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     

Chronic disseminated cutaneous histoplasmosis in an immunocompetent individual--a case report

A 45‐year‐old woman from central India reported to clinic with multiple swellings on the face and neck. She had red patches on her forearms and trunk, but there was a predominance of lesions on the face and neck. On examination, her face showed multiple, succulent, erythematous plaques which were mildly pruritic ( Fig. 1 ). There was no discharge. There were also some scattered erythematous papules and nodules on the face ( Fig. 1 ). Examination of the neck revealed multiple erythematous plaques, many of them with a linear orientation and central ulceration and crusting ( Fig. 2 ). The upper extremities showed multiple erythematous plaques, most of which were ulcerated ( Fig. 3 ). Plaques without ulceration had been present for the past 2 years. The patient had been treated in various centers around her village and in Baroda as a case of reactional leprosy.

Figure 1 Open in figure viewer PowerPoint Multiple, succulent, erythematous plaques, papules, and nodules on the face     

Prolidase deficiency

A 32‐year‐old mentally retarded woman was admitted to hospital with recurrent ulcers on her legs, which appeared for the first time at 8 years of age. Apart from recurrent lower respiratory tract infections and chronic otitis media, her personal history was unremarkable. Her parents were second‐degree relatives. The family history showed no similar disease or mental retardation. Physical examination revealed that the patient had an unusual facial appearance, with a high‐arched palate; she had multiple tooth caries ( Fig. 1 ).

Figure Figure 1  Open in figure viewer PowerPoint Facial appearance of the patient     

Angiolymphoid hyperplasia with eosinophilia and nephrotic syndrome

A 45-year-old woman from Afghanistan presented with a 1-year history of multiple itching and stinging lesions on both right and left auricular and periauricular areas. Skin examination revealed about eight superficial erythematous nodules, ranging from 0.2 to 1.2 cm in diameter, on both ears, as well as on the preauricular and retroauricular areas ( Fig. 1 ).

Figure 1 Open in figure viewer PowerPoint Multiple erythematous nodules and papules on the left auricular and periauricular areas     

Acute febrile neutrophilic dermatosis (Sweet's syndrome) with nodular episcleritis and polyneuropathy

A 56‐year‐old Japanese housewife presented with multiple erythematous lesions in association with ocular hyperemia and pain in the right upper and lower extremities, including the hands and feet. These symptoms were preceded by a sore throat with persistent fever higher than 38.5 °C for about 1 week. Dermatologic examination showed tender, dull‐red, erythematous lesions, measuring 1–2 cm in diameter, located predominantly on the forehead, cheeks, auricular region, neck, forearm, hands, and feet. A biopsy specimen obtained from an erythematous lesion on the right forearm revealed prominent edema in the papillary dermis and remarkable inflammatory cell infiltration throughout the entire dermis ( Fig. 1 ). The infiltrate predominantly consisted of neutrophils and nuclear dust without signs of vasculitis. In routine examination, the leukocyte count was 15,000/mL (normal range, 4000–8000/mL) with severe neutrophilia (80%). The C‐reactive protein (CRP) level was 17.65 mg/dL (normal range, < 0.5 mg/dL) and the anti‐streptolysin (ASLO) level was 611 IU/mL (normal range, < 166 IU/mL). In human leukocyte antigen (HLA) testing, HLA‐A2, ‐B39, ‐B35, ‐Cw2, and ‐Cw7 were positive, and HLA‐B51, ‐B54, and ‐Cw1 were negative.

Figure Figure 1  Open in figure viewer PowerPoint Histologic picture showing a dermal infiltrate of neutrophils     

Acute febrile neutrophilic dermatosis (Sweet's syndrome) with erythema nodosum and anterior scleritis. A case report

A 53-year-old Greek housewife was admitted to hospital because of painful erythematous lesions on the lower ( Fig. 1 ) and upper ( Fig. 2 ) extremities in association with painful ocular hyperemia. These symptoms were preceded by an upper respiratory infection with persistent high-grade fever for about 1 week. Erythematous lesions had appeared 3 days previous to admission. Her medical history included two previous episodes of erythema nodosum (unknown etiology), essential hypertension treated with perindopril 4 mg/day, diabetes mellitus type II under diet only, and multinodular goiter under treatment with thyroxine 0.1 mg/day.

Figure 1 Open in figure viewer PowerPoint Subcutaneous erythematous nodules on the anterior and posterior surfaces of the legs     

Folliculo-sebaceous cystic hamartoma.

Case 1 A 6‐month‐old boy presented to our clinic with a scalp lesion dating since birth ( Fig. 1 ). The lesion was in the form of an erythematous, dome‐shaped nodule, measuring around 1.5 cm in diameter and having a slightly irregular surface. The lesion was nonitchy, nontender, and showed limited mobility. Our clinical differential diagnosis included: meningocele, hemangioma, dermoid cyst, and apocrine nevus. A computed tomography (CT) scan was performed to exclude possible intracranial connection, and the lesion was surgically excised.

Figure 1 Open in figure viewer PowerPoint Case 1: erythematous nodule on the occipital area of a 6‐month‐old boy. The lesion was clinically suggestive of apocrine nevus, dermoid cyst, or meningocele     

Cutaneous and gastrointestinal tract hemangiomas associated with disappearing bones: Gorham syndrome.

A 42‐year‐old woman presented with a 15‐year history of increasingly severe headaches. Since birth, she had hemangiomas involving predominantly her sacrum and rectum that were associated with episodes of rectal and back pain and hematochezia. During adolescence, she had multiple surgical procedures to repair the hemangiomas. Her family had no history of similar disease. Parietal headaches developed at age 27 years. Radiographic evaluation revealed destructive lesions of the cranium, the right scapula, the symphysis pubis, and the sacroiliac joint. Her headaches were managed conservatively with pain medication and observation. When her headaches steadily worsened, she was referred to our institution for another opinion. On physical examination, her skull appeared flattened bilaterally ( Fig. 1 ) and was soft to palpation. Multiple, flesh‐colored skin polyps involving the sacral areas were noted ( Fig. 2 ); these were 3‐4 cm in diameter, soft, and compressible.

Figure 1 Open in figure viewer PowerPoint Patient’s skull appears flattened bilaterally with an asymmetric contour     

Cutaneous tuberculosis and pyoderma gangrenosum

A 59‐year‐old woman with multiple myeloma at stage IA exhibited recurrent pyoderma gangrenosum of 13 years’ duration. She also had a history of mitral regurgitation and cerebral infarction, but no significant family history was present. In September 1994, she noted a painful erythematous papule on her left foot, which was treated with a topical injection of triamcinolone. It responded well to this treatment at the time, but a similar eruption developed in the same place in February 1995, and enlarged to form an irregularly shaped, punched‐out ulcer with surrounding infiltrative erythema despite topical treatment ( Fig. 1 ). Further, since November 1994, she had noted pain in the right dorsal foot.

Figure 1 Open in figure viewer PowerPoint Necrotic ulcer with an elevated purulent border and pustules on the left foot     

Two cases of reactive perforating collagenosis arising at the site of healed herpes zoster.

Case 1 A 67‐year‐old South Korean woman presented with a painful eruption on the left trunk. Several groups of vesicles with an erythematous and edematous base were situated unilaterally within the distribution of the left T9 dermatome; they had been present for 7 days. A diagnosis of herpes zoster was made, and treatment with acyclovir, analgesics, tranquilizers, and wet dressings produced a moderate response. Two weeks after onset, the lesions appeared to have healed with a scar. Four months later, however, the patient noticed another eruption of papules in the postherpetic area ( Fig. 1A,B ).

Figure 1 Open in figure viewer PowerPoint Case 1. (A) Multiple erythematous papules on the left trunk along the T9 dermatome. (B) Multiple erythematous papules with a keratotic central plug     

Erythema nodosum associated with sporotrichosis

Case 1 A 34‐year‐old woman had ulcerated lesion 2 cm in diameter on the right leg of 2 months’ evolution. She also presented painful erythematous nodules on lower limbs accompanied by arthralgia appearing 1 month after the initial lesion ( Figure 1a ). The patient reported having been scratched on the right leg by a cat with sporotrichosis 15 days before the initial symptoms. Examination of the ulcerated lesion showed growth of Sporothrix schenckii, and histological investigation of one nodule showed a mononuclear inflammatory infiltrate in the hypodermis with a predominantly septal distribution, negative upon culture for fungi ( Figure 1b ). Radiographic examination of left ankle showed increased soft tissue, while other ancillary tests were normal. The patient was treated with itraconazole 100 mg/day for 4 months, with regression of Erythema nodosum (EN) on day 20.

Figure Figure 1  Open in figure viewer PowerPoint (a) Ulcerated lesions on right calf and erythematous nodules on lower limbs. (b) Histopathology of one lower limbs nodule, displaying small granuloma in the subcutaneous cellular tissue (HE, 4 ×)     

Treatment of localized epidermodysplasia verruciformis with tacalcitol ointment

A 69‐year‐old Japanese woman presented with multiple, erythematous, keratotic plaques distributed on her right breast, right shoulder, and left cubital fossa. The lesions varied in size from 5 mm to 6 cm. The patient had first noticed a small area of primary erythema on her left cubital fossa at the age of 18 years. The number and size of the lesions had increased for 50 years. A black nodule appeared on the plaque on the right breast 3 years ago and enlarged to 5 cm in diameter ( Fig. 1A ).

Figure 1 Open in figure viewer PowerPoint (a) Erythematous plaques varying in size distributed on both breasts. The biggest plaque contained hyperkeratotic tumor. The black nodule appeared on the plaque of the right breast. (b) Six months after black tumor removal, hypertrophic change was noted on the scar. Topical application of vitamin D3 analog caused regression in size and elevation of the largest keratotic plaque, and a decrease in hyperkeratosis of the other eruptions     

Bullous variant of Sweet's syndrome

A 69-year-old woman presented to our clinic as an emergency with erythematous, well-circumscribed plaques, which were partly vesicular, on her extremities and in her armpits, and additionally hemorrhagic blisters on both her palms and her fingers ( Fig. 1a ), which had developed 2 days after the first appearance of the skin lesions. The rapid onset of the lesions (within a few hours) and the pain associated with them were extremely troublesome to the patient. On admission she complained of fever, tiredness and being easily fatigued. Because of a urinary tract infection 1 month prior to admission, trospiumchloride was given. On clinical examination, body temperature was found to be above 38 °C and infraclavicular lymph nodes were enlarged but not tender.

Figure 1 Open in figure viewer PowerPoint (a) Bullae on the patient's right hand. (b) Multiple partly confluent vesicles with neutrophilic granulocytes intraepidermally and a dense interstitial perivascular infiltration of neutrophilic granulocytes and lymphomononuclear cells (H&E, ×200)     

Superficial cutaneous Trichosporon asahii infection in an immunocompetent host

A 16‐year‐old schoolgirl presented with a complaint of enlarging erythematous and mildly pruritic patches located on the buttocks of 2 years’ duration. She had been treated with a potent topical corticosteroid for many months without apparent benefit. She was in otherwise good health. She denied a history of hair infection, previous eruptions, asthma, or hay fever. No one in her family or friends had similar lesions. She had no pets in her house. Examination revealed the presence of two erythematous and slightly indurated plaques measuring approximately 16 cm × 9 cm and 6 cm × 11 cm in diameter on her right and left buttocks, respectively ( Fig. 1 ). Similar progressively enlarging lesions were present on the dorsum of her right hand, extending to the extensor aspect of the forearm and to the lateral, inner, palmar, and extensor aspects of the second, third, and fourth fingers, and on the dorsum of her left hand up to the flexor aspect of the wrist. A few erythematous papules clustering around these plaques in a satellite fashion were also detectable. Her scalp, pubic, axillary, eyebrow, and eyelash hair appeared normal with no concretions or soft, lightly pigmented, white to light‐brown, loosely attached, irregularly spaced nodules. There was no regional or generalized lymphadenopathy or hepatosplenomegaly. Routine laboratory investigations, human immunodeficiency virus (HIV) testing, and standard patch tests were negative.

Figure 1 Open in figure viewer PowerPoint Erythematous and slightly indurated plaques on the right and left buttocks     

Cutaneous extramedullary hematopoiesis in idiopathic myelofibrosis

A 67‐year‐old German woman presented with a 2‐month history of indolent erythematous macules and livid papulonodules of 0.5–1.5 cm in diameter scattered on her abdomen ( Fig. 1 ). On physical examination, the patient was alert, the liver was palpable 3 cm below the right costal margin, and the spleen was enlarged 3 cm below the left costal margin. There was no lymphadenopathy.

Figure 1 Open in figure viewer PowerPoint Clinical lesions with extramedullary hematopoiesis on the abdomen     

Disseminated cutaneous Mycobacterium chelonae infection after injection of bovine embryonic cells

A 50-year-old previously healthy white woman developed a tender erythematous draining subcutaneous nodule on her left cheek, 9 months after receiving multiple injections of bovine embryonic cells in different areas of the face, neck, and chest as a skin rejuvenation treatment. Over the subsequent 4 months, multiple similar nodules developed on the injected areas. The lesions, which were initially painful, became asymptomatic as they developed purulent drainage and ruptured onto the skin surface. There were no associated fevers, chills, or sweats. The nodules failed to respond to a 2-month course of oral prednisone and intralesional triamcinolone acetonide. Physical examination showed red, firm, subcutaneous nodules some of which were draining a serosanguinous exudate ( Fig. 1 ). While a presumptive diagnosis of foreign body granuloma was made, the possibility of an atypical mycobacterial infection remained, and therefore tissue was submitted for culture. While awaiting culture results, the patient was started on minocycline, 50 mg twice daily.

Figure 1 Open in figure viewer PowerPoint Neck with disseminated subcutaneous erythematous nodules due to M. chelonae that developed following injections of “bovine embryonic cells”     

Mycobacterium chelonae/abscessus complex infection in a liver transplant patient

A 25‐year‐old woman presented in October 1999 with fever, nausea, vomiting, and a nodular eruption that had developed over the previous 7 days. Her past medical history was significant for chronic sclerosing cholangitis, which necessitated a liver transplantation in 1994 and a second one in 1998 due to graft rejection. Upon admission, she was taking the following medications: prednisone 20 mg q.d., cyclosporine 375 mg p.o. b.i.d., sirolimus 10 mg p.o. q.d., levofloxacin 500 mg p.o. q.d., and ganciclovir 1000 mg p.o. t.i.d. On skin examination, there were tender, nonfluctuant, erythematous, subcutaneous nodules, 0.3–1.0 cm in diameter, scattered on her arms and legs (see Fig. 1 ). While undergoing diagnostic evaluation, the patient was empirically treated with intravenous antimicrobials for presumed sepsis as well as increased dosages of glucocorticosteroids for the possibility of acute graft rejection. Her laboratory data were significant for elevated liver function tests, blood urea nitrogen, and creatinine. A punch biopsy of a nodule on her left forearm showed a neutrophilic and histiocytic lobular and septal panniculitis (see Fig. 2 ), and all special stains, including acid‐fast bacillus (AFB) stains, and tissue cultures were negative for infectious organisms.

Figure 1 Open in figure viewer PowerPoint Erythema nodosum‐like nodules on the leg     

Multiple pilomatricoma with perforation

A 22‐year‐old woman presented to our clinic with a complaint of masses on various parts of her body. A mass on her right forearm had appeared 5 years ago and had enlarged during the past 6 months. Two lesions on the back of her neck had a 3‐year history, one lesion on her eyebrow had a 2‐year history, and one lesion on her left forearm had a 1‐year history. The lesion on her left forearm was discharging purulent material. Dermatologic examination revealed a 15 × 16 mm tumor on the right forearm, 11 × 6 mm and 10 × 5 mm tumors on the back of the neck, and a 20 × 20 mm tumor on the eyebrow; they were flesh‐colored, well‐defined, firm tumors. On her left forearm, there was a 12 × 10 mm, well‐defined, firm, blue–red tumor discharging chalky white granules; purulent material was detected ( Fig. 1 ).

Figure 1 Open in figure viewer PowerPoint Firm, blue–red tumor discharging chalky white granules     

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     

Erosive perianal lichen planus responsive to tacrolimus

A 46‐year‐old man presented with bleeding and painful sores around the anus of 2–3 years’ duration. The lesions had improved with a course of oral antimicrobials prescribed by a surgeon, who had performed a biopsy reported as showing nonspecific changes. Topical corticosteroids had also led to improvement, accompanied by the development of painful “pimples.” The patient had a history of recurrent oral herpes simplex, but denied other medical problems, persistent oral lesions, or human immunodeficiency virus risk factors. A total body skin examination revealed two shallow ulcerations of the perianal mucosa with minimal background erythema. No other cutaneous or mucosal lesions were noted. The remainder of the examination was unremarkable. A viral culture was negative, and there was no response to a 5‐day course of oral antiviral therapy (500 mg of valacyclovir twice daily). After avoiding topical therapies for 10 days, a lacy white discoloration was noted ( Fig. 1 ). Review of the original biopsy specimen showed a band‐like lymphocytic infiltrate in the papillary dermis with involvement of the basal layer, consistent with lichen planus.

Figure 1 Open in figure viewer PowerPoint Lacy white discoloration and erosions of the perianal mucosa