iron or an increase in the oral iron dose. Dialysis efficiency was improved in patients receiving inadequate dialysis. Patients with a subcutaneous epoetin alfa dose greater than 300 IU kg-1 week-1 were investigated for possible causes of epoetin alfa resistance, such as hyperparathy- roidism, aluminum toxicity, infection, or inflammation. Patients with a subcutaneous epoetin alfa dose less than 300 units kg-1 week-1 were eligible for an increased dose with a standard epoetin alfa-dosing protocol.

The most commonly identified causes of epoetin alfa nonresponse included iron deficiency, a low epoetin alfa dose, and epoetin alfa resistance caused by hyperparathyroidism, chronic infection, inflammation, or dialysis inadequacy. Many patients had more than one suspected cause of nonresponse.

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From October 1 to December 31, 2000, 212 patients were screened and 21 (10%) patients with a hemoglobin concentration less than 110 g/L for 3 consecutive months were identified (Table 1). All identified patients were receiving epoetin alfa, a multiple vitamin preparation (Dia-Vite, R&D Laboratories, Marina Del Rey, California), and iron supplementation. The majority (62%, 13/21) of patients were receiving intravenous iron dextran.

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