Sympathectomy-induced ichthyosis-like eruption

An 80-year-old African-American man, with a past medical history of childho od rheumatic fever, hypertension, coronary artery disease, unstable angina, and asbestosis, underwent cardiac catheterization 37 years ago for unstabl e angina. The postcatheterization course was complicated by a right brachia l arterial thrombosis. A venous brachial bypass graft was placed, with vasc ular supply to the affected arm restored. Postbypass, the patient recovered full use of the arm, but suffered from pe rsistent arm pain. Surgical sympathectomy was performed 1 year later. The p atient has been pain-free since, but noted soon after sympathectomy, unilat eral scaly dry skin, unilateral hypohidrosis of the axilla, and increased t emperature sensitivity on the affected limb. In the 37 subsequent years, de spite application of emollients, he reported no significant improvements or changes in the skin findings. The patient denied that other family members suffered from similar skin pro blems. He denied ever having atopy or other skin problems prior to the curr ent episode. On physical examination, dry plate-like scales were seen on the dorsum of t he right hand (Fig. 1A,B), right shoulder, and upper back, extending to the midline (Fig. 1C), in an area of distribution supplied by the injured nerv es. Mild follicular prominence of the affected extensor arm was also seen a s compared with the uninvolved arm (not shown). Bilateral 4-mm skin punch biopsies were obtained from the skin of the dorsu m of the affected hand and unaffected control hand, in identical locations between the first and second digits. Tissue specimens were split and each s ent in formalin and glutaraldehyde for routine histology and electron micro scopic evaluation, respectively. For electron microscopy specimens, samples were fixed in 3% glutaraldehyde solution, postfixed in ferrocyanide osmium tetroxide, and then samples were dehydrated in graded series of ethanol and embedded in epoxy resin. Ultrat hin sections were cut with a diamond knife on Sorval MT-2b ultramicrotome, mounted on copper grids, and examined in a JEOL EM 100 electron microscope. On routine microscopic evaluation, the affected skin demonstrated a thick h yperkeratotic and compact stratum corneum (Fig. 2), as compared with the lo ose basketweave appearance of the stratum corneum of the skin of the contro l hand (Fig. 3).A thin and hypodense granular layer with more diffuse and s mall keratohyaline granules was seen in the affected skin as compared with the control. The overall epidermal thickness, however, appeared unchanged. On electron microscopic evaluation, fewer, smaller, and more irregular kera tohyaline granules in the granular layer of the affected skin were noted (F ig. 4), as compared with the larger, more numerous stellate, polygonal conf iguration of the control skin (Fig. 5). In an area of comparable epidermal thickness, the affected skin granular layer was approximately 1-1.5 cells t hick, whereas the control skin granular layer was 2.5-3 cells thick. Striki ngly, the cornified layer in the affected skin was thickened with an abnorm ally dense ultrastructure, as compared with the control skin (Fig. 6).