Paracoccidioidomycosis: unusual clinical presentation and utility of computerized tomography scanning for diagnosis

A 57‐year‐old white man, born in Chaco in the north of Argentina, who had worked as a cotton picker until 20 years ago when he moved to the city of Buenos Aires, presented with an asymptomatic, 10 cm long, 3.5 cm wide ulcer on the back of the neck, with an erythematous, violaceous border and serosanguinous material in the micronodular center ( Fig. 1 ). No enlargement of the lymph nodes was present and the patient's general condition was good. The results of laboratory tests were within normal values, and candidin and purified protein derivative (PPD) tests were negative; chest X‐ray showed subtle interstitial infiltrates. Histopathologic study of the border and center of the ulcer showed a granulomatous infiltrate with giant cells and large, spherical to oval cells with multiple buds, typical of Paracoccidioides brasiliensis; Grocott stain showed yeast with various blastoconidia and the well‐known image of the “pilot wheel” ( Fig. 2 ). The study of fresh tissue confirmed the existence of yeast (10–40 µm) including buds. Culture was negative. Skin test with Fava Neto antigen (polysaccharides of P. brasiliensis) was positive (17 mm). Tests of contraimmunoelectrophoresis with paracoccidioidin antigen showed two negative and one positive band. As the initial chest X‐ray was not decisive, computerized axial tomography of the lung was carried out. The latter showed a pulmonary interstitial infiltrate of the right inferior lobe and a small infiltrate of the left inferior lobe. ( Fig. 3 ).

Figure 1 Open in figure viewer PowerPoint Painless ulcer with sharp border and serosanguinous crust     

Cutaneous Rosai-Dorfman disease preceding inguinal lymphadenopathy

A 33‐year‐old man presented with asymptomatic, gradually progressing, reddish nodules on the thigh of 1 year's duration. Six months later, nodules were noticed on the buttock of the same side. At the same time, the inguinal and femoral lymph nodes increased in size and could be seen as an elevated mass in the groin which, although painless, made the patient limp when walking. On examination, a cluster of pink nodules on an erythematous, oval, indurated area, measuring 10 cm × 5 cm, was seen on the lower medial aspect of the right thigh ( Fig. 1 ). A small, almost circular, cluster of papules was present on the lower part of the right buttock. Some of these lesions, according to the patient, were reducing in size. The right inguinal and femoral lymph nodes were markedly enlarged and firm. The overlying skin was normal. Clinical differential diagnoses of dermatofibrosarcoma and localized, cutaneous T‐cell lymphoma were considered in this patient. Systemic examination revealed no abnormality.

Figure 1 Open in figure viewer PowerPoint Cluster of reddish nodules over the thigh     

Subcutaneous granuloma annulare following herpes zoster

A 57‐year‐old Korean man developed a papulovesicular eruption on the right chest with unilateral T2 dermatomal distribution; acute herpes zoster (HZ) was diagnosed. The past medical history revealed diabetes mellitus, but was otherwise noncontributory. His pain gradually subsided with treatment in the Pain Clinic of the Anesthesiology Department. Five months later, however, new skin lesions composed of several papules were detected at the site of the HZ scar. There were several discrete, nontender, firm, erythematous papules of about 0.8 cm in diameter on the right chest ( Fig. 1 ). Histologic examination revealed foci of necrobiotic collagen surrounded by a vague palisade of histiocytes in the deep dermis and subcutis ( Fig. 2 ). Mucin deposits were seen within the center of the palisaded granuloma and there were scattered multinucleated giant cells. Gram, Gomeri‐methenamine silver, and acid‐fast stains were negative. Polarizing microscopy did not reveal any material. Subcutaneous granuloma annulare at the HZ scar was diagnosed, and intralesional injections of triamcinolone caused flattening of the papules after 4 weeks of follow‐up.

Figure 1 Open in figure viewer PowerPoint Skin examination revealed several discrete, nontender, firm, erythematous papules of about 0.8 cm in diameter on the right upper chest (T2 dermatome)     

Churg-Strauss syndrome manifested by urticarial plaques

A 49‐year‐old mestizo Mexican woman, who had suffered with asthma for 30 years, presented with a 6‐week history of fever, hyaline rhinorrea, myalgias, and arthralgias, with thoracic pain in the right apical and retrosternal region and dyspnea with little effort, without response to antimicrobials or bronchodilators. Four weeks previously, she had developed three painful urticarial plaques on the right thigh and genital region, accompanied by paresthesia in the same extremity. These correlated with the remission of asthma. Physical examination demonstrated three erythematous and edematous plaques, measuring from 1.5 cm to 20 cm, with ill‐defined borders ( Fig. 1 ), on the inner side of the right thigh, inguinal and crural regions. Laboratory tests showed a hemoglobin level of 14 g/dL, a hematocrit of 44%, leukocytes of 8003/mm³, eosinophils of 2020/mm³ (25.2%), platelets of 244,000/mm³, an erythrocyte sedimentation rate of 80 mm/h, and immunoglobulin E (IgE) elevated to 224 U/mL. Urinalysis, complement, and antinuclear antibody tests were normal or negative. Chest roentgenogram showed a micronodular infiltrate in the right apex and inferior lobe; X‐rays of the paranasal sinuses were normal. A biopsy of the skin demonstrated an infiltration in the dermis with a predominance of eosinophils infiltrating the vascular walls ( Fig. 2 ). There were no granulomas.

Figure 1 Open in figure viewer PowerPoint Erythematous and edematous urticaria‐like plaques on the thigh     

Acute onset of neutrophilic dermatosis in patients after therapy with a COX-2-specific inhibitor

Case 1 A 31‐year‐old black woman with an 8‐year history of Crohn's disease (CD) presented with multiple, erythematous, tender, leg nodules. She had started to develop these areas approximately 2 weeks earlier. About 1 week prior to the development of these areas, the patient had gone to her primary care physician because of increasing joint pains. She was given rofecoxib, 50 mg/day. A few months earlier, the patient had stopped taking the medication that had been prescribed for CD: sulfasalazine and prednisone. Since stopping sulfasalazine and prednisone, her gastrointestinal symptoms had increased. After starting rofecoxib, the patient did not notice any significant change in her gastrointestinal symptoms, although her arthritic symptoms improved. Earlier on the day of presentation, the patient's gastroenterologist had instructed her to stop rofecoxib, and to re‐start sulfasalazine and prednisone. On physical examination, the patient had multiple erythematous nodules on both legs, predominantly on the lower legs anteriorly and posteriorly ( Fig. 1a ). Some of the nodules showed central pustules and some showed superficial epidermal ulceration ( Fig. 1b ). A biopsy was performed on an indurated lesion that had not yet ulcerated.

Figure 1 Open in figure viewer PowerPoint Multiple, erythematous nodules on the legs of a patient with Crohn's disease (Case 1). Biopsy specimens from some lesions showed subepidermal pustule formation with or without epidermal ulceration     

Bowen's disease: an uncommon presentation

A 60‐year‐old man presented with a lesion over the abdomen of 12–13 years’ duration. The lesion had been gradually progressing over the years and was asymptomatic. It had been treated by application of 5‐fluorouracil in 1993, which had resulted in partial regression; however, it started to grow again. A similar lesion had occurred over the left thigh, 2 years after the abdominal lesion appeared, and was excised. Past personal and family history was noncontributory. General and systemic examination revealed no abnormality. Dermatologic examination revealed a plaque, 18 cm × 15 cm in size, over the abdomen. It was well defined and erythematous. In places, hyperpigmented, verrucous, firm papules of various sizes were seen at the periphery and center of the lesion. There was no atrophy, ulceration, bleeding, and lymphadenopathy ( Fig. 1 ). A differential diagnosis of hyperkeratotic lupus vulgaris, Bowen's disease, pagetoid type of basal cell carcinoma, squamous cell carcinoma, and superficial spreading melanoma was considered.

Figure 1 Open in figure viewer PowerPoint Clinical photograph of lesion over the abdomen     

Erythema induratum of bazin: role of polymerase chain reaction in diagnosis

A 55‐year‐old man presented with recurrent multiple ulcerative nodules and plaques of 1‐year duration over the lower extremities. They were recalcitrant to topical (hydrocortisone cream) and systemic (pentoxyfylline, cefotiam) drugs. Skin surface examination of the affected areas showed the skin to be studded with violaceous nodules and/or plaques. A few of these had draining ulcers. The nature of the fluid was serosanguous. The lesions were located on the shins of the legs ( Fig. 1 ). They were bilateral and asymmetrical. In addition, nontender, erythematous nodules of annular configuration were located on the right knee and elbow, and a few toes. The arterial pulsation was within normal limits. Serial hematoxylin‐eosin stained sections prepared from a representative lesion were marked by the presence of palisading granulomatous dermatitis ( Fig. 2 ). A granulomatous folluculitis in the deep dermis and a thrombotic arteriole in the subcutis were also found. Sections counter‐stained for the presence of acid‐fast bacilli were negative. Paraffin‐embedded biopsy specimens were subjected to DNA analysis using the IS6110 gene as a polymerase chain reaction (PCR) primer, and were found to be positive. Serial chest X‐rays taken at an interval of 4 months showed findings indicative of active pulmonary tuberculosis. Anti‐tubercular therapy (ATT) comprising 450 mg of rifampicin, 300 mg of isoniazid, 800 mg of pyrazinamide and 1500 mg of ethambutol was administered for a period of 2 months followed by 450 mg of rifampicin and 300 mg of isoniazid for another 2 months. There was perceptible healing of the lesions, leaving atrophic and hyperpigmented scars.

Figure 1 Open in figure viewer PowerPoint Multiple, violaceous, ulcerated plaques and nodules on the shins of both legs     

Nevus lipomatosus cutaneous superficialis with angiokeratoma

A 35‐year‐old woman presented with a nodular growth on her right buttock. She had more than a 20‐year history of multiple, asymptomatic, smooth, skin‐colored papules involving her right buttock. The lesions had increased in number over time and had become yellowish or pale red with coalescing nodules exhibiting irregular surfaces. There was no general malaise. Ten years earlier, a diagnosis of connective tissue nevus was made on the basis of a biopsy obtained at a local hospital, but the patient declined treatment at that time. During the past 10 years, the lesions had continued to develop. The medical and social history was otherwise unremarkable, and a general physical examination was negative except for the skin lesions. Cutaneous examination showed soft, yellowish or pale red to violaceous papules and nodules of various sizes with wrinkled surfaces, coalescing into plaques. The lesions were aggregated on her right buttock and extended onto the thigh. The biggest nodule, with a coarse and dry surface, was 40 mm in diameter ( Fig. 1 ). Histopathologic examination of the largest nodule revealed hyperkeratosis and epidermal hyperplasia with elongated rete ridges. There were thin‐walled, ectatic papillary dermal vessels engorged with red blood cells and masses of mature adipose cells throughout the dermis ( Fig. 2 ) (Tianwen G, Jianfang S. Non‐epidermal related. In: Tianwen G, Jianfang S, eds. Current Dermatopathology. Beijing: People's Medical Publishing House, 2001: 349–410). A diagnosis of nevus lipomatosus cutaneous superficialis with angiokeratoma was made. The patient declined excision.

Figure 1 Open in figure viewer PowerPoint Soft, yellowish or pale red to violaceous coalescing papules and nodules of various sizes, involving the right buttock and extending onto the thigh; the largest nodule has a coarse, dry surface     

Tertiary syphilis

Case 1 A 42‐year‐old married man reported heterosexual behavior with multiple partners, chronic alcoholism, and a previous history of urethritis. He presented with a 1‐year history of two asymptomatic, erythematous to violaceous, annular or polycyclic plaques, involving the anterior aspect of the left thigh. The lesions had raised, well‐defined, infiltrated borders, with irregular crusted ulcers at the periphery, and there was central healing with atrophy ( Fig. 1 ). Histologic examination of a skin biopsy specimen showed lymphocytes and plasma cells infiltrating the superficial and deep dermis, and epithelioid granulomas. Warthin–Starry stain for spirochetes was negative. Venereal Disease Research Laboratory (VDRL) test was reactive (1 : 64) and Treponema pallidum hemagglutination assay (TPHA) was positive. Tests for hepatitis B, hepatitis C, human immunodeficiency virus‐1 (HIV‐1), and HIV‐2 were negative. Neurologic examination revealed changes attributable to chronic alcoholism. VDRL test and TPHA of cerebrospinal fluid were negative. Echocardiogram showed moderate dilatation of the ascending aorta, thickening of the aortic valves, and moderate aortic insufficiency. The patient received 2.4 million units of benzathine penicillin G, intramuscularly, once per week for three consecutive weeks, with rapid resolution of the lesions. His wife had a nonreactive VDRL test and positive TPHA, and was treated with the same regimen.

Figure 1 Open in figure viewer PowerPoint Erythematous to violaceous plaque, with crusted and ulcerated border, on the left thigh     

Three cases of cutaneous sparganosis.

Case 1 A 64‐year‐old man visited our clinic complaining of an asymptomatic nodule on his right thigh, detected 10 days previously. Physical examination revealed a solitary subcutaneous nodule, 1.5 cm in diameter on his right thigh. Twenty years previously the patient had undergone surgery to remove a ‘‘worm’' from his leg. The patient stated that he enjoyed eating raw snakes. On performing excisional biopsy of the lesion, the white, flat, shiny sparganum was detected and removed ( Fig. la ). The histopathological study of the biopsy specimen showed several encapsulated, mummified sparganum pieces and dense lymphohistiocytic infiltration along with neutrophils and eosinophils ( Fig. lb) .

Figure 1 Open in figure viewer PowerPoint (a) A flat, band‐like, white glistening sparganum being removed from the right thigh of case 1. (b) An encapsulated, mummified sparganum piece showing degenerated internal organs (hematoxylin and eosin × 40)     

Rosacea fulminans (pyoderma faciale): successful treatment of a 3-year-old girl with oral isotretinoin.

A 3‐year‐old girl presented with several erythematous papules, pustules, cysts, and purulent discharging sinuses on the face. The lesions suddenly appeared on the cheeks 3 months previously and then rapidly extended to other areas of the face. She had been treated with a variety of topical and systemic antimicrobials (including erythromycin, cephalexin, dicloxacillin, and suIfamethoxazole‐trimethoprim) and topical corticosteroids with no effect. Examination revealed deep red erythema of facial skin with several papules, pustules, cysts, and draining sinuses on the cheeks, chin, perioral, and paranasal areas ( Fig. 1 ). No comedones or signs of hidradenitis suppurativa were observed. The child was otherwise in good health. She did not have a family history of severe acne vulgaris.

Figure 1 Open in figure viewer PowerPoint Patient before treatment     

Extensive xanthelasma associated with anaplastic large cell lymphoma and hyperimmunoglobulin E syndrome

A 57‐year‐old woman presented with a 6‐month history of an extensively spreading, yellowish patch on the periorbital areas and cheeks. A diagnosis of hyperimmunoglobulin E syndrome had been made at the age of 22 years on the basis of an eczematous eruption, recurrent furunculosis, and a persistently elevated immunoglobulin E (IgE) level. Her past medical history revealed that she had suffered from numerous recurrent bouts of chronic sinusitis, otitis media, oral candidiasis, orbital cellulitis, acne rosacea, and pneumonia caused by cytomegalovirus since her twenties. In addition, 1 year ago, anaplastic large cell lymphoma of the cervical lymph node (stage IIIb) developed, and she received six cycles of cyclophosphamide–doxorubicin–vincristine–prednisolone (CHOP) chemotherapy with partial remission. None of her family had any of these problems. Cutaneous examination showed extensive, symmetric, noninfiltrated macular areas of distinct yellow discoloration around the eyes and on both cheeks ( Fig. 1 ). There were also erythematous papulonodular eruptions on the nose and both cheeks, which were thought to be acne rosacea. Laboratory findings were normal, except for an elevated IgE level (8157 IU/mL). Serum concentrations of IgG, IgA, and IgM were normal. Serum complement levels were normal, as evidenced by normal C₃, C₄, and CH₅₀. Although she had a previous history of a decreased level (12%) of nitroblue tetrazolium (NBT) test (control, 53%), NBT test at our institute was normal. Neutrophil function tests, including neutrophil chemotaxis, neutrophil phagocytosis, neutrophil respiratory burst, and neutrophil microbial killing test, by flow cytometry, showed normal results. The serum lipid levels, including total cholesterol, triglyceride, low‐density lipoprotein‐cholesterol, and high‐density lipoprotein‐cholesterol, were normal. Serum lipoprotein electrophoresis was normal. A biopsy specimen revealed scattered foamy cells throughout the dermis. The larger clusters of foamy cells tended to group around the blood vessels of the dermis ( Fig. 2 ).

Figure 1 Open in figure viewer PowerPoint Extensively distributed, yellowish, flat xanthelasma on the face     

T-cell chronic lymphocytic leukemia mimicking dermatomyositis

A 57‐year‐old man was diagnosed with chronic lymphocytic leukemia (CLL) during routine hematologic evaluation. Two months later, the patient developed a mildly pruritic periorbital eruption and erythematous plaques in a photosensitive distribution. A skin biopsy at an outside institution showed nonspecific histopathologic changes. The patient was diagnosed with amyopathic dermatomyositis and treated with prednisone 1 mg/kg/day with no improvement. The patient was subsequently admitted to our institution for CLL chemotherapy. Physical examination on admission revealed bilateral, violaceous, nonblanching periorbital plaques ( Fig. 1A )and symmetric erythematous plaques with mottled hypo‐ and hyperpigmentation on the shoulders, proximal arms ( Fig. 1B ), and upper chest ( Fig. 1C ). Periungual erythema was noted. Muscle strength was normal. Laboratory examination was significant for a white cell count of 33,700/mm³ with 78% lymphocytes, a hematocrit of 25.8%, and a platelet count of 25,000/mm^3. The lymphocytes were almost exclusively CD4 T cells expressing CD2, CD3, CD5, and CD7. Electrolytes, liver function tests, creatine kinase, aldolase, antinuclear antibodies, and anti‐Jo antibodies were normal or negative. Several biopsies of the plaques on the arms were obtained. Histopathology revealed leukemic infiltration of the skin with monoclonal T lymphocytes positive for CD2, CD3, CD4, CD5, and CD7 ( Fig. 2 ). Steroids were discontinued. The patient died a week later from toxic epidermal necrolysis secondary to allopurinol.

Figure 1 Open in figure viewer PowerPoint Clinical findings included periorbital violaceous plaques mimicking a heliotrope eruption (a) and poikilodermatous‐appearing plaques on the lateral arms (b) and upper chest (c)     

Florid eruption of seborrheic keratoses associated with elevated insulin-like growth factor, hypoglycemia, and solitary fibrous tumor of the pleura

A 66‐year‐old man with a past medical history of hypertension and arthritis was hospitalized and treated for bacterial pneumonia. Chest X‐ray revealed a left‐sided chest mass. Computed tomography (CT) scan of the chest demonstrated a large heterogeneously enhancing mass occupying most of the left lower lobe and extending to the inferior aspect of the hilum. It measured 16.6 × 12 cm and caused a mild shift of the mediastinum to the right. The patient declined further work‐up or surgical resection of the mass. Dermatologic examination was unremarkable at that time. Over the next 5 months, numerous skin lesions erupted on the patient's trunk. He then experienced several syncopal episodes, at which time he was found to be profoundly hypoglycemic. It was suspected that the chest tumor was producing high serum levels of insulin‐like growth factor (IGF) resulting in hypoglycemia and syncope. Serum laboratory investigations were significant for glucose of 20 mg/dL (normal, 60–120 mg/dL), IGF‐1 of 39 ng/mL (normal, 152–494 ng/mL), IGF‐2 of 927 ng/mL (normal, 210–750 ng/mL), and insulin of < 5.0 microunits (MCU)/mL (normal, 0–30 MCU/mL). Surgical extirpation of the chest tumor was recommended. The dermatology service was consulted to evaluate whether the numerous skin lesions in the area of planned surgery would pose an increased risk of infection. Cutaneous examination revealed a dense aggregation of pigmented hyperkeratotic plaques with a “stuck‐on” appearance, predominantly localized on the trunk. Many were unusually large or darkly pigmented. A particularly dense distribution was apparent on the left side of the chest ( Fig. 1a ). Numerous large acrochordons were evident on the lower eyelids and in the axillary vaults. Acanthosis nigricans was not present. A biopsy specimen from a hyperkeratotic lesion on the left upper back revealed an acanthotic, hyperpigmented epidermis with a lamellar horn, anastomosing rete, and pseudohorn cysts ( Fig. 1b ).

Figure 1 Open in figure viewer PowerPoint (a) Dense aggregation of pigmented hyperkeratotic papules and plaques with a “stuck‐on” appearance predominantly localized on the left side of the trunk. Many are unusually large or darkly pigmented. (b) Photomicrograph of a biopsy specimen from a hyperkeratotic lesion on the left upper back. An acanthotic, hyperpigmented epidermis with a lamellar horn, anastomosing rete, and pseudohorn cysts is demonstrated (hematoxylin and eosin stain; original magnification, × 4)     

Leukoderma punctatum following systemic PUVA therapy

A 35‐year‐old woman with vitiligo vulgaris had been treated with psoralen plus UVA (PUVA) therapy for 15 months. She was given 4,5′,8‐trimethylpsoralen (0.6 mg/kg 3 days/week) and UVA exposure (UV 7001 K Waldmann PUVA chamber). She developed repigmentation over more than 50% of the vitiliginous area over a period of 1 year. During the last 6 months, she developed three to four episodes of acute phototoxic reactions, and UVA exposure had to be interrupted. This phototoxic response was probably partly due to excessive UV radiation exposure of the lesions on exposed sites as a result of the natural bright sunshine in India. On regular monthly assessment, numerous tiny hypopigmented macules, round to oval in shape with sharp margins and measuring about 1.5 mm, were distributed over the repigmented areas ( Fig. 1 ). The lesions were predominantly seen over the extremities and were distributed randomly without any perifollicular or marginal predilection. Considering the typical morphology and distribution of the lesions, a clinical diagnosis of leukoderma punctatum was made and a skin biopsy was taken from one such lesion. On histopathology examination, patchy loss of melanin in the basal layer was observed without any other remarkable change in the epidermis.

Figure Figure 1  Open in figure viewer PowerPoint Multiple, discrete, hypopigmented, punctiform macules measuring about 1–1.5 mm over the thigh     

Cutaneous phaeohyphomycosis caused by Veronaea botryosa observed as sclerotic cells in tissue

A 65‐year‐old Japanese female farmer had an erythematous, slightly scaly, indurated plaque on the dorsum of the left wrist of more than 3 years’ duration. She had a history of hepatitis C. Her medical history and family history were otherwise unremarkable. The lesion had begun as a small region of erythema on the dorsum of the left wrist 3 years previously and had gradually enlarged. The patient had seen a local physician and had been treated with topical steroids, topical antifungals, and topical vitamin D3 agents without improvement. Initial laboratory studies revealed slightly decreased numbers of white blood cells and thrombocytes, decreased albumin levels, and elevated liver enzymes, reflecting chronic hepatitis C. Clinical examination of the lesion revealed a well‐demarcated, erythematous, slightly scaly, indurated plaque of 22 mm × 28 mm in size on the dorsum of the left wrist ( Fig. 1 ). Superficial lymph nodes were nonpalpable. Direct microscopy revealed aggregates of thick‐walled spores, considered to be sclerotic cells, from which budding brown hyphae emanated ( Fig. 2a ).

Figure 1 Open in figure viewer PowerPoint A well‐demarcated, erythematous, slightly scaly, indurated plaque of 22 mm × 28 mm in size on the dorsum of the left wrist     

Multiple eccrine hidrocystomas associated with Graves' disease

A 20‐year‐old Korean woman presented in August 1999 with a 3‐month history of multiple, tiny papules on the periorbital and malar areas ( Fig. 1a ). She had noted hyperhidrosis for the preceding 6 months, even at room temperature. She had been well and had received no medication prior to her first visit to our clinic. Physical examination showed yellow colored, translucent, small papules, as well as finger tremor, exophthalmos, and a goiter. Histologic examination demonstrated cystic structures in the dermis lined with two layers of cuboidal epithelial cells ( Fig. 2 ). The epidermis was normal and the rete ridges were partially effaced. Immunohistochemical studies revealed that the epithelial cells of the cyst wall were carcinoembryonic antigen (CEA) positive but S‐100 protein negative.

Figure 1 Open in figure viewer PowerPoint Multiple tiny papules on the periorbital and malar areas before (a) and after (b) treatment for Graves’ disease     

Cutaneous HSV-2 infection with serial recurrences at multiple sites

A 60‐year‐old white male presented to the dermatology clinic in early 1997 complaining of painful, recurrent lesions on his arms, legs, and hands for several months. At presentation, he was noted to have a cluster of erythematous pustules on his right thigh and left palm ( Fig. 1 ). He had no systemic complaints, fever, chills or adenopathy. His past medical history included a seizure disorder, type 2 diabetes, coronary artery disease, benign prostatic hypertrophy, diverticulosis, and a history of bowel surgery. He reported he was in a monogamous relationship with a partner after the death of his wife of many years. He reported no history of similar lesions in the past. Biopsy of a lesion was performed, which was consistent with herpes virus infection. Basic screening labs at the time were all within normal limits. The lesions resolved within 10 days.

Figure Figure 1  Open in figure viewer PowerPoint Vesicular lesions on left palm     

Ecthyma gangrenosum.

Case 1. An 18-year-old white man with AML-M3 received allogeneic bone marrow transplantation (BMT) in August 1997. On the seventh day of BMT, he developed chills, fever (39.1 °C), anorexia, and perirectal pain. On physical examination, a hemorrhagic bulla and “punched out” ulceration were observed on the perirectal region. Subsequently, the ulcer was surrounded by a red, swollen, tender, cellulitic plaque ( Fig. 1 ).

Figure 1 Open in figure viewer PowerPoint The ulceration on the perianal region of the first patient     

An interesting case of colocalization of segmental lichen planus and vitiligo in a 14-year-old boy

A 14‐year‐old boy had segmental vitiligo (L_3?4) on the right thigh and leg for 4 years, and was advised to apply topical clobetasol propionate, 0.05%, in the night, with daily sun exposure for 10 min, as he refused to comply with topical psoralens. As there was no response to therapy even after 3 months, the patient stopped the steroid cream but continued with the sun exposure. Subsequently, the patient noticed gradual‐onset, itchy, violaceous, pigmented, raised lesions superimposed on the vitiligo macules. Cutaneous examination revealed violaceous, polygonal papules, 0.5 × 0.5 cm in size, some of which coalesced to form discrete violaceous plaques, confined to areas of vitiligo, with a clear‐cut demarcation from normal skin ( Fig. 1 ). The scalp, palms, soles, nails, and mucosa were normal. Histopathology of the polygonal papules revealed hyperkeratosis, wedge‐shaped hypergranulosis, irregular acanthosis with saw toothing of the rete ridges, basal cell liquefaction, and a band‐like lymphocytic infiltrate ( Fig. 2 ), consistent with lichen planus. The patient was subsequently prescribed fluticasone propionate (0.05%) ointment once daily for the lesions of lichen planus. There was a marked improvement in the lesions of lichen planus after 1 month.

Figure 1 Open in figure viewer PowerPoint Violaceous papules of lichen planus colocalized on vitiligo macules with associated leukotrichia seen on the right leg