A 26-year-old man with a history of uncontrolled hyperlipidemia presented with a six-month history of painful, multiple papules on his chest, back and limbs. The two-year-old tattoos on his right leg were covered by a linear arrangement of papules, suggesting a Koebner phenomenon ( Figure 1A). A biopsy from the lesions on the tattoos showed infiltration of nodular foam cells and a few multinucleate giant cells presenting within the dermis. Synthetic colours were observed in the hair follicle and the surrounding tissues ( Figure 1B). Our patient had a triglyceride level of 4.52 (normal 0.24-1.70) mmol/L and total cholesterol level of 10.5 (normal 2.8-5.7) mmol/ L. We diagnosed eruptive xanthomas and prescribed fenofibrate 200 mg/d. After four weeks of treatment with fenofibrate, the patient's papules had not resolved.The Koebner phenomenon refers to skin lesions occurring along lines of trauma. It has previously been reported in tattoos in conjunction with eruptive xanthoma and psoriasis.1-3 Our case is unusual in that the skin trauma occurred in the distant past, although at least two cases associated with remote skin trauma have been previously described.4 Our patient's tattoos were completed 18 months before the xanthomas appeared. Clinical images Eruptive xanthomas presenting in tattoosHui Gao MD, Jing Chen MDThis article has been peer reviewed.The authors have obtained patient consent.

Rationale:Madelung disease (MD), a rarely reported disease, also known as benign symmetric lipomatosis, a disorder resulting from alcoholic abuse. It's largely under-recognized and under-reported, possibly because of unawareness of the condition by physicians.Patient concerns:A 45-year-old Chinese man presented with intermittent fatigue and abdominal distension and progressive bilateral breast enlargement. He has been a heavy drinker for ten years before onset of the disease with an average daily alcohol intake of more than 120 g/day.Diagnosis:Due to the patient's symptoms, laboratory test results, radiographic findings, he was diagnosed with MD.Interventions:We treated him with abstinence from alcohol and supportive therapy.Outcomes:The patient is now in stable condition, with improvement in symptoms during follow-up.Lessons:Doctors, confronted with progressive bilateral breast enlargement in a patient with alcoholic liver disease, should be aware of the underreported MD. Recognition of this syndrome could help doctors establish diagnosis and emphasize the importance of alcohol abstinence as the mainstay of management.

To evaluate real dynamic assessment of tear film optical quality for monitoring and prevention of dry eye. Right eyes of 62 normal and 39 dry eye subjects were included. Dynamic measurement of objective scatter index (OSI) was performed by using the Optical Quality Analysis System II (OQAS II), correlation coefficient between OSI and time (CCOT) was calculated. According to whether the CCOT was significantly ascending, normal and dry eye groups were further subdivided for comparison. By using Scheimpflug-Placido topographer, non-invasive tear break-up time (NITBUT) was recorded, and a 2-dimensional precorneal tear film map was reconstructed and divided into central, middle, and peripheral corneal zones, distribution of tear break-up spots in the 3 corneal zones were analyzed. The numbers of tear break-up spots were higher in all the 3 corneal zones of the dry eye subjects ( P < .01), when compared with the normal subjects. The Dry Eye subjects with ascending CCOT had the shortest NITBUT ( P < .001–.034) and the most tear break-up spots over the whole cornea ( P < .001–.044). Between the dry eye subjects with non-ascending CCOT and those with ascending CCOT, difference of tear break-up spots was found significant only in the peripheral corneal zone ( P < .01). Non-ascending and ascending CCOT of dry eye patients reflect different stability of tear film. Real dynamic assessment of tear film optical quality is potential for monitoring and early prevention of dry eye.

position of the back. We speculate that chronic mechanical stress might have caused recurrent hematoma that led to a histiocytic reaction as HH.In conclusion, we present a case of HH associated with chronic mechanical stress. When we deal with subcutaneous tumors, especially in patients with spinal cord injury, we have to consider HH as a differential diagnosis.