Unusual case of cutaneous tuberculosis associated with rheumatoid arthritis: a case report and literature review

We report a 47-year-old female patient with a 10-year history of rheumatoid arthritis who presented with painful ulcerative plaques on the extremities at our clinic in St. Zahra University Hospital on February 2001.
These plaques, diagnosed as cutaneous leishmaniasis, were 2 years old, but the patient was without any cure from the specific treatment she had been prescribed. Later, these skin lesions were misdiagnosed as pyoderma gangrenosum and she was treated by high-dose oral prednisolone, but she did not improve at all.
After she was referred to our clinic, routine laboratory tests, PPD, chest X-ray and skin biopsy with tissue cultures were carried out. Finally, her cutaneous lesions turned out to be cutaneous tuberculosis, which responded successfully to antituberculosis treatment.     

Kaposi's sarcoma in a patient with psoriasis vulgaris

A 54-year-old woman presented with angiomatous lesions located on the upper extremities and right cruris. Histopathological findings were typical of Kaposi's sarcoma (KS). She had had mild to moderate psoriasis since she was 25 years old. She had been using cilazapril (an angiotensin-converting enzyme inhibitor) for the last 9 months. She had had similar lesions in the past while taking the same medication. Because our patient's KS lesions had developed during treatment with cilazapril, the drug was stopped. One month later, spontaneous regression of KS nodules was noted and after 4 months no KS lesions were seen.     

Severe pneumonia caused by combined infection with Pneumocystis jiroveci, parainfluenza virus type 3, cytomegalovirus, and Aspergillus fumigatus in a patient with Stevens-Johnson syndrome/toxic epidermal necrolysis

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe adverse cutaneous reactions to drugs. We report here the first case of severe pneumonia caused by an unusual combined infection with Pneumocystis carinii (jiroveci), parainfluenza virus type 3, cytomegalovirus and Aspergillus fumigatus in a 63-year-old female patient with allopurinol-induced SJS/TEN overlap syndrome. Following treatment with high-dose systemic corticosteroids and intravenous immunoglobulin for SJS/TEN, her mucocutaneous lesions improved and she was due to be discharged. However, 15 days after cessation of corticosteroids, she developed pneumonia. Broncho-alveolar lavage revealed that the cause of infection was Pneumocystis carinii (jiroveci), parainfluenza virus type 3, cytomegalovirus and Aspergillus. These findings indicate that patients with SJS/TEN, particularly those treated with systemic corticosteroids, may be susceptible to infection with combinations of pathological agents resulting from damage to the bronchial epithelia.     

Bildgebende Diagnostik der aktinischen Porokeratose mittels optischer Kohärenztomographie (OCT)

Disseminated superficial actinic porokeratosis (DSAP) is a rare, genetically heterogeneous skin disorder. We report a case of a 73-year-old female patient who was diagnosed with DSAP by optical coherence tomography (OCT) and histology. During the last 4 years prior to diagnosis, she had developed numerous (pre)malignant lesions of the skin of the lower legs including actinic keratoses, squamous cell carcinomas and Bowen's disease. DSAP lesions and actinic keratoses were resistant to topical treatment with imiquimod and retinoids, but improved with photodynamic therapy (PDT).     

Autoerythrocyte sensitization syndrome with vertigo and hemilateral auditory impairment

Autoerythrocyte sensitization syndrome (AES) is characterized by recurrent, painful purpura or ecchymosis. Testing for the reappearance of lesions after injection of the patient's own erythrocytes is usually useful for the diagnosis of AES, but the significance of this test is still controversial. As the lesions often appear in patients with psychiatric disorders, mental factors such as depression and stress are considered to be involved in the occurrence and exacerbation of AES. We report a 28-year-old woman who presented recurrent episodes of painful purpura with vertigo and hemilateral auditory impairment after difficulties at her workplace. After the diagnosis of AES, she was referred for psychiatric counselling, after which the symptoms disappeared. These findings suggest that treatment for psychological disorders is important in patients with AES.     

Complete resolution of recurrent calciphylaxis with long-term intravenous sodium thiosulfate

A 35-year-old morbidly obese woman on home haemodialysis presented with painful indurated subcutaneous nodules histologically characteristic of calciphylaxis. After failing to respond to conventional treatment, she was commenced on an intravenous infusion of 25 g of sodium thiosulfate three times per week. Two weeks after commencing sodium thiosulfate, the pain resolved completely. By 12 weeks, the lesions had healed and the infusions were ceased. Two months later, skin lesions recurred, but resolved again within 3 months of recommencement of sodium thiosulfate treatment, which was continued for 8 months. The treatment was well tolerated. There has been no recurrence of lesions in the 18 months since the cessation of sodium thiosulfate. Clinical trials to determine the optimum dose and duration of therapy for sodium thiosulfate treatment of calciphylaxis should be given priority because of its high rate of success in treating what is otherwise a severe and mostly lethal condition.     

Atypical purpura fulminans with benign monoclonal gammopathy

A 67-year-old woman with a history of thrombophlebitis had been taking warfarin sodium for 1 1/2 years when she developed multiple skin lesions resembling warfarin-induced skin necrosis or purpura fulminans. Despite discontinuing the warfarin and administering prednisone, the lesions increased in size. Disseminated intravascular coagulation (DIC) was found and resolved with heparin sodium therapy, and her skin lesions healed. This patient was believed to have an atypical form of purpura fulminans rather than warfarin-induced skin necrosis because of the duration of warfarin therapy and the dramatic resolution with heparin. A monoclonal (IgG) gammopathy was found, which stabilized as the skin lesions resolved, and fulfilled the criteria for a benign (asymptomatic) monoclonal gammopathy.     

Acrokeratosis Paraneoplastica with Adenocarcinoma of the Colon Treated with Topical Tretinoin

Acrokeratosis paraneoplastica, or Bazex syndrome, is one of the paraneoplastic syndromes. The characteristic skin lesions include palmoplantar keratoderma, psoriasiform skin lesions, hyperpigmentation, and nail dystrophy. The most common associated neoplasms are squamous cell carcinoma of the upper respiratory tract and other kinds of tumors with cervical lymph node metastasis. A 63-year-old woman presented with an 11 month history of hyperkeratotic lesions on the palms and soles. Ten months before she had been diagnosed with adenocarcinoma of the colon and undergone a left hemicolectomy. We report a case of acrokeratosis paraneoplastica associated with colon cancer which persisted after removal of the primary cancer, but resolved with topical tretinoin treatment.     

An unusual presentation of subcutaneous granuloma annulare in association with juvenile-onset diabetes: case report and literature review

Subcutaneous granuloma annulare (SGA) is a rarely reported subtype of granuloma annulare that occurs almost exclusively in children. The etiology of these lesions is unknown, although a possible relationship to insulin-dependent diabetes mellitus (IDDM) has been proposed in the literature. Here we present an unusual case of SGA on the right forearm in a 3-year-old girl. Unlike the typical lesions noted on the extremities, on magnetic resonance imaging her lesions involved the subcutaneous tissue and adjacent muscles in multiple locations. Histopathologically, the case was consistent with SGA but was unusual in its distribution involving multiple muscles, a finding that has not been previously reported. Weeks after incisional biopsy, she was readmitted with diabetic ketoacidosis (DKA) secondary to IDDM. After treatment of her DKA and control of her glycemia, the forearm SGA vanished, which supported the pathologic diagnosis and alleviated our concerns secondary to the unusual distribution.     

Pyoderma gangrenosum associated with sclerosing cholangitis, type 1 diabetes mellitus and ulcerative colitis.

We describe the case of a 22-year-old black female with type 1 diabetes mellitus diagnosed when she was 12 years old. She first presented (March 1994) with pustules and ulcerations on the upper and lower limbs, trunk and scalp at the age 17. The diagnosis of pyoderma gangrenosum was made. Since presentation, changes in liver function were detected and subsequent study led to the diagnosis of sclerosing cholangitis. The diagnosis of ulcerative colitis was made after colonoscopy. Partial response was obtained with minocycline and clofazimine, but treatment with 5-aminosalicylic acid achieved no improvement of the ulcerations. Liver transplantation, followed by immunosuppressive therapy led to complete regression of the cutaneous lesions.     

A Case of Pyoderma Gangrenosum with Ulcerative Colitis Treated with Mesalazine

Pyoderma gangrenosum (PG) manifests as recurrent deep ulceration of the skin and PG is associated with a variety of disorders. Approximately 30% of the cases of PG develop in patients with inflammatory bowel disease. A 34-year-old woman presented with a one-week history of recurrent ulcers on the right cheek and back. She was diagnosed with ulcerative colitis (UC) 4 years previously and with PG 1 year previously. The clinical course of the skin lesions followed the status of her UC. The patient''s skin lesions and bowel symptoms were not improved with prednisolone. After she was started on mesalazine, we observed rapid resolution of skin lesions and bowel symptoms. Herein, we report a case of recurrent PG with UC, and we discuss the possible association between these two conditions, and the efficacy of mesalazine therapy for the treatment of PG combined with UC.     

Wegener肉芽肿1例

报告1例Wegener肉芽肿病。患者女，29岁。主要表现为肺部炎症，抗生素治疗无效，鼻黏膜糜烂，舌部溃疡，双下肢紫癜和坏死性结痂。组织病理检查：鼻黏膜糜烂为非特异性炎症：小腿皮疹为坏死性血管火和肉芽肿性血管炎改变。实验室检查：抗中性粒细胞胞质抗体（cANCA）和蛋白酶3（PR3）-ANCA均阳性，肾功能不全。给予甲泼泥龙80mg/d和环磷酰胺100mg/d治疗，2周后小腿皮疹消退，但肾功能改善不明显，转入肾脏科继续治疗。     

Tiopronin-induced lichenoid eruption in a patient with liver disease and positive patch test reaction to drugs with sulfhydryl group

A 62-year-old woman suffering from liver cirrhosis developed lichenoid eruptions after 2 years of treatment with tiopronin. The lesions healed spontaneously within a month after withdrawal of the drug. In patch testing, the patient reacted positively, not only to tiopronin, but also to captopril and D-penicillamine, neither of which she had ever taken before. The provocation test was positive only to tiopronin, and its histological findings revealed lichenoid reaction. It is suggested that the sulfhydryl group may play a role in the etiology of tiopronin-induced lichenoid drug eruption.     

A 14-year-old girl with lichenoid sarcoidosis successfully treated with tacrolimus

We report a case of lichenoid sarcoidosis in a young girl treated by oral tacrolimus and methylprednisolone. The patient had had a skin eruption from 1 year of age and had developed uveitis at 2 years of age. Her sight had become affected by the uveitis at 8 years of age. When she was 14, she was admitted to the ophthalmology department of our hospital to start treatment with tacrolimus (FK506). She was referred to the department of dermatology for her skin lesions, which were flat, pinkish or normal skin-colored papules scattered on her extremities and the backs of her hands. Upon histology, epithelioid granulomas were seen in the upper dermis and around the erector pili muscles. She received tacrolimus (FK506) 6 mg/day for 3 months for her uveitis. The eye lesions subsided somewhat, and the skin lesions were almost healed after the 3-month course of tacrolimus. However, 4 months after stopping the tacrolimus, her skin and eye lesions relapsed. At that point, she was started on methylprednisolone 16 mg/day for her uveitis. With the methylprednisolone treatment, the inflammation of the eye lesion immediately healed, as did the skin lesions.     

Cutaneous sporotrichosis with refractory and reinfectious lesions in a healthy female

We report a 71-year-old Japanese healthy female with an unusual clinical course of sporotrichosis; she developed infectious lesions on the face and the left upper limb at different periods. The initial lesion appeared on her right cheek and nose in 1992. Histopathologic and fungal examinations comfirmed the diagnosis of sporotrichosis. She was treated with oral potassium iodide and/or itraconazole and topical heat therapy. She had three recurrences and her facial plaque, which was resistant to several conventional treatments, was eventually excised and then grafted in 1996. After the surgical procedure, oral medication was continued for two months. In 2001, new lesions appeared on her left hand and forearm, which were anatomically different from the former lesions. Based on histopathologic and mycological findings, we confirmed reinfection with sporotrichosis. She was again treated with potassium iodide. The cutaneous lesions completely resolved after 26 weeks without surgical treatment.     

Concurrent Sweet's syndrome and leukemia cutis in patients with myeloid disorders

A 74-year-old woman with chronic auricular fibrillation, arterial hypertension, hypercholesterolemia, ischemic cardiopathy, and peripheral arteriopathy presented with purpuric lesions on the lower limbs (Fig. 1) and, to a lesser extent, on the anterior area of the chest. The mucous membranes were not affected. In 1989, she was diagnosed with anemia that evolved until 1998, when a bone marrow biopsy revealed a myelodysplastic syndrome unclassified in French-American-British Group (FAB). The patient has required periodic transfusions since February 1999. A skin biopsy of the purpuric lesions revealed a leukocytoclastic vasculitis; the lesions cleared with topical corticosteroid treatment. In May 1999, the patient presented with inflammatory and painful lesions localized on the vulva (Fig. 2), which had evolved over several days, without fever. No lesions were observed in other locations. A cutaneous biopsy showed an intense dermal edema and a diffuse and polymorphous dermal infiltrate involving the follicular structures. Exocytosis, spongiosis, and mucin deposits, demonstrated by Alcian blue stain, were observed in the follicular epithelium. Mature neutrophils were predominant in the dermal infiltrate, but a small number of eosinophils and immature cells were also present (Fig. 3). The myelogenous origin of the immature lining cells was further confirmed by positive staining of intracytoplasmic granules with naphthol-ASD chloroacetate sterase (Leder's stain). Vasculitis was not observed. Routine laboratory tests revealed 3030 leukocytes/mm(3) (60% neutrophils), a hemoglobin level of 8.4 g/dL, and 92,000 platelets/mm(3). Treatment with 30 mg/day of prednisone was started, and the lesions cleared slowly within 4 weeks. A new bone marrow biopsy in September 1999 showed a similar appearance to that taken in 1998. The patient died in January 2000 as a result of pneumonia with cardiac and respiratory failure. A 66-year-old man presented with a febrile syndrome that had evolved over 5 days, and painful and pruritic cutaneous lesions on the face and posterior neck (Fig. 4). Three months before, the patient was diagnosed with chronic myelogenous leukemia in acceleration phase. Examination revealed an edematous and erythematous face with pustular lesions on the surface, also involving the neck and the upper part of the back. The histopathologic examination revealed an intense edema and abscesses in the dermis. The infiltrate of these lesions was composed of mature neutrophils with the presence of abundant immature cells with a myelogenous aspect (Fig. 5). Analytical studies revealed 26,130 leukocytes/mm(3) (42% blasts). No specific treatment for Sweet's syndrome was administered and the lesions showed an improvement within 5 days. Eight days after admission, the patient died as a result of acute hemorrhage, before treatment for leukemia was initiated.     

Successive development of cutaneous polyarteritis nodosa, leucocytoclastic vasculitis and Sweet's syndrome in a patient with cervical lymphadenitis caused by Mycobacterium fortuitum

Mycobacterium fortuitum is a rapidly growing mycobacterium found in soil and water throughout the world. It can cause diseases in immunocompetent patients, usually resulting in localized skin and soft tissue infections. Cervical lymphadenitis caused by M. fortuitum is rare. We report a 46-year-old woman in whom skin lesions of cutaneous polyarteritis nodosa, leucocytoclastic vasculitis and Sweet's syndrome had successively developed before the diagnosis of cervical lymphadenitis caused by M. fortuitum was made. The skin lesions responded to colchicine and systemic corticosteroids but recurred intermittently. After establishment of the diagnosis, she received treatment with clarithromycin and ciprofloxacin. The cervical lymph nodes decreased in size 6 months later and no more new skin lesions were found.     

Progressive nodular histiocytosis in a child with a hypothalamic tumor

We report a 13-year-old girl with multiple cutaneous histiocytic lesions, precocious puberty, growth hormone deficiency and a hypothalamic tumour. We conclude that she has progressive nodular histiocytosis, but this case illustrates the difficulty in differentiating the type II histiocytoses.     

Erythema elevatum diutinum complicated by rheumatoid arthritis.

A 53-year-old female developed erythema elevatum diutinum (EED) twelve years after the onset of rheumatoid arthritis. The arthritis had been well controlled for the last several years. Annular purpuric macules were characteristically complicated by common nodular and plaque lesions. Both leukocytoclastic vasculitis and fibrosis were observed in the macular lesions, indicating that the lesions were a manifestation of an early phase of EED. Both types of skin lesions disappeared with treatment with dapsone. They have not relapsed for two years after stopping the dapsone. The leukocytoclastic vasculitis was thought to have developed independently of the rheumatoid arthritis. She had noticed sicca symptoms two years before the appearance of EED, but she did not satisfy the diagnostic criteria for Sjögren's syndrome.     

Beneficial Neurological Effects Observed in a Patient with Psoriasis Treated with Etanercept

A 53-year-old woman with a history of psoriasis presented with severe cutaneous lesions associated with psoriasis. The woman was mentally handicapped; she was able to converse monosyllabically with her mother only and was very limited in social interactions. After preliminary investigations, a biological treatment was proposed. Etanercept was started in October 2006. The patient responded rapidly and, after 3 months, achieved a 75% improvement in the psoriasis area and severity index (PASI 75) score. Most notable, however, was that she began interacting with other people, even if they were not familiar to her. Subsequent cutaneous relapses were treated successfully with etanercept. Very few articles regarding etanercept and neurological or psychiatric problems are present in the literature. According to recent studies, etanercept could improve verbal fluency and cognitive and behavioural functions in Alzheimer’s disease, so that we can suggest a potential role and use in neurological disorders.