Rosacea-Like Lesions due to Familial Mycobacterium avium-intracellulare Infection

Mycobacterium avium-intracellulare (MAI) is a non-tuberculous, nonlepromatous or "atypical" mycobacterium now seen frequently in patients with acquired immunodeficiency syndrome (AIDS). In the past decade, the incidence appears to have increased in non-AIDS patients. Although cutaneous involvement is rare, two brothers without detectable immune defects who both presented with cutaneous MAI infection are described; the older brother also has disseminated disease. The cutaneous presentation of MAI, as well as immune and genetic defects that may predispose to mycobacterial infection, are discussed.     

Clinical and epidemiological aspects of American cutaneous leishmaniasis with genital involvement

Genital lesions are an unusual presentation of American cutaneous leishmaniasis. Conditions such as disseminated cutaneous leishmaniasis and HIV infection may be associated with genital involvement. The authors present five cases of American cutaneous leishmaniasis with genital lesions and discuss the clinical and epidemiological aspects observed in this case series.     

Cutaneous manifestations of human papillomaviruses: a review

Human papillomaviruses (HPVs) are small DNA viruses of the papovavirus family, with more than 100 types already described. Their importance in human disease cannot be overemphasized because these agents are among the most common pathogens in cutaneous infectious diseases and are very important in a subset of predominantly, but not exclusively, genital squamous-cell carcinomas. HPVs can be associated with a variety of cutaneous as well as mucosal manifestations. Some types of HPVs are associated with increased risk of epithelial malignancies; these have been divided into low-risk and high-risk types based on their oncogenic potential. Clinical and histological features of HPV infection vary according to individual susceptibility (e.g., immunosuppressed patients), site of involvement, and type of HPV implicated. The histological features of HPV infection are very easy to identify on sections stained with hematoxylin and eosin. However, many findings usually associated with HPV infection are entirely non-specific. Additional current diagnostic methods for identification of HPV in tissues include techniques based on the detection of viral DNA; namely, in-situ hybridization and polymerase chain reaction (PCR). This article reviews the main clinical and histopathological cutaneous manifestations of HPV infection, including common warts, plantar warts, plane warts, condyloma acuminatum, Bowenoid papulosis, and epidermodysplasia verruciformis. Emphasis is placed on the clinical and histological features of these various manifestations, including a brief discussion about the routinely used laboratory methods for detecting HPV in tissues.     

Primary cutaneous cryptococcal cellulitis secondary to insect bite in an immunosupressed patient after liver transplantation

Cutaneous cryptococcosis is usually a manifestation of disseminated disease, especially in immunosuppressed patients. Primary cutaneous cryptococcosis has also been described in some patients without evidence of systemic disease. Distinguishing between primary and secondary cutaneous cryptococcosis may be difficult as patients can be asymptomatic or cutaneous lesions may precede systemic involvement by some months. Features supporting primary disease are a history of cutaneous inoculation, and solitary superficial lesions on uncovered parts of the body. We present a liver transplant patient with cutaneous cryptococcal cellulitis subsequent to an insect bite, without systemic involvement and with excellent response to treatment with amphotericin B for 15 days and surgical debridement plus oral fluconazole for 3 months. In immunosupressed patients with cellulitis a cryptococcal infection must be excluded. If cutaneous cryptococcosis is diagnosed, systemic evaluation and prompt lengthy treatment are required.     

Concurrent Cytomegalovirus,M. Tuberculosis and M. Avium-Intracellulare Cutaneous Infection in an HIV Patient

We report a 25-year-old HIV-positive man with a past medical history of disseminated cytomegalovirus (CMV) infection, who developed cutaneous lesions during a disseminated mycobacterium infection. The histological changes of CMV and acid-fast bacilli were seen on histopathology of the lesions. Cultures were positive for M. tuberculosis and M. avium-intracellulare (MAI). CMV is frequently isolated from HIV patients, but skin involvement is rare. The association of CMV and mycobacteria can occur in cutaneous lesions of AIDS patients, but concurrent cutaneous involvement of CMV, M. tuberculosis, and MAI is unusual. These findings emphasize the polymorphous presentation of infectious disorders in AIDS patients and the need for multiple biopsies and for special stains in such patients.     

Oral and cutaneous features of acute human immunodeficiency virus infection

Acute infection with human immunodeficiency virus (HIV-1) may give rise to a febrile illness with distinctive clinical features. Oral and cutaneous involvement may be prominent. Two cases are reported that illustrate this syndrome, and the importance of its early recognition is emphasized.     

Cutaneous community-acquired and hospital-acquired methicillin-resistant Staphylococcus aureus

The clinical presentation of methicillin-resistant Staphylococcus aureus (MRSA) infection ranges from asymptomatic colonization to cutaneous and invasive involvement. This review discusses the cutaneous presentations of community-acquired MRSA (CA-MRSA) and hospital-acquired MRSA (HA-MRSA) that one may encounter in the hospital or outpatient setting. Cutaneous CA-MRSA and HA-MRSA are often clinically indistinguishable, although they have different epidemiologic profiles and virulence factors. Bacterial culture is necessary for diagnosis and guides treatment, as infection with CA-MRSA and HA-MRSA require distinct clinical management. Guidelines for surgical interventions and antibiotic treatment of CA-MRSA and HA-MRSA will be discussed. Strategies for MRSA decolonization and prevention of further spread will also be reviewed.     

Juvenile xanthogranuloma as a sequel to Langerhans cell histiocytosis: a report of three cases

We report three children who had multisystem Langerhans cell histiocytosis (LCH) with cutaneous involvement and subsequently developed juvenile xanthogranuloma (JXG). JXG appeared 3--6 years after the initial manifestation of LCH. JXG lesions, which presented as yellowish papules, revealed typical Touton giant cells and were factor XIIIa positive but S100 and CD1a negative. Non-LCH histiocyte disorders, such as JXG, are known to occur as a reaction to a variety of external stimuli such as infection and trauma. It is therefore conceivable that the inflammatory reaction associated with LCH may have precipitated the development of JXG in our patients. Alternatively, one could speculate that this association might be due to a common histogenetic precursor of the cell types involved.     

Cutaneous sarcoid with varied morphology associated with hypercalcaemia and renal impairment

Sarcoidosis is a multisystem disorder of unknown aetiology, which presents with hilar lymphadenopathy, pulmonary infiltration, and ocular and cutaneous involvement. Cutaneous lesions often present as erythema nodosum, maculopapular, plaque, scar, subcutaneous nodule or lupus pernio. Most patients with cutaneous involvement have a single type of skin lesion, but some cases may have ≥ 2 types. We report a case of sarcoidosis presenting with various types of skin lesions. The case was also complicated by hypercalcaemia and renal dysfunction, and was successfully treated with oral corticosteroids. Presentation of various skin lesions may indicate systemic organ involvement requiring treatment with systemic corticosteroid.     

Cutaneous plasmacytomas. A review and presentation of an unusual case.

Recent reviews separate four types of plasma cell tumor: multiple myeloma, extramedullary plasmacytoma (without multiple myeloma), solitary myeloma of bone, and plasma cell leukemia. Cutaneous plasma cell tumors may arise from lymphatic or vascular spread of tumor (metastatic cutaneous plasmacytoma) or by direct extension from bone lesions. The former, metastatic cutaneous plasmacytomas, are quite rare. Specific malignant plasmacyte cutaneous tumors can also be seen in extramedullary plasmacytoma, solitary myeloma of bone, and plasma cell leukemia. We present a patient with multiple myeloma and lymphedema of the right arm, who developed a pathologic fracture of the right humerus and subsequently developed numerous metastatic cutaneous plasmacytomas localized to the lymphedematous arm. Direct immunofluorescence of frozen sections and enzymatically released cells from tumor nodule failed to reveal cell-associated immunoglobulins.     

Varicella-zoster virus vasculitis: a case of recurrent varicella without epidermal involvement

New types of diseases due to the varicella-zoster virus (VZV) are increasingly recognized. A case of cutaneous VZV vasculitis without epidermal involvement is presented. The patient received chemotherapy for a large B cell lymphoma. He presented a few painless papules on one hand and in the axilla. A lymphocytic vasculitis was evidenced. Immunohistochemistry revealed the presence of VZV in endothelial cells and dermal dendrocytes. Nerves and keratinocytes were free of the virus infection. Such a presentation probably represents a mild form of recurrent varicella with prominent but limited vascular involvement.     

Clinical patterns of cutaneous nontuberculous mycobacterial infections

BACKGROUND: Cutaneous nontuberculous mycobacterial infections result from external inoculation, spread of a deeper infection, or haematogenous spread of a disseminated infection. There are two species-specific infections (fish-tank or swimming-pool granuloma, due to Mycobacterium marinum, and Buruli ulcer, caused by M. ulcerans). Most infections, however, produce a nonspecific clinical picture. OBJECTIVES: To define clinical patterns of cutaneous disease in nontuberculous mycobacterial infections. METHODS: Fifty-one patients with cutaneous nontuberculous mycobacterial infections were reviewed. Clinical and histopathological features of normal hosts and immunosuppressed patients were compared. Two subgroups of immunosuppressed patients were distinguished: patients with cutaneous infection and patients with a disseminated infection and cutaneous involvement. RESULTS: In immunosuppressed patients the number of lesions was significantly higher. Abscesses and ulceration were also more frequently observed. Different species were found in normal hosts and immunosuppressed patients. Several clinical patterns of cutaneous infection were defined: lymphocutaneous or sporotrichoid lesions; nonlymphocutaneous lesions at the site of trauma; folliculitis and furunculosis involving the lower extremities; disseminated lesions on the extremities in immunosuppressed patients. Two patterns were observed in patients with a disseminated infection: localized cutaneous lesions and disseminated cutaneous and mucosal lesions. CONCLUSIONS: Cutaneous manifestations of nontuberculous mycobacterial infections may be classified according to criteria such as cutaneous lesions and immune status.     

Human papillomavirus in the era of highly active antiretroviral therapy for human immunodeficiency virus: an immune reconstitution‐associated disease?

Human immunodeficiency virus (HIV)-related cutaneous and anogenital disease in the highly active antiretroviral therapy (HAART) era presents challenging problems for dermatologists. Immune reconstitution-associated diseases (IRADs) are common and important consequences of HAART. Dermatologists should be aware of the cutaneous manifestations of IRAD. The prevalence of clinical human papillomavirus (HPV)-related disease is increased in HIV and does not appear to be diminished by HAART. Many patients on HAART are dogged by persistent cutaneous warts. Anogenital precancer is also common in HIV and may be burgeoning with HAART. Clinicians should be aware of the increased risk of cervical, penile and vulval/vaginal cancers in treated and untreated patients with HIV. The increase in HPV infection in HIV-infected individuals may be, at least partly, due to increased exposure to diverse HPV types, particularly high-risk types that might be able to persist for longer in anogenital regions. Alternatively, persistent/emergent HPV disease in HIV infection might represent persistent or modulated immunodysregulation after HAART and be viewed as a form of IRAD. The immunopathogenesis of HPV IRAD is fascinating and possibly determined by host genotype.     

Clinical and histopathological spectrum of cutaneous vasculitis in rheumatoid arthritis

BACKGROUND: Cutaneous manifestations are the most frequent, and often the initial feature of extra-articular involvement in patients with rheumatoid vasculitis. OBJECTIVES: The purpose of the study was to evaluate the clinical and histological spectrum of cutaneous vasculitis and the associated systemic involvement in patients with rheumatoid vasculitis. METHODS: Among 525 patients with rheumatoid arthritis, 20 tissue specimens with histologically proven cutaneous necrotizing vasculitis from 11 patients were investigated by studying the types and levels of affected vessels and related clinical features. RESULTS: Small-vessel vasculitis identified as dermal necrotizing venulitis was found in 10 patients, clinically characterized by palpable purpura, maculopapular erythema, erythema elevatum diutinum and haemorrhagic blisters. Arteritis histologically resembling cutaneous polyarteritis nodosa, clinically characterized by subcutaneous nodules, livedo reticularis, atrophie blanche and deep ulcers was identified in four patients all with systemic complications. Coexistence of venulitis and arteritis was identified in three patients. Different cutaneous vasculitic manifestations often coexisted and recurred in the same patient. Three patients with systemic complications of mononeuritis multiplex (two of three), interstitial pulmonary fibrosis (two of three) and abdominal microaneurysms (one of three) died within 1 year of onset of the cutaneous vasculitis. Immunofluorescence demonstrated vessel wall deposition of IgM and/or complement in six of the seven patients examined. CONCLUSIONS: Features of cutaneous rheumatoid vasculitis overlapping both the characteristics of cutaneous necrotizing venulitis and cutaneous polyarteritis nodosa together with coexistence of these different type of vasculitis in the same or different lesional skin account for the associated diverse cutaneous vasculitic manifestations. Although dermal venulitis (leucocytoclastic vasculitis) was the most common presentation, the presence of leucocytoclastic vasculitis in rheumatoid patients did not necessarily indicate a favourable prognosis. Associations with mononeuritis multiplex and bowel involvement had a fatal prognosis, while patients with superficial dermal venulitis without other extra-articular involvement may follow a favourable prognosis.     

Topical phosphonoacetic acid treatment of cutaneous herpes simplex infections in the guinea pig

Phosphonoacetic acid (PAA) was evaluated as therapy for primary cutaneous herpes simplex virus (HSV) infections in guinea pigs. Epilated areas of skin were inoculated with HSV type 1 and treated in a blind fashion with topical PAA 2% cream or placebo cream, the initial application varying from 3 to 84 hours after inoculation. PAA applied 3 hours after inoculation aborts clinical infection. Even when applied 84 hours after inoculation (12 hours after the appearance of clinical lesions), PAA reduces the severity of primary HSV infection, and thus may be suitable for the treatment of human HSV infections.     

Granuloma annulare-like eruption due to chronic Epstein-Barr virus infection

A 32-year-old woman afflicted with a severe, chronic Epstein-Barr virus (CEBV) infection of 12 months' duration developed an unusual, granuloma annulare-like eruption. The cutaneous disorder, which paralleled the clinical course of her disease, was characterized by slightly raised, erythematous, annular lesions predominantly involving the face and arms, with sporadic involvement elsewhere. Histopathologic examination of biopsy material obtained from affected skin disclosed a granulomatous dermatitis. The patient's symptoms and cutaneous eruption resolved after systemic corticosteroid therapy. This eruption may represent a distinct cutaneous component of CEBV infection with clinically granuloma annulare-like features or the mere serendipitous association of CEBV infection and an unusual granulomatous dermatitis. Because of the unusual clinical appearance of the eruption and its clear correlation with disease activity, we speculate that it likely represents a distinct cutaneous condition, heretofore unreported, caused by CEBV infection.     

Cutaneous Fusarium solani infection in childhood acute lymphoblastic leukaemia

Cutaneous involvement is often an initial presentation of infection with Fusarium species, which occurs more commonly in immunocompromised hosts and may be either localized or widespread. Skin lesions typically appear as red or grey macules, which may develop central ulceration and black eschar. Secondary dissemination to extracutaneous organs may occur in immunocompromised hosts, especially those with prolonged and severe neutropenia. We describe a case of widespread cutaneous involvement after infection with Fusarium solani in childhood acute lymphoblastic leukaemia that responded successfully to treatment with prolonged liposomal amphotericin B.     

Eyelid involvement of primary cutaneous lymphomas: A clinical perspective

Eyelids may be affected in systemic, ocular adnexal and primary cutaneous lymphomas (PCLs). The frequency of eyelid involvement in PCLs is still not well known and it is not a predilection site for any type. While primary cutaneous T-cell lymphomas (CTCLs) are more commonly seen than primary cutaneous B-cell lymphomas (CBCLs), especially mycosis fungoides (MF) as by far the most frequent type, B cell lymphomas are reported to be the commonest type in eyelid localization on the contrary. PCLs may be located on the eyelids, as the sole manifestation or in association with the involvement of other parts of the eye and elsewhere of the body. MF may present with a rich spectrum of clinical features on the eyelids mostly seen in folliculotropic subtype and advanced-stage disease. Erythematous scaly patches or plaques representing the most commonly encountered eyelid MF lesions may mimic many other dermatological conditions. Diffuse thickening, oedema, poikilodermic changes, atrophy and wrinkling are other suggestive findings of eyelid MF. Milia-like papules, madarosis and ectropion are also seen in the folliculotropic variant of MF, as ectropion is more typical for Sezary syndrome. Eyelids are also a typical location for tumoural MF which has been suggested as a poor prognostic indicator in MF. Papulonodular lesions, large tumours, ulceration, diffuse infiltration, oedema and subcutaneous atrophy on the eyelids may also be seen in other types of PCLs. Keep in mind, the rich clinical spectrum of PCLs on the eyelids may be crucial in early diagnosis in this special localization.     

Coexistence of two types of clinical lesions in childhood-onset mastocytosis

The vast majority of mastocytosis appear in childhood, urticaria pigmentosa (UP) and mastocytomas being the most common types. Terms such as "xanthelasmoid mastocytosis", "pseudoxanthomatous mastocytosis" or "nodular mastocytosis" have been introduced in the literature to describe the presence of yellowish papular or nodular lesions. We describe two children with cutaneous mastocytosis showing yellowish lesions in combination with other skin lesions. A 10-year-old girl presented with asymptomatic lesions in her vulva at birth, and developed brownish macules on her trunk years after. An eight-year-old boy presented with multiple yellowish papular lesions on his trunk, neck and limbs coexisting with a few clinically anetodermic lesions. No systemic involvement was found and the skin biopsy confirmed a cutaneous mastocytosis in both cases. The two patients are currently asymptomatic and are being periodically followed up. Mastocytoses may show a variety of clinical lesions, sometimes leading to misdiagnosis. Although there are previous reports, involvement of the mucosae and secondary anetoderma are not common findings in cutaneous mastocytoses. We consider that cutaneous manifestations of mastocytoses compose a clinical spectrum, thus explaining the coexistence of different clinical lesions and the development of uncommon presentations.     

Dermatofibrosarcoma protuberans presenting as a subcutaneous mass: a clinicopathological study of 15 cases with exclusive or near-exclusive subcutaneous involvement

Dermatofibrosarcoma protuberans (DFSP), a cutaneous fibrohistiocytic tumor of intermediate (borderline) malignancy, typically arises in the dermis and subsequently infiltrates the subcutaneous tissue. Very rarely DFSP may either arise within the subcutaneous fat without dermal involvement or show very extensive subcutaneous involvement with only minimal and clinically subtle dermal involvement. We present the clinicopathological features of 15 cases of DFSP showing exclusive or near-exclusive involvement of the subcutaneous fat. The differential diagnosis with other subcutaneous spindle cell neoplasms is emphasized. Awareness of this rare subset of DFSP should prevent its misdiagnosis as other less aggressive tumor types.