肺部奴卡菌病并皮肤播散1例（附文献复习）

奴卡菌病是一种少见的皮肤和／或系统感染性疾病，主要由星形奴卡菌感染引起。笔者近期诊治一例，现报道如下，并复习近期文献报道，就奴卡菌病的临床表现、诊断、治疗及预后等做一简要分析，以供临床诊治参考。     

奴卡菌性足菌肿

报告1例奴卡菌性足菌肿。患者男,56岁。左腹股沟术后出现皮肤红肿、破溃、脓液溢出半年。组织病理检查可见大量肉芽性炎性浸润,并见小脓肿形成,其内可见硫磺颗粒;分泌物涂片+抗酸染色镜检见阳性菌,菌丝内连串阳性颗粒;脓液培养见奴卡菌,诊断为奴卡菌性足菌肿。给予复方磺胺甲恶唑联合头孢曲松治疗,皮损完全消失。     

HIV阳性患者合并皮肤奴卡菌病一例

患者,女,66岁。2年前无明显诱因鼻尖部出现浸润性斑块、结节、厚重的黄痂,皮损逐渐增多。HIV抗体（+）,皮损表面脓性分泌物培养提示奴卡菌。进一步培养菌株提取基因组DNA,经扩增测序后,提示该奴卡菌分型为巴西奴卡菌。     

急性原发性皮肤巴西奴卡菌感染

报告1例原发性皮肤巴西奴卡菌感染。患者男,26岁。因左侧面部红肿伴发热、左颈部淋巴结肿大4 d入院。体格检查:左侧面部钱币大皮肤肿物,质软,中央少许浆脓分泌物,部分结痂。脓液细菌培养和鉴定为巴西奴卡菌,经复方磺胺甲恶唑口服治疗后好转。     

急性原发性皮肤奴卡菌病1例

男 ,45岁。因右眼外上方红肿、表面多个小脓头伴发热、右耳前淋巴结肿大 3天入院。脓液细菌培养、鉴定为巴西奴卡菌 ,经舒普琛、丁胺卡那、复方新诺明治疗后痊愈。     

奴卡氏菌性足菌肿1例

患者男，34岁，左膝外伤后1年局部皮下组织出现红肿，硬化，窦道流脓，肌腱肿块，伴腹股沟淋巴结肿大，组织病理诊断肌腱肿块为足菌肿，窦道内肉芽组织培养有巴西奴卡氏菌生长，以青霉素G和复方甲基异恶唑连续用药2个月结合外科手术治疗，皮损和肿块完全消退，随访8个月未见复发。     

豚鼠奴卡氏菌引起足菌肿1例报告（附药敏测定）

报告国内首例由豚鼠奴卡氏菌引起的足菌种，并进行药敏测定，为今后临床选择用药提供了实验依据。用纸片法测定此菌对１０种抗生素敏感，２６种中药试管内抑菌生长的初步实验观察表明，１１种中药对此菌有抑菌作用。     

星形奴卡菌性足菌肿1例

患者女,40岁。左足背被田间竹枝戳伤后出现结节、肿块,部分破溃伴少量溢脓,逐渐加重8年。皮损组织病理示:真皮组织中见散在分布放射状结构的杵状体,周围有大量中性粒细胞、淋巴细胞及组织细胞浸润。深部组织真菌镜检和培养均(-),深部组织脓液培养见菌落生长,菌种鉴定为星形奴卡菌。诊断:星形奴卡菌性足菌肿。予复方磺胺甲恶唑、青霉素G和阿米卡星联合治疗,局部清创处理后好转。     

微波联合卡介菌多糖核酸、咪喹莫特治疗尖锐湿疣疗效观察

目的:观察微波联合卡介菌多糖核酸、咪喹莫特治疗尖锐湿疣的临床疗效。方法:治疗组41例采用微波联合卡介菌多糖核酸、咪喹莫特治疗,对照组32例单用微波凝固治疗。结果:治疗组和对照组间治愈率有显著性差异(X2=17.44,P〈0.001)。对照组治疗的复发率显著高于治疗组。结论:微波凝固治疗后外用咪喹莫特治疗尖锐湿疣效果好,再联用卡介菌多糖核酸肌注明显降低复发率。     

卡介菌多糖核酸注射液加液氮冷冻治疗面部扁平疣临床观察

目的:了解卡介菌多糖核酸注射液联合液氮冷冻治疗扁平疣的效果。方法:治疗组104例,卡介菌多糖核酸注射液每次2支(1 m l/支)肌注,隔日1次,联合液氮冷冻治疗,每周1次,3周为1疗程。对照组92例,只使用液氮冷冻治疗,每周1次,3周为1疗程。结果:治疗组3周后有效率达89.42%,对照组有效率65.21%,经过统计学处理有显著性差异(2=7.98,P<0.05)。结论:卡介菌多糖核酸注射液联合液氮冷冻治疗扁平疣疗效显著。     

原发性皮肤毛霉病

报告1例原发性皮肤毛霉病.患者男,57岁.右前臂埋置静脉套管针17 d后局部出现红肿,迅速坏死并扩大.患者患2型糖尿病及慢性肾功能不全.皮肤科检查示右前臂大片坏死区,上覆黑色焦痂及渗出.取黑痂及渗液行真菌镜检,镜下可见大量粗大、无分隔、垂直分枝的菌丝,培养第2天即有棉花糖样菌落生长,初步诊断为皮肤毛霉病.皮损行组织病理检查,PAS染色示真皮及皮下组织可见较多粗大、无分隔菌丝,确诊为皮肤毛霉病.给予两性霉素B脂质体泵入、坏死组织清创术、术后外敷两性霉素B脂质体溶液及外用人成纤维细胞生长因子.患者伤口愈合良好,随访4个月无复发.     

A case of Bockenheimer's syndrome (genuine diffuse phlebectasia): venous involvement inside muscles was detected by magnetic resonance imaging

We report a 13-year-old girl with an extensive bluish phlebectasia of the upper right arm and right side of the chest, which had been present since birth. There was no difference in length between the right (affected) and left (healthy) limbs, but the involved limb was thicker than the noninvolved limb. Magnetic resonance imaging showed distended veins with slow blood flow under the skin of the right limb. The veins inside the muscles of forearm were also involved. Histological examination of the bluish lesions revealed large phlebectasia showing distended veins without any proliferation of endothelial cells. The amount of elastin in the walls of these veins was decreased. The patient was diagnosed with Bockenheimer's syndrome. The characteristics of this rare syndrome are indicated and discussed.     

Pseudocarcinomatous hyperplasia mimicking squamous cell carcinoma in a case of CD56‐positive cytotoxic T‐cell lymphoma

We present the case of an 84‐year‐old patient with a cutaneous CD56 positive cytotoxic T‐cell lymphoma associated with substantial pseudocarcinomatous hyperplasia mimicking squamous cell carcinoma (SCC). The patient presented with a 7‐month history of several progressive, ulcerated plaques on his right forearm. An initial biopsy showed changes consistent with a diagnosis of SCC for which the patient underwent surgical treatment. Several months later, the patient developed recurrent ulcerated plaques on the right forearm of which several biopsies were performed. The biopsies repeatedly showed marked pseudocarcinomatous hyperplasia resembling SCC. Deeper punch biopsies, however, showed a dense superficial and deep infiltrate of markedly atypical lymphocytes. Immunohistochemical analysis revealed strong positive staining for CD3, CD8, CD56 with negative stains for CD30 and Epstein‐Barr virus‐encoded small non‐polyadenylated RNAs (EBER). Staining for beta F1 and gamma‐delta T‐cell receptor (γδ TCR) were both negative. This constellation was most consistent with a diagnosis of cutaneous peripheral T‐cell lymphoma, unspecified in association with marked pseudocarcinomatous hyperplasia. Our case adds cutaneous peripheral T‐cell lymphoma, unspecified to the list of conditions associated with pseudocarcinomatous hyperplasia (PCH) and illustrates once again the potential pitfalls of distinguishing marked pseudocarcinomatous hyperplasia from SCC.     

Co‐infection of Scedosporium apiospermum and Mycobacterium chelonae in an immunocompetent host

A 75‐year‐old man presented with multiple, scaly, erythematous, grouped papules, nodules and plaques with tenderness ranging from the right forearm to hand dorsum and the right lower leg for 2–3 months. Five months prior to presentation, the patient had received an antibiotic skin test on his right forearm. Lesions appeared approximately 2–3 months after the antibiotic skin test, slowly progressing without clinical improvement. Culture for fungus on the right forearm revealed growth of Scedosporium apiospermum. The tissue acid‐fast bacilli (AFB) culture for the right forearm and right leg revealed growth of non‐tuberculous mycobacteria which was Mycobacterium chelonae, and subsequent tissue polymerase chain reaction of both sites reported positive signs of M. chelonae. On diastase periodic acid‐Schiff stain of the biopsy specimen of the right forearm, fungal hyphae were found while rod‐shaped bacilli could be seen in AFB stain for the biopsy specimen of the right leg. The patient was treated with oral clarithromycin and ciprofloxacin along with an oral antifungal agent for 13 weeks. After the treatment, the lesions subsided and left a scar. We report a rare case of co‐infection of S. apiospermum and M. chelonae in an immunocompetent host.     

皮肤淋巴管型孢子丝菌病1例

患者女,57岁。右拇指、腕部及前臂结节伴瘙痒和疼痛3月。右前臂皮损组织病理示:化脓性肉芽肿性改变。真菌培养见申克孢子丝菌生长。诊断:皮肤淋巴管型孢子丝菌病。     

Pediatric case of anaplastic lymphoma kinase‐positive anaplastic large cell lymphoma forming a solitary skin tumor on the forearm

A 5‐year‐old girl noticed a rapidly growing reddish nodule on her right forearm. Although oral antibiotics had been administrated for 2 weeks, the tumor enlarged. Skin biopsy revealed excessive infiltration of atypical neoplastic cells expressing CD4, CD30 and anaplastic lymphoma kinase (ALK). These histological and immunohistochemical findings were consistent with anaplastic large cell lymphoma (ALCL). Computed tomography showed multiple lymphadenopathy, but lymph node biopsy and bone marrow examination did not show any evidence of systemic dissemination. However, due to the positive results for ALK and multiple lymphadenopathy, we diagnosed ALK‐positive ALCL forming a solitary skin tumor on the forearm. The patient received chemotherapy and presented marked improvement. This paper discusses the difficulty of diagnosing pediatric ALK‐positive ALCL limited to the skin and reviews the medical published work.     

Bullous delayed pressure urticaria; pressure testing may produce a systemic reaction

We report a patient with bullous delayed pressure urticaria (DPU) and chronic idiopathic urticaria (CIU) in whom a systemic reaction occurred. The reaction occurred 18 h after a pressure test had been performed on the right forearm. Blood histamine levels were more elevated in the sample taken from the forearm on which the test had been applied. Skin biopsy revealed both intraepidermal and subepidermal bullae with a sparse dermal inflammatory infiltrate and direct immunofluorescence showed linear deposition of fibrinogen along the epidermodermal basement membrane. As far as we are aware this is only the third case of bullous DPU reported and the first associated with generalized urticaria and angioedema and severe broncho-obstruction. Possible pathophysiological mechanisms are discussed.     

Idiopathic unilateral circumscribed hyperhidrosis

A 21-year-old man presented with a hyperhidrotic area on the extensor aspect of the right forearm and wrist. The lesion was 8 × 15 cm in size and was sharply demarcated. The patient complained of profuse sweating that lasted 10–80 min and that was sometimes precipitated by heat.
We obtained two different punch biopsies from the left and right wrists. The biopsies showed apparently normal histologic findings. Neurologic examination was normal. We then performed a conventional iodinated-starch test for sweating. Before the test, the right arm was of an orange colour with iodine-starch powder; dark blue droplets were seen on the hyperhidrotic area after provocation by heat (Figs 1 and 2).
Laboratory findings revealed a normal complete blood cell count and normal results of renal and liver function tests. Aluminium chloride cream (20%) was used as treatment, but the hyperhidrosis was not controlled.     

A case of subcutaneous sarcoidosis in a patient with Cushing's syndrome

A 41-year-old female visited our department complaining of asymptomatic subcutaneous nodules on the right forearm. She had been diagnosed as having Cushing syndrome due to an adrenal tumor 5-months previously. After she underwent surgery for the adrenal tumor, the subcutaneous nodules gradually increased in number. Physical examination showed ill-defined plate-like subcutaneous indurations on the bilateral lower extremities, buttocks, and right forearm. A biopsy of one of the subcutaneous indurations showed non-caseating epithelioid cell granulomas involving the hypodermis and subcutaneous tissues. The patient was diagnosed as having sarcoidosis based on the Japan Society of Sarcoidosis and Other Granulomatous Disorders 2015 criteria. Skin lesions decreased in size and had completely disappeared. Although the mechanism is unknown, there may be a possibility that the activity of sarcoidosis is suppressed by high cortisol concentrations due to Cushing syndrome.     

Acquired Microcystic Lymphatic Malformation of the Distal Upper Extremity Mimicking Verrucae Vulgaris

An 18‐year‐old African American male with a history of congenital lymphedema of the right upper extremity presented for evaluation of multiple verrucous lesions on his right hand. Clusters of 2 to 4‐mm dome‐shaped vesicles were intermixed with scattered verrucous papules on the right forearm and the dorsal and palmar aspects of the hand. Histopathology of one the verrucous lesions showed well‐circumscribed areas of dilated lymphatic vascular channels with lymph in the lumen. The patient was diagnosed with microcystic lymphatic malformation, verrucous type. This article reviews the literature regarding reports of this variant of microcystic lymphatic malformation in the pediatric population.