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514 Correspondence Journal of the American Academy of Dermatology ]Fig. 2. The well-defined tumor exhibits elongated and merging epidermal ridges with enlarged pale cells. The elongated dermal papillae have widened blood vessels. A moderate polymorphonuclear infiltrate is present. (Original magnification, x 10.) gulfment of the extruded glycogen. In their cases, how- ever, phagocytosis was accomplished by the epidermal Langerhans celts, whereas in our case glycogen was present in the upper dermal macrophages. Mark Roytman, M.D., Azriel Frumkin, M.D.. and Mark Allen Everett, M.D. University of Oklahoma Health Sciences Center Oklahoma City, OK 73104 REFERENCES 1. Degos R, Delort J, Civatte J, Poiares Baptista A. Tumeur 6pidermique d'aspect particulier: Acanthome ,~ cellules claires. Ann DermatoI Syph 1962;89:361-71. 2. KerI H. Das Klarzellenakanthom. Hautarzt 1977;28: 456-62. 3. Fine RM, Chernosky ME. Clinical recognition of clear ceil acanthoma (Degos'). Arch Dermatol 1969;100: 559-63. 4. Duperrat B, Vanbremeersch F, David V, Masearo JM, Bedard A. Forme g6ante de ]'Acanthome de Degos. Bull Soc Fr Dermatol Syph 1966;73:884-6. 5. Grossin M, Mazer JM, Auffret N, Prfaux J, Belffich S. Formes rares de l'acanthome h cellules cfaires. Ann Der- matol Venereol 1983;110:721-2. 6. Desmons F, Breuillard F, Thomas P, Leonardelli J, Hil- debrand HF. Multiple clear-cell acanthoma (Degos): his- tochemical and ultrastruetural study of two cases. Int J Dermatol 1977; 16:203-19. Pemphigus vulgaris probably induced by penicillin To the Editor: A 58-year-old Jewish woman, suffering from erysipelas on her left leg, was treated with five Fig. 1. Ulcerative lesion on the lips. injections of procaine penicillin, 2,000,000 U/day in- tramuscularly for 5 days; after 1 month she developed ulceration of the mucosa of the mouth and lips (Fig. 1), as well as vesicular lesions on the skin of the body. Histologic examination of one of the lesions on the oral mucosa and the skin showed an intraepidermal suprabasal vesicle with acantholysis. Immunofluores- cent microscopy of the perivesicular tissue showed an intercellular deposition of IgG and C3. Indirect im- munofluorescent test showed anti-intercellular sub- stance antibodies. The results of a complete blood cell count, 12 factor automated chemical analysis (SMA 12), and urinalysis were within normal limits. Human lymphocyte antigen (HLA) typing was performed and found to be A28, A30, B35, CW4, DR4, DR5. A migration inhibition test was performed, with the patient's lymphocytes re- sponding positively to penicillin, according to a mod- ification of Rajapakse and Glynn's method. ~ The mi- gration index was normal (0.91). A mast cell degran- ulation test showed 88% degranulation in the presence of penicillin, indicating antibodies (IgE type) against penicillin. The patient was treated with fluocortolone, 120 mg/day. The lesions cleared after a few weeks and the fluocortolone dosage was gradually decreased until it was stopped completely after about 6 months. Discussion. Pemphigus may be precipitated by exposure of patients to certain drugs, of which D-penicillamine2'3 and captopril (an oral inhibitor of angiotensin-converting enzyme)4 are the best known. Penicillin itself has been described as inducing pem- phigus vulgaris. 5'6 It has been estimated that 7% of patients taking penicillamine for at least 6 months de- veloped pemphigus. 2 Most of the patients had pem- phigus foliaceus, a few, pemphigus erythematosus, and
