CONCOMITANT CUTANEOUS METASTATIC TUBERCULOUS ABSCESSES AND MULTIFOCAL SKELETAL TUBERCULOSIS

Tuberculosis, one of the oldest diseases known to affect humans is caused by the bacteria mycobacterium tuberculosis. The disease usually affects the lungs, although, in up to one third of cases, other organs are involved. Metastatic tuberculosis abscess is a rare form of skin tuberculosis. It is characterized by nodule and abscess formation throughout the body after hematogenous spread of mycobacterium tuberculosis from a primary focus during a period of impaired immunity. Tuberculosis osteomyelitis is also a rare form of extrapulmonary tuberculosis in pediatric age group. Skeletal tuberculosis pathogenesis is related to reactivation of hematogenous foci or spread from adjacent paravertebral lymph nodes. Weight-bearing joints are affected most commonly. Bilateral hand and foot bone involvement is rarely reported. We present a five-year-old girl with two very rare presentations of the disease such as osteomyelitis and metastatic skin abscess.     

METASTATIC CROHN'S DISEASE OF EXTERNAL GENITALIA

Metastatic Crohn''s disease is an uncommon extraintestinal manifestation of Crohn''s disease. Its hallmark features include the presence of cutaneous noncaseating granulomas that are noncontiguous with the gastrointestinal tract or fistula. We report a rare case of metastatic Crohn''s disease involving the external genitalia in a 14-year-old girl. Diagnosis was based on skin biopsy. Patient had complete recovery on treatment with oral and topical steroids along with azathioprine.     

HYPERTROPHIC LUPUS VULGARIS: AN UNUSUAL PRESENTATION

Lupus vulgaris is the most common form of cutaneous tuberculosis occurring in previously sensitized individuals with a high degree of tuberculin sensitivity. Various forms including plaque, ulcerative, hypertrophic, vegetative, papular, and nodular forms have been described. A 30-year-old male patient presented with a very large hypertrophic lupus vulgaris lesion over left side of chest since 22 years. Histopathological examination showed granulomatous infiltration without caseation necrosis. The Mantoux reaction was strongly positive. Hypertrophic lupus vulgaris of such a giant size and that too at an unusual site is extremely rare and hence is being reported.     

CUTANEOUS MANIFESTATIONS OF SYSTEMIC LUPUS ERYTHEMATOSUS IN A TERTIARY REFERRAL CENTER

Background:

Systemic lupus erythematosus (SLE) is an autoimmune disease with multiorgan involvement. The skin is the second most commonly affected organ. SLE with skin lesions can produce considerable morbidity resulting from painful skin lesions, alopecia, disfigurement, etc. Skin lesions in patients with lupus may be specific (LE specific) or may be non specific (LE non specific). Acute cutaneous LE (Lupus specific) has a strong association with systemic disease and non-specific skin lesions always indicate disease activity for which patients present to rheumatologists and internists. Therefore, a thorough understanding of the cutaneous manifestations of SLE is essential for most efficient management.

Aims:

The aims of this study were to evaluate the patterns and prevalence of skin lesions in patients with SLE and to assess the relationship between skin lesions and other systemic involvement.

Materials and Methods:

At the Department of Rheumatology and Clinical Immunology, IPGME&R in Kolkata, 150 patients with SLE fulfilling the clinical and laboratory criteria of the American Rheumatology Association (updated 1982) were examined and followed-up for cutaneous manifestations between January 2002 and January 2007.

Results:

Skin lesions were important clinical features. About 45 patients (30%) presented with skin lesions although all patients had skin lesions during the follow-up period. Skin changes noted were as follows: Lupus specific lesions: malar rash in 120 patients (80%), photosensitive dermatitis in 75 patients (50%), generalized maculopapular rash in 40 patients (26.67%), discoid rash in 30 patients (20%), subacute cutaneous lupus erythematosus (SCLE) in 5 patients (3.34%), lupus profundus in 5 patients (3.34%). The lupus non-specific lesions were non-scarring alopecia in 130 patients (86.67%), oral ulcers in 85 patients (56.67%), vasculitic lesions in 50 patients (33.34%), bullous lesions in 15 patients (10%), Raynaud''s phenomenon in 10 patients (6.67%), pyoderma gangrenosum in 2 patients (1.34%), erythema multiforme in 10 patients (6.67%), and nail fold infarcts in 2 patients (1.34%); however, mucosal discoid lupus, lichenoid discoid lupus, livedo reticularis, sclerodactyly, etc. were not detected. Patients having lupus-specific skin lesions e.g., malar rash were associated with systemic involvement, whereas those having lupus non-specific skin lesions were associated with disease flare.

Conclusions:

Skin lesions in patients with SLE are important disease manifestations and proper understanding is essential for diagnosis and efficient management.     

MUCOSAL PATCH ON ANUS: A RARE SEQUEL OF SODOMY

A case of mucosal patch on the perianal area of a 15-year-old boy with history of frequent sodomy is presented here.     

CUTANEOUS ZYGOMYCOSIS DUE TO SAKSENAEA VASIFORMIS IN AN IMMUNOCOMPETENT HOST

Saksenaea vasiformis is an emerging zygomycete species, most often associated with cutaneous, subcutaneous and rhino- orbito-cerebral infections. Herein, we report a case of cutaneous zygomycosis of face caused by Saksenaea vasiformis in a 54-year-old immunocompetent female. The diagnosis was carried out by microscopy using KOH mount, Gram staining, Gomori''s methenamine silver staining, hemotoxylin and eosin staining and culture on Sabouraud''s Dextrose agar without actidione. Slide cultures were put up on Czapek Dox agar, which showed typical flask-shaped sporangium with rhizoids. The patient was treated successfully with intravenous amphotericin B.     

BOWENOID PAPULOSIS OF THE GENITALIA SUCCESSFULLY TREATED WITH TOPICAL TAZAROTENE: A REPORT OF TWO CASES

Bowenoid papulosis is a rare condition of the genital area caused by human papilloma virus. Clinically, it resembles viral wart and histopathologically Bowen''s disease. We herein report two male patients presenting with multiple flat papules on the penis and scrotum. The second patient was HIV-positive. Histopathology showed features of bowenoid papulosis. Both the patients were treated with topical tazarotene gel 0.05%. Lesions cleared within 2 weeks in both the patients.Second patient had recurrences that cleared after retreatment with tazarotene.     

A clinical and histopathological profile of patients with cutaneous tuberculosis

Extrapulmonary tuberculosis constitutes about 10% of all cases of tuberculosis, and cutaneous tuberculosis makes up only a small proportion of these cases. Despite prevention programs, tuberculosis is still progressing endemically in developing countries. Commonest clinical variant of cutaneous tuberculosis in our study was lupus vulgaris seen in 55% patients followed by scrufuloderma seen in 25% patients followed by orificial tuberculosis, tuberculosis verrucosa cutis, papulonecrotic tuberculid, and erythema induratum seen in 5% each. The commonest site of involvement was limbs seen in 50% patients followed by neck seen in 25% patients, face in 15%, and trunk in 10% patients. Maximum percentage of patients (55%) had duration of cutaneous tuberculosis between 6-12 months followed by 35% between 13-24 months, 5% had duration of cutaneous tuberculosis less than 6 months, and the rest 5% had duration more than 24 months. The commonest histopathological feature in our study was tuberculoid granuloma with epitheloid cell and Langhans giant cells seen in 70% patients, hyperkeratosis was seen in 15% patients and AFB bacilli were seen in 5% patients.     

INCREASED INCIDENCE OF TUBERCULOSIS IN PATIENTS OF SYSTEMIC SCLEROSIS ON DEXAMETHASONE PULSE THERAPY: A SHORT COMMUNICATION FROM KASHMIR

Background:

Systemic sclerosis is a multi-systemic autoimmune disorder affecting predominantly the skin, lungs, gut and kidneys.

Purpose:

To report the increased incidence of tuberculosis in patients of systemic sclerosis on dexamethasone pulse (DP) therapy.

Methods:

Forty-seven patients of systemic sclerosis were included in the study. After taking a complete history and doing a detailed physical examination, the patients were submitted to a battery of investigations including complete hemogram (CBC) with erythrocyte sedimentation rate (ESR(F)), Chest X-ray CXR (PA view) Mantoux test and urine analysis. CBC, ESR and urine examination was done monthly and CXR were repeated six-monthly.

Findings:

Seven patients on DP therapy developed genitourinary tuberculosis. Four had pulmonary tuberculosis. One patient developed tubercular lymphadenitis, one patient succumbed to miliary tuberculosis.

Conclusion:

There is an increased incidence of tuberculosis amongst patients of systemic sclerosis on DP therapy.

Limitation of the Study:

There was no control group of systemic sclerosis patients not on DP therapy to rule out the confounding effect of the disease per se predisposing to tuberculosis as all our patients as a matter of routine were put on steroid pulse. Also, the increased incidence of tuberculosis was detected incidentally while on monthly follow-up.     

A clinical study of dermatoses in diabetes to establish its markers

Background:

Cutaneous manifestations of diabetes mellitus generally appear subsequent to the development of the disease, but they may be the first presenting signs and in some cases they may precede the primary disease manifestation by many years.

Aims:

The aim of our study was to study the spectrum of dermatoses in diabetics, to know the frequency of dermatoses specific to diabetes mellitus (DM), and to establish the mucocutaneous markers of DM.

Material and Methods:

The study was conducted at a diabetic clinic and our department between September 2008 and June 2010. Two hundred and twenty-four diabetic patients were included in the study group and those with gestational diabetes were excluded. Healthy age- and sex-matched individuals were taken as controls.

Results:

The male to female ratio was 1 : 1.21. Type 2 DM was seen in 89.7% and type 1 DM in 10.3% of the patients. Dermatoses were seen in 88.3% of the diabetics compared to 36% in non-diabetic controls (P<0.05). Cutaneous infections were the most common dermatoses followed by acanthosis nigricans and xerosis in diabetics. Type 2 DM was found to have an increased risk of complications than type 1 DM. Complications of diabetes were seen in 43.7% of the diabetic cases. Diabetic dermopathy, loss of hair over the legs, diabetic foot ulcer, and so on, were found to be the cutaneous markers of DM in our group of cases.

Conclusion:

Dermatoses were more common in diabetics than non-diabetics. Cutaneous infections formed the largest group of dermatoses in DM.     

GIANT CUTANEOUS HORN

A 53-year-old male presented with a giant cutaneous horn over the left leg. Cutaneous horn was excised and primary closure of the defect was done under spinal anesthesia. Histopathology showed underlying seborrheic keratosis. Cutaneous horn has been noticed on top of many clinical conditions of diverse etiology, such as actinic keratoses, wart, molluscum contagiosum, seborrheic keratoses, keratoacanthoma, basal cell and squamous cell carcinoma. We report a patient with giant cutaneous horn on the leg successfully treated by excision and wound closure.     

CUTANEOUS PANCREATIC METASTASIS: A CASE REPORT AND REVIEW OF LITERATURE

Pancreatic cancer is one of the most dangerous human cancers and will continue to be a major unsolved health problem as we enter the 21^st century. This is the case despite advances in imaging technology and surgical management. Indeed, 80% to 90% of pancreatic cancers are diagnosed either at the locally advanced or metastatic stage. Cutaneous metastases originating from pancreatic cancer are relatively rare. The most common site of cutaneous metastasis is the umbilicus, and this is known as the Sister Joseph''s nodule. Very few patients have been reported with cutaneous lesions disclosing a pancreatic carcinoma at sites other than the umbilical area. To the best of our knowledge, there have been no previous reports on cutaneous pancreatic metastasis in Egypt. This is a report on a patient with cutaneous pancreatic metastases at the neck and review of reported non-umbilical cutaneous metastases from pancreatic carcinoma in the literatures.     

BIOLOGICS: TARGET-SPECIFIC TREATMENT OF SYSTEMIC AND CUTANEOUS AUTOIMMUNE DISEASES

Biologics are becoming important in the treatment of systemic and cutaneous autoimmune diseases. They are designed to target specific components of immune system. As the new drugs are capable of targeting proteins in a more specific fashion, yet have lower risks of systemic side-effects, they have considerable advantages over the older immunomodulators. The development of TNF-alpha blockers in the treatment of psoriasis, psoriatic arthritis, rheumatoid arthritis, Crohn''s disease and ankylosing spondylitis have been major breakthroughs. Likewise, B-cell depletion has proved to be equally revolutionary for the treatment of lupus, pemphigus, certain vasculitides etc. But all said and done, the development of these molecules and their clinical usage are still at evolving stages. Consensus needs be formed to further categorize the clinical profiles of the patients in whom biologics are to be used in the future, given that the long-term safety profiles of these agents are very much unknown at present.     

ISOLATION OF BACTERIA CAUSING SECONDARY BACTERIAL INFECTION IN THE LESIONS OF CUTANEOUS LEISHMANIASIS

Background:

Cutaneous Leishmaniasis (CL) is a parasitic disease characterized by single or multiple ulcerations. Secondary bacterial infection is one of the complications of the disease that can increase the tissue destruction and the resulting scar.

Objective:

To effectively determine the incidence of real secondary bacteria infection in cutaneous leishmaniasis, we designed the current study.

Methods and Materials:

This was a cross-sectional study performed in Skin Diseases and Leishmaniasis Research Centre, Isfahan, Iran. In this study, 854 patients with confirmed CL were enrolled. Samples were taken from all the patients. Sterile swaps were achieved for the ulcer exudates and scraping was used for nonulcerated lesions. All the samples were transferred to tryptic soy broth medium. After 24 h of incubation in 37°C, they were transferred to eosin methylene blue agar (EBM) and blood agar. Laboratory tests were used to determine the species of bacteria. All of the collected data were analyzed by SPSS software and chi-square.

Results:

Among 854 patients with confirmed cutaneous leishmaniasis, 177 patients (20.7%) had positive cultures for secondary bacterial infection. Bacteria isolated from the lesions were as follows: Staphylococcus aureus - 123 cases (69.4%), coagulase negative Staphylococcus - 41 cases (23.1%), E. coil - 7 cases (3.9%), Proteus - 3 cases (1.7%) and Klebsiella - 3 cases (1.7%).

Conclusions:

The incidence of secondary bacterial infection in lesions of CL was 20.7%. The most common isolated pathogen was Staphylococcus aureus. The incidence of secondary bacterial infection was significantly more in the ulcerated lesions as compared with nonulcerated lesions (P = 0.00001).     

LICHEN SCROFULOSORUM: AN IMPORTANT MARKER OF OCCULT TUBERCULOSIS

Lichen scrofulosorum is a tuberculid that is usually seen in children or young adults. Although a rare occurrence, this tuberculid is an important marker of occult tuberculosis, which may not be detected otherwise. We report here a case of lichen scrofulosorum in a ten year-old boy with typical grouped lichenoid papules on the trunk associated with axillary tuberculous lymphadenitis.     

CHILDHOOD CUTANEOUS VASCULITIS: A COMPREHENSIVE APPRAISAL

Cutaneous vasculitides in childhood are rare and often present with clinical features distinct from adults. Diagnosis of cutaneous vasculitides in children was difficult because of lack of a satisfactory classification systems for this age group. A new international classification system for childhood vasculitis has been discussed in the following section along with important clinical features, diagnostic modalities, and recent therapeutic developments of important vasculitides in children.     

A clinicopathological study of cutaneous tuberculosis at Dibrugarh district, Assam

Background:

Cutaneous tuberculosis forms a small subset of extra pulmonary tuberculosis and has a worldwide distribution.

Aims:

The present study is an attempt to find out the incidence, clinical spectrum, and histopathological features of cutaneous tuberculosis.

Materials and Methods:

A total of 42 cases of newly diagnosed patients of cutaneous tuberculosis attending dermatology out patient department over a period of 1 year were included in the study. A detailed clinical examination and investigations including histopathological examination were carried out.

Results:

Scrofuloderma was the most common form seen in 50% cases followed by lupus vulgaris in 42.86%, tuberculosis verrucosa cutis in 4.76%, and lichen scrofulosorum in 2.38% cases. The Mantoux test was positive in 83.33% cases. Characteristic tuberculoid granulomas were seen in 72.22% cases of lupus vulgaris, 42.86% cases of scrofuloderma and all cases of tuberculosis verrucosa cutis and lichen scrofulosorum.

Conclusion:

Cutaneous tuberculosis is still highly prevalent in upper Assam. Early diagnosis and treatment are essential to prevent its complications.     

CUTANEOUS MANIFESTATIONS IN PATIENTS SUSPECTED OF CHIKUNGUNYA DISEASE

Context:

An epidemic of chikungunya disease occurred in India during late 2005 through 2006 affecting nearly 1,400,000 people.

Aim:

To study the cutaneous manifestations in suspected cases of chikungunya disease.

Settings and Design:

Patients who attended our outpatient departments from January 2006 to September 2006 were prospectively included if they had symptoms of chikungunya disease according to the ‘case definition’ of the National Institute of Communicable Diseases, Directorate General of Health Services, Government of India. The criteria were an acute illness characterized by the sudden onset of fever and several symptoms such as joint pain, headache, backache, photophobia, and eruption during an epidemic of chikungunya fever in the absence of confirmatory serological tests.

Materials and Methods:

A total of 115 patients (65 men and 50 women) who satisfied the above criteria were enrolled for the study.

Results:

An erythematous maculopapular rash subsiding without any sequelae in 3-4 days was the most common cutaneous finding in our patients. Genital ulcers distributed predominantly over the scrotum and base of the penile shaft in men and labia majora in women were the second most common manifestation. Other manifestations included tenderness/edema of hands and feet, grouped hyperpigmented macules over the nose and cheeks, fixed drug eruptions, erythema nodosum, erythema multiformae, generalized urticarial eruptions, and flare up of pre-existing psoriasis and lichen planus.

Conclusions:

To conclude, a plethora of cutaneous manifestations were noted in suspected cases of chikungunya disease. Genital ulcers, to the best of our knowledge, have not been reported during the earlier epidemics but have been reported by others during the present one.     

A Case of Extensive Multifocal Tuberculosis Verrucosa Cutis

Tuberculosis is probably as old as the human race itself. Cutaneous tuberculosis constitutes a very small proportion of extra pulmonary tuberculosis. Extensive, multifocal involvement of cutaneous tuberculosis is a very rare manifestation. We report one such case of extensive, multifocal tuberculosis verrucosa cutis in a 30-year-old immunocompetent male patient in the absence of any primary tubercular focus.